[Chlamydia mimics suspected ovarian cancer in a 21-year-old patient]. / Chlamydia-infectie imiteert ovariumcarcinoom.

BACKGROUND: The antigen CA125 is mainly known as a tumour marker in ovarian cancer, but may also be elevated in benign gynaecological disorders and non-gynaecological diseases. CASE DESCRIPTION: We examined a 21-year-old patient in the gynaecological oncology outpatient clinic, after she was referred with abnormal ovaries on ultrasound and a significantly elevated CA125. The patient had seen a gynaecologist four weeks earlier because of persistent abdominal pain, deep dyspareunia and vaginal bleeding after insertion of a Mirena IUD that has since been removed. The IUD turned out to be placed in the presence of an undiagnosed STD (Chlamydia), which seems to explain the abnormal ovaries and elevated tumour marker due to pelvic inflammatory disease (PID). CONCLUSION: PID can present atypically resembling ovarian carcinoma. Before inserting an IUD, evaluation of sexual history is essential to estimate the risk of an STI and, if necessary, to perform diagnostics.

Gate-tuned anomalous Hall effect driven by Rashba splitting in intermixed LaAlO3/GdTiO3/SrTiO3.

The Anomalous Hall Effect (AHE) is an important quantity in determining the properties and understanding the behaviour of the two-dimensional electron system forming at the interface of SrTiO3-based oxide heterostructures. The occurrence of AHE is often interpreted as a signature of ferromagnetism, but it is becoming more and more clear that also paramagnets may contribute to AHE. We studied the influence of magnetic ions by measuring intermixed LaAlO3/GdTiO3/SrTiO3 at temperatures below 10 K. We find that, as function of gate voltage, the system undergoes a Lifshitz transition while at the same time an onset of AHE is observed. However, we do not observe clear signs of ferromagnetism. We argue the AHE to be due to the change in Rashba spin-orbit coupling at the Lifshitz transition and conclude that also paramagnetic moments which are easily polarizable at low temperatures and high magnetic fields lead to the presence of AHE, which needs to be taken into account when extracting carrier densities and mobilities.

Inhomogeneous superconductivity and quasilinear magnetoresistance at amorphous LaTiO3/SrTiO3 interfaces.

We have studied the transport properties of LaTiO3/SrTiO3 (LTO/STO) heterostructures. In spite of 2D growth observed in reflection high energy electron diffraction, transmission electron microscopy images revealed that the samples tend to amorphize. Still, we observe that the structures are conducting, and some of them exhibit high conductance and/or superconductivity. We established that conductivity arises mainly on the STO side of the interface, and shows all the signs of the two-dimensional electron gas usually observed at interfaces between STO and LTO or LaAlO3, including the presence of two electron bands and tunability with a gate voltage. Analysis of magnetoresistance (MR) and superconductivity indicates the presence of spatial fluctuations of the electronic properties in our samples. That can explain the observed quasilinear out-of-plane MR, as well as various features of the in-plane MR and the observed superconductivity.

TGFß-mediated expression of TGFß-activating integrins in SSc monocytes: disturbed activation of latent TGFß?

INTRODUCTION: The pathophysiology of systemic sclerosis (SSc) is closely linked to overactive TGFß signaling. TGFß is produced and circulates in latent form, making its activation crucial for signaling. This activation can be mediated via integrins. We investigated the balance between active and latent TGFß in serum of SSc patients and investigated if this correlates with integrin expression on monocytes. METHODS: A TGFß/SMAD3- or BMP/SMAD1/5-luciferase reporter construct was expressed in primary human skin fibroblasts. Both acidified and non-acidified sera of ten SSc patients and ten healthy controls were tested on these cells to determine total and active TGFß and BMP levels respectively. A pan-specific TGFß1/2/3 neutralizing antibody was used to confirm TGFß signaling. Monocytes of 20 SSc patients were isolated using CD14+ positive selection, and integrin gene expression was measured using qPCR. Integrin expression was modulated using rhTGFß1 or a small molecule inhibitor of TGFBR1: SB-505124. RESULTS: SSc sera induced 50% less SMAD3-reporter activity than control sera. Serum acidification increased reporter activity, but a difference between healthy control and SSc serum was no longer observed, indicating that total TGFß levels were not different. Addition of a pan-specific TGFß1/2/3 neutralizing antibody fully inhibited SMAD3-reporter activity of both acidified and not-acidified control and SSc sera. Both HC and SSc sera induced similar SMAD1/5-reporter activity, and acidification increased this, but not differently between groups. Interestingly, expression of two integrin alpha subunits ITGA5 and ITGAV was significantly reduced in monocytes obtained from SSc patients. Furthermore, ITGB3, ITGB5, and ITGB8 expression was also reduced in SSc monocytes. Stimulation of monocytes with TGFß1 induced ITGA5 and ITGAV but lowered ITGB8 expression, whereas the use of the TGFß receptor inhibitor SB-505124 had the opposite effect. CONCLUSION: Total TGFß serum levels are not different between SSc patients and controls, but TGFß activity is. This coincides with a reduced expression of TGFß-activating integrins in monocytes of SSc patients. Because TGFß regulates expression of these integrins in monocytes, a negative feedback mechanism possibly underlies these observations.

Improving shared decision-making in a clinical obstetric ward by using the three questions intervention, a pilot study.

BACKGROUND: Shared decision-making (SDM) is an important aspect of modern health care. Many studies evaluated different interventions to improve SDM, however, none in an inpatient clinical setting. A tool that has been proven effective in an outpatient department is the three questions intervention. These questions are created for patients to get optimal information from their medical team and to make an informed medical decision. In this study, we evaluated the feasibility and effectiveness of this simple intervention on SDM in the obstetric inpatient department of a university hospital in the Netherlands. METHOD: This is a clinical pilot before and after study, using mixed methods with quantitative and qualitative data collection. The three questions were stated on a card; (i.e. 1) What are my options; 2) What are the possible benefits and harms of those options; 3) How likely are each of those benefits and harms to happen to me?). The study period lasted 6 weeks in which all patients admitted to the obstetric ward were asked to participate in the study. In the first 3 weeks patients did not receive the three questions intervention (pre-intervention group). In the final 3 weeks all patients included received the intervention (intervention group). The main quantitative outcome measure was the level of SDM measured using the SDM-Q9 questionnaire at discharge (range 0-100). In addition, interviews with four patients of the intervention group were conducted and qualitatively analyzed. RESULTS: Thirty-three patients were included in the pre-intervention group, 29 patients in the intervention group. The mean score of the SDM-Q9 in the pre-intervention group was 65.5 (SD 22.83) and in the intervention group 63.2 (SD 20.21), a not statistically significant difference. In the interviews, patients reported the three questions to be very useful. They used the questions mainly as a prompt and encouragement to ask more specific questions. DISCUSSION: No difference in SDM was found between the two groups, possibly because of a small sample size. Yet the intervention appeared to be feasible and simple to use in an inpatient department. Further studies are needed to evaluate the impact of implementation of these three questions on a larger scale.

An alternative ICU staffing model: implementation of the non-physician provider.

INTRODUCTION: Literature in Europe regarding implementation of nurse practitioners or physician assistants in the intensive care unit (ICU) is lacking, while some available studies indicate that this concept can improve the quality of care and overcome physician shortages on ICUs. The aim of this study is to provide insight on how a Dutch ICU implemented non-physician providers (NPP), besides residents, and what this staffing model adds to the care on the ICU. METHODS: This paper defines the training course and job description of NPPs on a Dutch ICU. It describes the number and quality of invasive interventions performed by NPPs, residents, and intensivists during the years 2015 and 2016. Salary scales of NPPs and residents are provided to describe potential cost-effectiveness. RESULTS: The tasks of NPPs on the ICU are equal to those of the residents. Analysis of the invasive interventions performed by NPPs showed an incidence of central venous catheter insertion for NPPs of 20 per fulltime equivalent (FTE) and for residents 4.3 per FTE in one year. For arterial catheters the NPP inserted 61.7 per FTE and the residents inserted 11.8 per FTE. The complication rate of both groups was in line with recent literature. Regarding their salary: after five years in service an NPP earns more than a starting resident. CONCLUSION: This is the first European study which describes the role of NPPs on the ICU and shows that practical interventions normally performed by physicians can be performed with equal safety and quality by NPPs.

Effects of training physicians in electronic prescribing in the outpatient setting on clinical, learning and behavioural outcomes: a cluster randomized trial.

AIMS: Electronic prescribing systems may improve medication safety, but only when used appropriately. The effects of task analysis-based training on clinical, learning and behavioural outcomes were evaluated in the outpatient setting, compared with the usual educational approach. METHODS: This was a multicentre, cluster randomized trial [EDUCATional intervention for IT-mediated MEDication management (MEDUCATE trial)], with physicians as the unit of analysis. It took place in the outpatient clinics of two academic hospitals. Participants comprised specialists and residents (specialty trainees, in the UK) and their patients. Training took the form of a small-group session and an e-learning. The primary outcome was the proportion of medication discrepancies per physician, measured as discrepancies between medications registered by physicians in the electronic prescribing system and those reported by patients. Clinical consequences were estimated by the proportion of patients per physician with at least one missed drug-drug interaction with the potential for causing adverse drug events. A questionnaire assessed physicians' knowledge and skills. RESULTS: Among 124 participating physicians, primary outcome data for 115 (93%) were available. A total of 1094 patients were included. A mean of 48% of registered medications per physician were discrepant with the medications that their patients reported in both groups (P = 0.14). Due to registration omissions, a mean of 4% of patients per physician had one or more missed drug-drug interactions with the potential to cause a clinically relevant adverse drug event in the intervention group, and 7% in controls (P = 0.11). The percentages of correct answers on the knowledge and skills test were higher in the intervention group (57%) compared with controls (51%; P = 0.01). CONCLUSION: The training equipped outpatient physicians with the knowledge and skills for appropriate use of electronic prescribing systems, but had no effect on medication discrepancies.

Interventions to support shared decision-making for women with heavy menstrual bleeding: A systematic review.

This review studies women's preferences for shared decision-making about heavy menstrual bleeding treatment and evaluates interventions that support shared decision-making and their effectiveness. PubMed, Cochrane, Embase, Medline and ClinicalTrials.gov were searched. Three research questions were predefined: 1) What is the range of perspectives gathered in studies that examine women facing a decision related to heavy menstrual bleeding management?; 2) What types of interventions have been developed to support shared decision-making for women experiencing heavy menstrual bleeding?; and 3) In what way might women benefit from interventions that support shared decision-making? All original studies were included if the study population consisted of women experiencing heavy menstrual bleeding. We used the TIDieR (Template for Intervention: Description and Replication) checklist to assess the quality of description and the reproducibility of interventions. Interventions were categorized using Grande et al. guidelines and collated and summarized outcomes measures into three categories: 1) patient-reported outcomes; 2) observer-reported outcomes; and 3) doctor-reported outcomes. Fifteen studies were included. Overall, patients preferred to decide together with their doctor (74%). Women's previsit preference was the strongest predictor for treatment choice in two studies. Information packages did not have a statistically significant effect on treatment choice or satisfaction. However, adding a structured interview or decision aid to increase patient involvement did show a positive effect on treatment choice and results, patient satisfaction and shared decision-making related outcomes. In conclusion shared decision-making is becoming more important in the care of women with heavy menstrual bleeding. Structured interviews or well-designed (computerized) tools such as decision aids seem to facilitate this process, but there is room for improvement. A shared treatment choice is only possible after careful provision of information, elicitation of patients' preferences and integrating those preferences. Interventions should be designed accordingly.

Imaging pulsed laser deposition growth of homo-epitaxial SrTiO3 by low-energy electron microscopy.

By combining low-energy electron microscopy with in situ pulsed laser deposition we have developed a new technique for film growth analysis, making use of both diffraction and real-space information. Working at the growth temperature, we can use: the intensity and profile variations of the specular beam to follow the coverage in a layer-by-layer fashion; real-space microscopy to follow e.g. atomic steps at the surface; and electron reflectivity to probe the unoccupied band structure of the grown material. Here, we demonstrate our methodology for homo-epitaxial growth of SrTiO3. Interestingly, the same combination of techniques will also be applicable to hetero-epitaxial oxide growth, largely extending the scope of research possibilities.

Striped nanoscale phase separation at the metal-insulator transition of heteroepitaxial nickelates.

Nucleation processes of mixed-phase states are an intrinsic characteristic of first-order phase transitions, typically related to local symmetry breaking. Direct observation of emerging mixed-phase regions in materials showing a first-order metal-insulator transition (MIT) offers unique opportunities to uncover their driving mechanism. Using photoemission electron microscopy, we image the nanoscale formation and growth of insulating domains across the temperature-driven MIT in NdNiO3 epitaxial thin films. Heteroepitaxy is found to strongly determine the nanoscale nature of the phase transition, inducing preferential formation of striped domains along the terraces of atomically flat stepped surfaces. We show that the distribution of transition temperatures is a local property, set by surface morphology and stable across multiple temperature cycles. Our data provide new insights into the MIT of heteroepitaxial nickelates and point to a rich, nanoscale phenomenology in this strongly correlated material.

OPTION(5) versus OPTION(12) instruments to appreciate the extent to which healthcare providers involve patients in decision-making.

OBJECTIVE: The 12-item "observing patient involvement" (OPTION(12))-instrument is commonly used to assess the extent to which healthcare providers involve patients in health-related decision-making. The five-item version (OPTION(5)) claims to be a more efficient measure. In this study we compared the Dutch versions of the OPTION-instruments in terms of inter-rater agreement and correlation in outpatient doctor-patient consultations in various settings, to learn if we can safely switch to the shorter OPTION(5)-instrument. METHODS: Two raters coded 60 audiotaped vascular surgery and oncology patient consultations using OPTION(12) and OPTION(5). Unweighted Cohen's kappa was used to compute inter-rater agreement on item-level. The association between the total scores of the two OPTION-instruments was investigated using Pearson's correlation coefficient (r) and a Bland & Altman plot. RESULTS: After fine-tuning the OPTION-manuals, inter-rater agreement for OPTION(12) and OPTION(5) was good to excellent (kappa range 0.69-0.85 and 0.63-0.72, respectively). Mean total scores were 23.7 (OPTION(12); SD=7.8) and 39.3 (OPTION(5); SD=12.7). Correlation between the total scores was high (r=0.71; p=0.01). OPTION(5) scored systematically higher with a wider range than OPTION(12). CONCLUSION: Both OPTION-instruments had a good inter-rater agreement and correlated well. OPTION(5) seems to differentiate better between various levels of patient involvement. PRACTICAL IMPLICATION: The OPTION(5)-instrument is recommended for clinical application.

Temperature dependence of spin pumping and Gilbert damping in thin Co/Pt bilayers.

We report on the temperature dependence of the spin-pumping effect and the Gilbert damping in Co/Pt bilayers grown on Silicon oxide by measuring the change of the linewidth in a ferromagnetic resonance (FMR) experiment. By varying the Co thickness d(Co) between 1.5 nm and 50 nm we find that the damping increases inversely proportional to d(Co) at all temperatures between 300 K and 5 K, showing that the spin pumping effect does not depend on temperature. We also find that the linewidth increases with decreasing temperature for all thicknesses down to about 30 K, before leveling off to a constant, or even decreasing again. This behavior is similar to what is found in bulk ferromagnets, leading to the conclusion that in thin films a conductivity-like damping mechanism is present similar to what is known in crystals.

MEDUCATE trial: effectiveness of an intensive EDUCATional intervention for IT-mediated MEDication management in the outpatient clinic - study protocol for a cluster randomized controlled trial.

BACKGROUND: Using information technology for medication management is an opportunity to help physicians to improve the quality of their documentation and communication and ultimately to improve patient care and patient safety. Physician education is necessary to take full advantage of information technology systems. In this trial, we seek to determine the effectiveness of an intensive educational intervention compared with the standard approach in improving information technology-mediated medication management and in reducing potential adverse drug events in the outpatient clinic. METHODS/DESIGN: We are conducting a multicenter, cluster randomized controlled trial. The participants are specialists and residents working in the outpatient clinic of internal medicine, cardiology, pulmonology, geriatrics, gastroenterology and rheumatology. The intensive educational intervention is composed of a small-group session and e-learning. The primary outcome is discrepancies between registered medication (by physicians) and actually used medication (by patients). The key secondary outcomes are potential adverse events caused by missed drug-drug interactions. The primary and key secondary endpoints are being assessed shortly after the educational intervention is completed. Sample size will be calculated to ensure sufficient power. A sample size of 40 physicians per group and 20 patients per physician will ensure a power of >90 %, which means we will need a total of 80 physicians and 1,600 patients. DISCUSSION: We performed an exploratory trial wherein we tested the recruitment process, e-learning, time schedule, and methods for data collection, data management and data analysis. Accordingly, we refined the processes and content: the recruitment strategy was intensified, extra measures were taken to facilitate smooth conductance of the e-learning and parts were made optional. First versions of the procedures for data collection were determined. Data entry and analysis was further standardized by using the G-standard database in the telephone questionnaire. TRIAL REGISTRATION: ISRCTN registry: ISRCTN50890124 . Registered 10 June 2013.

Task analysis of information technology-mediated medication management in outpatient care.

AIMS: Educating physicians in the procedural as well as cognitive skills of information technology (IT)-mediated medication management could be one of the missing links for the improvement of patient safety. We aimed to compose a framework of tasks that need to be addressed to optimize medication management in outpatient care. METHODS: Formal task analysis: decomposition of a complex task into a set of subtasks. First, we obtained a general description of the medication management process from exploratory interviews. Secondly, we interviewed experts in-depth to further define tasks and subtasks. SETTING: Outpatient care in different fields of medicine in six teaching and academic medical centres in the Netherlands and the United States. PARTICIPANTS: 20 experts. Tasks were divided up into procedural, cognitive and macrocognitive tasks and categorized into the three components of dynamic decision making. RESULTS: The medication management process consists of three components: (i) reviewing the medication situation; (ii) composing a treatment plan; and (iii) accomplishing and communicating a treatment and surveillance plan. Subtasks include multiple cognitive tasks such as composing a list of current medications and evaluating the reliability of sources, and procedural tasks such as documenting current medication. The identified macrocognitive tasks were: planning, integration of IT in workflow, managing uncertainties and responsibilities, and problem detection. CONCLUSIONS: All identified procedural, cognitive and macrocognitive skills should be included when designing education for IT-mediated medication management. The resulting framework supports the design of educational interventions to improve IT-mediated medication management in outpatient care.

Communication at an online infertility expert forum: provider responses to patients' emotional and informational cues.

Online patient-provider communication has become increasingly popular in fertility care. However, it is not known to what extent patients express cues or concerns and how providers respond. In this study, we investigated cues and responses that occur in online patient-provider communication at an infertility-specific expert forum. We extracted 106 threads from the multidisciplinary expert forum of two Dutch IVF clinics. We performed the following analyses: (1) thematic analysis of patients' questions; and (2) rating patients' emotional and informational cues and subsequent professionals' responses using an adaptation of the validated Medical Interview Aural Rating Scale. Frequencies of themes, frequencies of cues and responses, and sequences (what cue is followed by what response) were extracted. Sixty-five infertile patients and 19 providers participated. The most common themes included medication and lifestyle. Patients gave more informational than emotional cues (106 versus 64). Responses to informational cues were mostly adequate (61%). The most common response to emotional cues was empathic acknowledgment (72%). Results indicate that an online expert forum could have a positive effect on patient outcomes, which should guide future research. Offering infertile patients an expert forum to communicate with providers can be a promising supplement to usual care in both providing information and addressing patients' concerns.

Controlled mechnical modification of manganite surface with nanoscale resolution.

We investigated the surfaces of magnetoresistive manganites, La(1-x)Ca(x)MnO3 and La(2-2x)Sr(1+2x)Mn2O7, using a combination of ultrahigh vacuum conductive, electrostatic and magnetic force microscopy methods. Scanning as-grown film with a metal tip, even with zero applied bias, was found to modify the surface electronic properties such that in subsequent scans, the conductivity is reduced below the noise level of conductive probe microscopy. Scanned areas also reveal a reduced contact potential difference relative to the pristine surface by ∼0.3 eV. We propose that contact-pressure of the tip modifies the electrochemical potential of oxygen vacancies via the Vegard effect, causing vacancy motion and concomitant changes of the electronic properties.

Dental technology services and industry trends in New Zealand from 2010 to 2012.

OBJECTIVE: To provide a snapshot of the New Zealand dental technology industry and influencing factors. BACKGROUND: Developing an understanding of the commercial dental laboratory environment in New Zealand can provide insight into the entire dental industry. METHODS: A web-based survey was the primary method for data collection, with separate questionnaires used for dental laboratory owners and dental technician employees. RESULTS: The mean net income for dental laboratory owners in New Zealand was similar to that of the United Kingdom, at $40.50 per hour. Clinical dental technicians are the highest paid employees, with a mean of $33.49 per hour. The mean technical charge for complete dentures was $632.59; including clinical services, it was $1907.00. The mean charge for a porcelain-fused-to-metal (PFM) crown was $290.27. Dental laboratory owners expressed fear about the possibility of losing dental clients to overseas laboratories due to the availability and cheap charge of offshore work. Only 25.4% of dental laboratories surveyed had computer-aided design (CAD) facilities, and even fewer (7.9%) had computer-aided manufacturing (CAM) systems. CONCLUSION: Clinical dental technology appears to be prospering. The dental technology industry appears to be adapting and remains viable, despite facing many challenges.

Interface-induced room-temperature ferromagnetism in hydrogenated epitaxial graphene.

We show ferromagnetic properties of hydrogen-functionalized epitaxial graphene on SiC. Ferromagnetism in such a material is not directly evident as it is inherently composed of only nonmagnetic constituents. Our results nevertheless show strong ferromagnetism with a saturation of 0.9µ(B)/hexagon projected area, which cannot be explained by simple magnetic impurities. The ferromagnetism is unique to hydrogenated epitaxial graphene on SiC, where interactions with the interfacial buffer layer play a crucial role. We argue that the origin of the observed ferromagnetism is governed by electron correlation effects of the narrow Si dangling bond states in the buffer layer exchange coupled to localized states in the hydrogenated graphene layer. This forms a quasi-three-dimensional ferromagnet with a Curie temperature higher than 300 K.

Giant magnetic susceptibility of gold nanorods detected by magnetic alignment.

We have determined the magnetic properties of single-crystalline Au nanorods in solution using an optically detected magnetic alignment technique. The rods exhibit a large anisotropy in the magnetic volume susceptibility (Δχ(V)). Δχ(V) increases with decreasing rod size and increasing aspect ratio and corresponds to an average volume susceptibility (χ(V)), which is drastically enhanced relative to bulk Au. This high value of χ(V) is confirmed by SQUID magnetometry and is temperature independent (between 5 and 300 K). Given this peculiar size, shape, and temperature dependence, we speculate that the enhanced χ(V) is the result of orbital magnetism due to mesoscopic electron trajectories within the nanorods.

Mechanical control of electroresistive switching.

Hysteretic metal-insulator transitions (MIT) mediated by ionic dynamics or ferroic phase transitions underpin emergent applications for nonvolatile memories and logic devices. The vast majority of applications and studies have explored the MIT coupled to the electric field or temperarture. Here, we argue that MIT coupled to ionic dynamics should be controlled by mechanical stimuli, the behavior we refer to as the piezochemical effect. We verify this effect experimentally and demonstrate that it allows both studying materials physics and enabling novel data storage technologies with mechanical writing and current-based readout.