Objective: Anxiety, depression and greater pain intensity before total knee arthroplasty (TKA) may increase the probability of revision surgery for remaining symptoms even without clear pathology... Show moreObjective: Anxiety, depression and greater pain intensity before total knee arthroplasty (TKA) may increase the probability of revision surgery for remaining symptoms even without clear pathology or technical issues. We aimed to assess whether preoperative anxiety/depression and pain intensity are associated with revision TKA for less clear indications. Methods: Less clear indications for revision were defined after a Delphi process in which consensus was reached among 59 orthopaedic knee experts. We performed a cox regression analyses on primary TKA patients registered in the Dutch Arthroplasty Registry (LROI) who completed the EuroQol 5D 3 L (EQ5D-3 L) anxiety/depression score to examine associations between preoperative anxiety/depression and pain (Numeric Rating Scale (NRS)) with TKA revision for less clear reasons. These analyses were adjusted for age, BMI, sex, smoking, ASA score, EQ5D-3 L thermometer and OKS score. Results: In total, 25.9% patients of the 56,233 included patients reported moderate or severe symptoms of anxiety/depression on the EQ5D-3 L anxiety/depression score. Of those, 615 revisions (45.5%) were performed for less clear reasons for revision (patellar pain, malalignment, instability, progression of osteoarthritis or arthrofibrosis). Not EQ5D-3 L anxiety/depression score, but higher NRS pain at rest and EQ5D-3 L pain score were associated with revision for less clear reason (HR: 1.058, 95% CI 1.019-1.099 & HR: 1.241, 95% CI 1.044-1.476, respectively). Conclusion: Our findings suggest that pain intensity is a risk factor for TKA revision for a less clear reason. The finding that preoperative pain intensity was associated with reason for revision confirms a likely influence of subjective, personal factors on offer and acceptance of TKA revision. The association between anxiety/depression and reason for revision after TKA may also be found when including more specific outcome measures to assess anxiety/depression and we therefore hope to encourage further research on this topic with our study, ideally in a prospective setting. Study design: Longitudinal Cohort Study Level III, Delphi Consensus Show less
Objectives: The aim of this study was to identify and prioritize aspects essential for decision making in patients with diffuse cutaneous systemic sclerosis (dcSSc) and to gain insight into... Show moreObjectives: The aim of this study was to identify and prioritize aspects essential for decision making in patients with diffuse cutaneous systemic sclerosis (dcSSc) and to gain insight into information preferences of treatment options which could guide development of a leaflet for patients.Methods: A three-round Delphi study was conducted with a panel of patients with dcSSc. The questionnaire was based on a systematic literature search regarding benefits and harms of four main treatment options in dcSSc: methotrexate, mycophenolate mofetil, cyclophosphamide pulses and stem cell transplantation. Patients were asked to identify information that is essential for making a treatment decision. After the third round, a live, online discussion was held in order to reach consensus on these items and to discuss the content and design of the leaflet. Consensus was defined as > 75% agreement among panel members.Results: Of the 36 patients invited, 78% (n = 28) participated in one or more rounds, 67% (n = 24) completed the first, 69% (n = 25) the second and 75% (n = 27) the third round. In the last round, median age of participants was 51 years (interquartile range, 18) and median disease duration 4 years (interquartile range, 5); 52% were female. Patients had been treated with mycophenolate mofetil (67%), methotrexate (44%), cyclophosphamide (41%), autologous stem cell transplantation (26%), rituximab (4%) or were treatment-naive (7%). Eight patients joined the live panel discussion. The panel reached consensus on seven benefits (prolonged progression-free survival, improved quality of life, improved daily functioning, improved pulmonary function, improved skin thickness, improved mobility and reduced fatigue) and four harms (treatment-related mortality, infections, cardiac damage, increased risk of cancer) as essential information for decision making. Also a design of a leaflet was made.Conclusion: This study identified information about treatment options in dcSSc that should be addressed with patients. Our results can be used to develop effective patient information. Show less
The diversity of students’ achievement levels within classrooms has made it essential forteachers to adapt their lessons to the varying educational needs of their students(‘differentiation’).... Show moreThe diversity of students’ achievement levels within classrooms has made it essential forteachers to adapt their lessons to the varying educational needs of their students(‘differentiation’). However, the term differentiation has been interpreted in diverse waysand there is a need to specify what effective differentiation entails. Previous reports oflow to moderate application of differentiation underscore the importance of practicalguidelines for implementing differentiation. In two studies, we investigated how teachersshould differentiate according to experts, as well as the degree to which teachers alreadyapply the recommended strategies. Study 1 employed the Delphi technique and focusgroup discussions to achieve consensus among eleven mathematics experts regarding afeasible model for differentiation in primary mathematics. The experts agreed on a fivestepcycle of differentiation: (1) identification of educational needs, (2) differentiatedgoals, (3) differentiated instruction, (4) differentiated practice, and (5) evaluation ofprogress and process. For each step, strategies were specified. In Study 2, theDifferentiation Self-Assessment Questionnaire (DSAQ) was developed to investigate howteachers self-assess their use of the strategies recommended by the experts. Whileteachers (N = 268) were moderately positive about their application of the strategiesoverall, we also identified areas of relatively low usage (including differentiation forhigh-achieving students) which require attention in teacher professional development.Together, these two studies provide a model and strategies for differentiation in primarymathematics based on expert consensus, the DSAQ which can be employed in futurestudies, and insights into teachers’ self-assessed application of specific aspects ofdifferentiation. Show less
Room for improvement is present in the treatment of migraine in primary care. However, inviting all patients who receive prescriptions for __2 triptans each month to have an evaluation consultation... Show moreRoom for improvement is present in the treatment of migraine in primary care. However, inviting all patients who receive prescriptions for __2 triptans each month to have an evaluation consultation with their general practitioner (GP), produces insufficient effect on headache outcomes and costs. However, it remains important to stay alert on patients who are candidate for preventive treatment. When discussing the possibility of preventive treatment, GPs should keep in mind possible barriers in patients. Also, GPs have to ask themselves if they do not deny patients a possibly effective treatment because of their own negative ideas towards preventive medication. Also, we learned that when designing pragmatic studies in primary care, there are methodological issues that make it harder to prove the effectiveness of an intervention. First, the outcomes of pragmatic studies in primary care can negatively affected by changes in the behaviour of GPs and patients in the control group. Second, the quality of life outcome measures that are often used in this type of research are harder to validate and to interpret than the more robust outcome measures that are used in clinical trials Show less
Velde, C.J.H. van de; Boelens, P.G.; Borras, J.M.; Coebergh, J.W.; Cervantes, A.; Blomqvist, L.; ... ; Valentini, V. 2014
