Objective To explore what information sources medical specialists currently use to inform their medical decision-making.Design Qualitative, semistructured interviews.Setting and participants A... Show moreObjective To explore what information sources medical specialists currently use to inform their medical decision-making.Design Qualitative, semistructured interviews.Setting and participants A total of 20 semistructured interviews were conducted with 10 surgeons and 10 internal medicine specialists who work in academic and/or regional hospitals in the Netherlands.Results Medical specialists reported that they primarily rely on their general knowledge and experience, rather than actively using information sources. The sources they use to update their knowledge can be categorised into 'scientific publications', 'guidelines or protocols', and 'presentations and meetings'. When medical specialists feel their general knowledge and experience are insufficient, they use three different approaches to find answers in response to clinical questions: consulting a colleague, actively searching the literature and asking someone else to search the literature.Conclusion Medical specialists use information sources to update their general knowledge and to find answers to specific clinical questions when they feel their general knowledge and experience are insufficient. An important finding is that medical specialists prefer accessible information sources (eg, consulting colleagues) over existing evidence-based medicine tools. Show less
BACKGROUND: Current approaches for pathogen identification in community-acquired pneumonia (CAP) remain suboptimal, leaving most patients without a microbiological diagnosis. If better diagnostic... Show moreBACKGROUND: Current approaches for pathogen identification in community-acquired pneumonia (CAP) remain suboptimal, leaving most patients without a microbiological diagnosis. If better diagnostic tools were available for differentiating between viral and bacterial CAP. unnecessary antibacterial therapy could be avoided in viral CAP patients. METHODS: In 156 adults hospitalized with CAP classified to have bacterial. viral, or mixed viral-bacterial infection based on microbiological testing or both microbiological testing and procalcitonin (PCT) levels, we aimed to identify discriminatory host transcriptional signatures in peripheral blood samples acquired at hospital admission, by applying Dual-color-Reverse-Transcriptase-Multiplex-Ligation-dependent-Probe-Amplification (dc-RT MLPA). RESULTS: In patients classified by microbiological testing, a 9-transcript signature showed high accuracy for discriminating bacterial from viral CAP (AUC 0.91. 95% CI 0.85-0.96). while a 10-transcript signature similarly discriminated mixed viral-bacterial from viral CAP (AUC 0.91, 95% CI 0.86-0.96). In patients classified by both microbiological testing and PCT levels, a 13-transcript signature showed excellent accuracy for discriminating bacterial from viral CAP (AUC 1.00, 95% CI 1.00-1.00), while a 7-transcript signature similarly discriminated mixed viral-bacterial from viral CAP (AUC 0.93, 95% CI 0.87-0.98). CONCLUSION: Our findings support host transcriptional signatures in peripheral blood samples as a potential tool for guiding clinical decision-making and antibiotic stewardship in CAP. Show less
Liver function is measured regularly in liver transplantation (LT) candidates. Currently, these previous disease development data are not used for survival prediction. By constructing and... Show moreLiver function is measured regularly in liver transplantation (LT) candidates. Currently, these previous disease development data are not used for survival prediction. By constructing and validating joint models (JMs), we aimed to predict the outcome based on all available data, using both disease severity and its rate of change over time. Adult LT candidates listed in Eurotransplant between 2007 and 2018 (n = 16 283) and UNOS between 2016 and 2019 (n = 30 533) were included. Patients with acute liver failure, exception points, or priority status were excluded. Longitudinal MELD(-Na) data were modeled using spline-based mixed effects. Waiting list survival was modeled with Cox proportional hazards models. The JMs combined the longitudinal and survival analysis. JM 90-day mortality prediction performance was compared to MELD(-Na) in the validation cohorts. MELD(-Na) score and its rate of change over time significantly influenced patient survival. The JMs significantly outperformed the MELD(-Na) score at baseline and during follow-up. At baseline, MELD-JM AUC and MELD AUC were 0.94 (0.92-0.95) and 0.87 (0.85-0.89), respectively. MELDNa-JM AUC was 0.91 (0.89-0.93) and MELD-Na AUC was 0.84 (0.81-0.87). The JMs were significantly (p < .001) more accurate than MELD(-Na). After 90 days, we ranked patients for LT based on their MELD-Na and MELDNa-JM survival rates, showing that MELDNa-JM-prioritized patients had three times higher waiting list mortality. Show less
Objective:Oppositional defiant disorder (ODD) consists of irritable and oppositional behaviors, both of which are associated with different problems. However, it is unclear whether irritability and... Show moreObjective:Oppositional defiant disorder (ODD) consists of irritable and oppositional behaviors, both of which are associated with different problems. However, it is unclear whether irritability and oppositionality enable classification of clinic-referred children and adolescents into mutually exclusive groups (e.g., high in oppositionality, low in irritability), and whether this classification is clinically meaningful.Method:As part of a clinical protocol, ODD behaviors were assessed at referral through a comprehensive diagnostic interview and questionnaire. Parent- and teacher-reported ODD of 2,185 clinic-referred 5- to 18-year-olds (36.9% females) were used in latent class analysis. Resulting ODD classes were compared, concurrently at referral, and, longitudinally at the end of the diagnostic and treatment process, on various clinically relevant measures that were completed by various informants, including mental health problems, global functioning, and Diagnostic and Statistical Manual of Mental Disorders (DSM) classifications.Results:Three classes emerged with high, moderate, and low levels of both irritability and oppositionality. At referral, the high class experienced the highest levels of mental health problems and DSM classifications. Importantly, all ODD classes defined at intake were predictive of diagnostic and treatment outcomes months later. Notably, the high class had higher rates of clinician-based classifications of ODD and conduct disorder, and the lowest levels of pre- and posttreatment global functioning. Additionally, the low class exhibited higher rates of generalized anxiety disorder and fear disorders.Conclusions:Irritability and oppositionality co-occur in clinic-referred youths to such an extent that classification based on these behaviors does not add to clinical inference. Instead, findings suggest that the overall ODD severity at referral should be used as a guidance for treatment. Show less
Meziyerh, S.; Zwart, T.C.; Etten, R.W. van; Janson, J.A.; Gelder, T. van; Alwayn, I.P.J.; ... ; Vries, A.P.J. de 2020
The current coronavirus disease 2019 (COVID-19) pandemic requires extra attention for immunocompromised patients, including solid organ transplant recipients. We report on a case of a 35-year-old... Show moreThe current coronavirus disease 2019 (COVID-19) pandemic requires extra attention for immunocompromised patients, including solid organ transplant recipients. We report on a case of a 35-year-old renal transplant recipient who suffered from a severe COVID-19 pneumonia. The clinical course was complicated by extreme overexposure to the mammalian target of rapamycin inhibitor everolimus, following coadministration of chloroquine and lopinavir/ritonavir therapy. The case is illustrative for dilemmas that transplant professionals may face in the absence of evidence-based COVID-19 therapy and concurrent pressure for exploration of experimental pharmacological treatment options. However, the risk-benefit balance of experimental or off-label therapy may be weighed differently in organ transplant recipients than in otherwise healthy COVID-19 patients, owing to their immunocompromised status and potential drug interactions with immunosuppressive therapy. With this case report, we aimed to achieve increased awareness and improved management of drug-drug interactions associated with the various treatment options for COVID-19 in renal transplant patients. Show less
Kranenburg, F.J.; Cessie, S. le; Caram-Deelder, C.; Bom, J.G. van der; Arbous, M.S. 2019
Background and ObjectivesThe aim of this study was to assess potentially relevant clinical characteristics which influence the decision to transfuse red cells in critically ill patients with low... Show moreBackground and ObjectivesThe aim of this study was to assess potentially relevant clinical characteristics which influence the decision to transfuse red cells in critically ill patients with low haemoglobin concentrations (6.0–10.0 g/dl).Materials and MethodsThis was a retrospective observational cohort study of patients admitted between November 2004 and May 2016 at the intensive care unit (ICU) of the Leiden University Medical Center, Netherlands. Haemoglobin measurements, clinical variables and the subsequent transfusion decision were extracted from the electronic health records. Clinical variables were grouped by organ system. We first examined the association of each of the clinical variables with the decision to transfuse during the following 6 h after a haemoglobin measurement using generalized estimating equations. We then compared the predictive abilities of single variables within an organ system and the predictive ability of an organ system’s combined variables using the change in Akaike information criterion (AIC).ResultsA total of 83 394 haemoglobin measurements of 10 947 ICU admissions were included. Haemoglobin concentration was the most predictive for red cell transfusion. After the haemoglobin concentration, the combined variables for General Health, followed by the organ systems Cardiovascular and Pulmonary, were most predictive for red cell transfusion. Within these organ systems, the APACHE II score, referring department, APACHE admission diagnosis subgroup, troponin concentration, lactate concentration, respiratory rate, PaO2/FiO2 and ventilation mode had the highest predictive ability.ConclusionHaemoglobin concentration is the dominant predictor for red cell transfusion. Other clinical characteristics are also predictive, though to a lesser extent. Show less
Rodenburg-Vandenbussche, S.; Carlier, I.; Hemert, I. van; Hemert, A. van; Stiggelbout, A.; Zitman, F. 2019
Rationale, aims, and objectives People worldwide are affected by psychiatric disorders that lack a "best" treatment option. The role of shared decision-making (SDM) in psychiatric care seems... Show moreRationale, aims, and objectives People worldwide are affected by psychiatric disorders that lack a "best" treatment option. The role of shared decision-making (SDM) in psychiatric care seems evident, yet remains limited. Research on SDM in specialized mental health is scarce, concentrating on patients with depressive disorder or psychiatric disorders in general and less on patients with anxiety and obsessive-compulsive disorder (OCD). Furthermore, recent research concentrates on the evaluation of interventions to promote and measure SDM rather than on the feasibility of SDM in routine practice. This study investigated patients' and clinicians' perspectives on SDM to treat depression, anxiety disorders, and OCD as to better understand SDM in specialized psychiatric care and its challenges in clinical practice. Methods Transcripts of eight focus groups with 17 outpatients and 33 clinicians were coded, and SDM-related codes were analysed using thematic analyses. Results Motivators, responsibilities, and preconditions regarding SDM were defined. Patients thought SDM should be common practice given the autonomy they have over their own bodies and felt responsible for their treatments. Clinicians value SDM for obtaining patients' consent, promoting treatment adherence, and establishing a good patient-clinician relationship. Patients and clinicians thought clinicians assumed the most responsibility regarding the initiation and achievement of SDM in clinical practice. According to clinicians, preconditions were often not met, were influenced by illness severity, and formed important barriers (eg, patient's decision-making capacity, treatment availability, and clinicians' preferences), leading to paternalistic decision-making. Patients recognized these difficulties, but felt none of these preclude the implementation of SDM. Personalized information and more consultation time could facilitate SDM. Conclusions Patients and clinicians in specialized psychiatric care value SDM, but adapting it to daily practice remains challenging. Clinicians are vital to the implementation of SDM and should become versed in how to involve patients in the decision-making process, even when this is difficult. Show less
Ploeg, M.A. van der; Streit, S.; Achterberg, W.P.; Beers, E.; Bohnen, A.M.; Burman, R.A.; ... ; Poortvliet, R.K.E. 2019
