RESUMEN
AIM: To evaluate the effectiveness of motivational interviewing (MI) performed by MI-trained podiatrists in improving adherence to wearing orthopedic shoes in comparison to usual care in people with diabetes at low-to-high risk of ulceration. METHODS: People with diabetes with loss of protective sensation and/or peripheral artery disease, and with orthopedic shoes prescription were allocated to receive one MI-consultation by a podiatrist randomized to MI training (n = 53) or usual care only (n = 68). Adherence was measured as the percentage of steps taken while wearing orthopedic shoes, determined using an insole temperature microsensor and wrist-worn activity tracker during one week at 3 and 6 months. RESULTS: The proportion of participants ≥80 % adherent to wearing their orthopedic shoes was higher in the control group than in the MI-intervention group at 3 months (30.9 % versus 15.1 %; p = 0.044), and not significantly different at 6 months (22.1 % versus 13.2 %; p = 0.210). Average adherence was also higher in the control group than the intervention group at both 3 months (60.9 % versus 50.9 %; p = 0.029) and 6 months (59.9 % versus 49.5 %; p = 0.025). CONCLUSIONS: One podiatrist-led MI-consultation in its current form did not result in higher adherence to wearing orthopedic shoes in people with diabetes 3 and 6 months after inclusion. TRIAL REGISTRATION: Netherlands Trial Register NL7710 (available on the International Clinical Trials Registry Platform).
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Diabetes Mellitus , Úlcera del Pie , Entrevista Motivacional , Enfermedades Vasculares Periféricas , Humanos , Zapatos , Diabetes Mellitus/terapiaRESUMEN
Polyunsaturated fatty acids (PUFAs) have important electrochemical properties and have been implicated in the pathophysiology of major depressive disorder (MDD) and its treatment. However, the relation of PUFAs with electroconvulsive therapy (ECT) has never been investigated. Therefore, we aimed to explore the associations between PUFA concentrations and response to ECT in patients with MDD. We included 45 patients with unipolar MDD in a multicentre study. To determine PUFA concentrations, we collected blood samples at the first (T0) and twelfth (T12) ECT-session. We assessed depression severity using the Hamilton Rating Scale for Depression (HAM-D) at T0, T12 and at the end of the ECT-course. ECT-response was defined as 'early response' (at T12), 'late response' (after ECT-course) and 'no' response (after the ECT-course). The PUFA chain length index (CLI), unsaturation index (UI) and peroxidation index (PI) and three individual PUFAs (eicosapentaenoic acid [EPA], docosahexaenoic acid [DHA] and nervonic acid [NA]) were associated with response to ECT using linear mixed models. Results showed a significant higher CLI in 'late responders' compared to 'non responders'. For NA, 'late responders' showed significantly higher concentrations compared to 'early'- and 'non responders'. In conclusion, this study provides the first indication that PUFAs are associated with the efficacy of ECT. This indicates that PUFAs' influence on neuronal electrochemical properties and neurogenesis may affect ECT outcomes. Thereby, PUFAs form a potentially modifiable factor predicting ECT outcomes, that warrants further investigation in other ECT-cohorts.
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Trastorno Depresivo Mayor , Terapia Electroconvulsiva , Humanos , Terapia Electroconvulsiva/métodos , Ácido Eicosapentaenoico , Ácidos DocosahexaenoicosRESUMEN
BACKGROUND: Podiatrists are key professionals in promoting adequate foot self-care for people with diabetes at high-risk of developing foot ulcers. However, merely informing patients about the advantages of foot self-care is insufficient to realise behavioural change. Motivational interviewing (MI) is a promising person-centred communication style that could help to create a working alliance between healthcare providers and patient to improve foot self-care. This study aims to observe and analyse the application of MI in consultations carried out by MI-trained and non-MI-trained podiatrists with their patients, and explore podiatrists' attitudes and experiences towards MI. METHODS: Eighteen podiatrists (median age: 28.5 years, 10 female and 8 male) followed a three-day basic training in MI and 4 podiatrists (median age: 38.5 years, 4 female) were not trained in MI. To observe and rate the MI-fidelity in daily clinical practice, audio recordings from the MI-trained and non-MI-trained podiatrists were scored with the Motivational Interviewing Treatment Integrity code. Individual, semi-structed, in-depth interviews were conducted with the MI-trained podiatrists to explore their attitudes towards and experiences with MI. These data sources were triangulated to describe the effect of training podiatrists in MI for their clinical practice. RESULTS: The MI-trained podiatrists scored significantly higher than the non-MI-trained podiatrists on two of four global MI-related communication skills (empathy, p = 0.008 and change talk, p = 0.008), on one of five core MI-adherent behaviours (affirmation, p = 0.041) and on one of the other behaviour counts (simple reflections, p = 0.008). The podiatrists mainly reported their attitudes and experiences regarding partnership and cultivating change talk, during the interviews. In addition, they also mentioned facilitators and barriers to using MI and indicated whether they experienced MI as having added value. CONCLUSIONS: The MI-trained podiatrists used the principles of MI at a solid beginner proficiency level in their clinical practice in comparison to the non-MI-trained podiatrists, who did not reach this level. This achievement is in accordance with the basic MI-training they received. This multi-method study reveals that podiatrists can be effectively trained in applying MI in daily clinical practice. TRIAL REGISTRATION: Netherlands Trial Register NL7710. Registered: 6 May 2019.
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Diabetes Mellitus , Pie Diabético , Entrevista Motivacional , Adulto , Técnicos Medios en Salud , Comunicación , Pie Diabético/prevención & control , Femenino , Humanos , Masculino , Entrevista Motivacional/métodos , Derivación y ConsultaRESUMEN
BACKGROUND: Diabetic foot ulcers have a high impact on mobility and daily functioning and lead to high treatment costs, for example, by hospitalization and amputation. To prevent (re)ulcerations, custom-made orthopedic shoes are considered essential. However, adherence to wearing the orthopedic shoes is low, and improving adherence was not successful in the past. We propose a novel care approach that combines motivational interviewing (MI) with a digital shoe-fitting procedure to improve adherence to orthopedic shoes. The aim of this trial is to assess the (cost-)effectiveness of this novel care approach compared to usual care (no MI and casting-based shoe-fitting) in promoting footwear adherence and ulcer prevention. METHODS: The trial will include people with diabetes, with IWGDF Risk categories 1-3, who have been prescribed orthopedic shoes. Participants will be randomized at the level of the podiatrist to the novel care approach or usual care. The primary outcome is the proportion of participants who adhere to the use of their orthopedic shoes, that is, who take at least 80% of their total daily steps with orthopedic shoes. A temperature microsensor will be built into the participants' orthopedic shoes to measure wearing time continuously over 12 months. In addition, daily activity will be measured periodically using log data with an activity monitor. Data from the temperature microsensor and activity monitor will be combined to calculate adherence. (Re-)experienced complications after receiving orthopedic shoes will be registered. Questionnaires and interviews will measure the experiences of participants regarding orthopedic shoes, experiences of podiatrists regarding motivational interviewing, care consumption, and quality of life. Differences in costs and quality of life will be determined in a cost-effectiveness analysis. DISCUSSION: This trial will generate novel insights into the socio-economic and well-being impact and the clinical effectiveness of the novel care approach on adherence to wearing orthopedic shoes. TRIAL REGISTRATION: Netherlands Trial Register NL7710 . Registered on 6 May 2019.
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Diabetes Mellitus , Pie Diabético , Entrevista Motivacional , Actividades Cotidianas , Pie Diabético/diagnóstico , Pie Diabético/prevención & control , Humanos , Calidad de Vida , Ensayos Clínicos Controlados Aleatorios como Asunto , ZapatosRESUMEN
OBJECTIVE: To determine, by expert consensus, the essential substeps of fetoscopic laser surgery (FLS) for twin-twin transfusion syndrome (TTTS) that could be used to create an authority-based curriculum for training in this procedure among fetal medicine specialists. METHODS: A Delphi survey was conducted among an international panel of experts (n = 98) in FLS. Experts rated the substeps of FLS on a five-point Likert-type scale to indicate whether they considered them to be essential, and were able to comment on each substep, using a dedicated online platform accessed by the invited tertiary care facilities that specialize in fetal therapy. Responses were returned to the panel until consensus was reached (Cronbach's α ≥ 0.80). All substeps that were rated ≥ 4 by 80% of the experts were included in the evaluation instrument. RESULTS: After the first iteration of the Delphi procedure, a response rate of 74% (73/98) was reached, and in the second and third iterations response rates of 90% (66/73) and 81% (59/73) were reached, respectively. Among a total of 81 substeps rated in the first round, 21 substeps had to be re-rated in the second round. Finally, from the initial list of substeps, 55 were agreed by experts to be essential. In the third round, the 18 categorized substeps were ranked in order of importance, with 'coagulation of all anastomoses that cross the equator' and 'determination of fetoscope insertion site' as the most important. CONCLUSIONS: A total of 55 substeps of FLS for TTTS were defined by a panel of experts to be essential in the procedure. This list is the first authority-based evidence to be used in the development of a final training model for future fetal surgeons.
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Técnica Delphi , Transfusión Feto-Fetal/cirugía , Fetoscopía/métodos , Terapia por Láser/métodos , Simulación por Computador , Consenso , Femenino , Fetoscopía/educación , Humanos , Embarazo , Encuestas y Cuestionarios , Centros de Atención TerciariaRESUMEN
OBJECTIVE: A dysbalance of proteases and their inhibitors is instrumental in remodeling of atherosclerotic plaques. One of the proteases implicated in matrix degradation is cathepsin-S (CatS). To address its role in advanced lesion composition, we generated chimeric LDLr(-/-) mice deficient in leukocyte CatS by transplantation with CatS(-/-)xLDLr(-/-) or with LDLr(-/-) bone marrow and administered a high-fat diet. METHODS AND RESULTS: No difference in aortic root lesion size could be detected between CatS(+/+) and CatS(-/-) chimeras. However, leukocyte CatS deficiency markedly changed plaque morphology and led to a dramatic reduction in necrotic core area by 77% and an abundance of large foam cells. Plaques of CatS(-/-) chimeras contained 17% more macrophages, 62% less SMCs, and 33% less intimal collagen. The latter two could be explained by a reduced number of elastic lamina fractures. Moreover, macrophage apoptosis was reduced by 60% with CatS deficiency. In vitro, CatS was found to be involved in cholesterol metabolism and in macrophage apoptosis in a collagen and fibronectin matrix. CONCLUSIONS: Leukocyte CatS deficiency results in considerably altered plaque morphology, with smaller necrotic cores, reduced apoptosis, and decreased SMC content and collagen deposition and may thus be critical in plaque stability.
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Aorta/enzimología , Aterosclerosis/enzimología , Catepsinas/metabolismo , Matriz Extracelular/metabolismo , Leucocitos/enzimología , Animales , Aorta/inmunología , Aorta/patología , Apoptosis , Aterosclerosis/etiología , Aterosclerosis/inmunología , Aterosclerosis/patología , Trasplante de Médula Ósea , Catepsinas/antagonistas & inhibidores , Catepsinas/deficiencia , Catepsinas/genética , Movimiento Celular , Proliferación Celular , Células Cultivadas , Colesterol/metabolismo , Colágeno/metabolismo , Dieta Aterogénica , Modelos Animales de Enfermedad , Tejido Elástico/metabolismo , Femenino , Células Espumosas/enzimología , Leucocitos/efectos de los fármacos , Leucocitos/inmunología , Macrófagos Peritoneales/enzimología , Ratones , Ratones Noqueados , Miocitos del Músculo Liso/metabolismo , Necrosis , Inhibidores de Proteasas/farmacología , Receptores de LDL/deficiencia , Receptores de LDL/genética , Quimera por TrasplanteRESUMEN
2 infants, a boy aged 8 weeks and a girl aged 5 months, presented with symptoms of fat-soluble vitamin deficiencies. The first infant had frequently voluminous bowel movements, anaemia and was not thriving; he had anaemia due to vitamin-E deficiency. The second infant had multiple haematomas on the trunk and legs due to a vitamin-K deficiency-related clotting disorder. The sweat test was positive in both cases, confirming the diagnosis of cystic fibrosis. The infants were treated with supplementary pancreatic enzymes and fat-soluble vitamins A, D, E and K. Cystic fibrosis rarely presents with symptoms of fat-soluble vitamin deficiency. However, in cases of unexplained haemolytic anaemia or haemorrhagic disorder due to vitamin E or K deficiencies, respectively, cystic fibrosis should be considered as a possible cause.
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Fibrosis Quística/diagnóstico , Deficiencia de Vitamina E/complicaciones , Deficiencia de Vitamina K/complicaciones , Vitaminas/uso terapéutico , Anemia Hemolítica/etiología , Trastornos de la Coagulación Sanguínea/etiología , Fibrosis Quística/tratamiento farmacológico , Fibrosis Quística/etiología , Femenino , Humanos , Lactante , Masculino , Deficiencia de Vitamina E/tratamiento farmacológico , Deficiencia de Vitamina K/tratamiento farmacológicoRESUMEN
A 6-month-old girl had been ill with a cold for several days and was increasingly drowsy. She had been fully vaccinated against Haemophilus influenzae type b and had meningitis due to H. influenzae type a. She made a complete recovery after treatment with ceftriaxone and amoxicillin. In the Netherlands, vaccination with the conjugated H. influenzae type b vaccine was started in 1993 and since then invasive infections caused by H. influenzae type b have almost disappeared. Vaccination may suppress carriership of H. influenzae type b. However, vaccination does not elicit cross-protective antibodies against other serotypes of H. influenzae. H. influenzae non-type b may profit from the vaccination state, resulting in a higher carrier rate and an increased incidence of invasive infections. In the Netherlands, H. influenzae type a as the causative agent of an invasive infection has been recorded for the first time since registration started in 1975 and since then five such cases have been reported. In the literature, 45 cases of infection with H. influenzae type a have been described up until now.
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Haemophilus influenzae/patogenicidad , Meningitis por Haemophilus/microbiología , Amoxicilina/uso terapéutico , Antibacterianos/uso terapéutico , Ceftriaxona/uso terapéutico , Femenino , Vacunas contra Haemophilus/inmunología , Haemophilus influenzae/clasificación , Haemophilus influenzae/inmunología , Haemophilus influenzae tipo b/inmunología , Humanos , Lactante , Meningitis por Haemophilus/tratamiento farmacológico , Meningitis por Haemophilus/prevención & control , Países BajosRESUMEN
UNLABELLED: Perinatal exposure to Dutch background dioxin levels is rather high. Studies of calamities have shown that dioxins negatively influence the respiratory system. It was hypothesized that perinatal exposure to background dioxin levels leads to lung suboptimality, probably through developmental interference. This study aimed to assess lung function in relation to perinatal dioxin exposure. Spirometry was performed in 41 healthy children (aged 7-12 y. mean 8.2 y) with known perinatal dioxin exposure. The ratio of forced expiratory volume in I s to forced vital capacity (FEV1/FVC ratio) was determined. A complete medical history was taken. The prenatal exposure ranged from 8.74 to 88.8 (mean 34.6) ng TEQ dioxin kg fat(-1), measured in breast milk. The postnatal exposure ranged from 4.34 to 384.51 (mean 75.4) ng TEQ dioxin. Twelve children had to be excluded. A significant decrease in lung function in relation to both prenatal (p = 0.045) and postnatal (p = 0.0002) dioxin exposure was seen in the 29 non-excluded children. A clinical association between chest congestion and perinatal dioxin exposure was seen. CONCLUSION: Perinatal background dioxin exposure may be inversely associated with the FEV1/ FVC ratio.