Francisca Galindo-Garre

Motivational profiles of medical students: Association with study effort, academic performance and exhaustion

BackgroundStudents enter the medical study with internally generated motives like genuine interest (intrinsic motivation) and/or externally generated motives like parental pressure or desire for status or prestige (controlled motivation). According to Self-determination theory (SDT), students could differ in their study effort, academic performance and adjustment to the study depending on the endorsement of intrinsic motivation versus controlled motivation. The objectives of this study were to generate motivational profiles of medical students using combinations of high or low intrinsic and controlled motivation and test whether different motivational profiles are associated with different study outcomes.MethodsParticipating students (N = 844) from University Medical Center Utrecht, the Netherlands, were classified to different subgroups through K-means cluster analysis using intrinsic and controlled motivation scores. Cluster membership was used as an independent variable to assess differences in study strategies, self-study hours, academic performance and exhaustion from study.ResultsFour clusters were obtained: High Intrinsic High Controlled (HIHC), Low Intrinsic High Controlled (LIHC), High Intrinsic Low Controlled (HILC), and Low Intrinsic Low Controlled (LILC). HIHC profile, including the students who are interest + status motivated, constituted 25.2% of the population (N = 213). HILC profile, including interest-motivated students, constituted 26.1% of the population (N = 220). LIHC profile, including status-motivated students, constituted 31.8% of the population (N = 268). LILC profile, including students who have a low-motivation and are neither interest nor status motivated, constituted 16.9% of the population (N = 143). Interest-motivated students (HILC) had significantly more deep study strategy (p < 0.001) and self-study hours (p < 0.05), higher GPAs (p < 0.001) and lower exhaustion (p < 0.001) than status-motivated (LIHC) and low-motivation (LILC) students.ConclusionsThe interest-motivated profile of medical students (HILC) is associated with good study hours, deep study strategy, good academic performance and low exhaustion from study. The interest + status motivated profile (HIHC) was also found to be associated with a good learning profile, except that students with this profile showed higher surface strategy. Low-motivation (LILC) and status-motivated profiles (LIHC) were associated with the least desirable learning behaviours.

From admission to death: prevalence and course of pain, agitation, and shortness of breath, and treatment of these symptoms in nursing home residents with dementia

OBJECTIVES Burdensome symptoms frequently develop as part of the dementia trajectory and influence quality of life. We explore the course of symptoms and their treatment during nursing home stay to help target adequate symptom management. DESIGN Data were collected as part of the Dutch End of Life in Dementia study, a longitudinal observational study with up to 3.5 years of follow-up. Physicians performed assessments at baseline, semiannually, and shortly after death of pain, agitation, shortness of breath, and treatment provided for these symptoms. SETTING Long-term care facilities (28) in the Netherlands. PARTICIPANTS Newly admitted nursing home residents (372) in variable stages of dementia. MEASUREMENTS We described prevalence and course of symptoms, and treatment provided for these symptoms. We used generalized estimating equations to evaluate the longitudinal change in symptoms and their treatment, and the associations between the symptoms of pain and agitation, as well as between stage of dementia and symptoms. RESULTS Pain was common (varying from 47% to 68% across the semiannual assessments) and frequently persistent (36%-41% of all residents); it increased to 78% in the last week of life. Agitation was the most common symptom (57%-71%), and also frequently persistent (39%-53%), yet it decreased to 35% in the last week of life. Shortness of breath was less common (16%-26%), but it increased to 52% at the end of life. Pain was not significantly associated with agitation. Advanced dementia was associated with more pain only. Treatment changed in particular at the end of life. Pain was treated mostly with acetaminophen (34%-52%), and at the end of life with parenteral opioids (44%). Agitation was mostly treated nonpharmacologically (78%-92%), and at the end of life anxiolytics were the most frequently prescribed treatment (62%). Overall, aerosolized bronchodilators were the most frequently prescribed treatment for shortness of breath (29%-67%), but at the end of life, this was morphine (69%). CONCLUSION Pain and agitation were common and frequently persisted in residents with dementia during nursing home stay, but symptom management intensified only at the end of life. Symptom control may be suboptimal from admission, and a stronger focus on symptom control is needed at an earlier stage than the end of life.

The identification of cognitive subtypes in Alzheimer's disease dementia using latent class analysis

Objective Alzheimers disease (AD) is a heterogeneous disorder with complex underlying neuropathology that is still not completely understood. For better understanding of this heterogeneity, we aimed to identify cognitive subtypes using latent class analysis (LCA) in a large sample of patients with AD dementia. In addition, we explored the relationship between the identified cognitive subtypes, and their demographical and neurobiological characteristics. Methods We performed LCA based on neuropsychological test results of 938 consecutive probable patients with AD dementia using Mini-Mental State Examination as the covariate. Subsequently, we performed multinomial logistic regression analysis with cluster membership as dependent variable and dichotomised demographics, APOE genotype, cerebrospinal fluid biomarkers and MRI characteristics as independent variables. Results LCA revealed eight clusters characterised by distinct cognitive profile and disease severity. Memory-impaired clusters—mild-memory (MILD-MEM) and moderate-memory (MOD-MEM)—included 43% of patients. Memory-spared clusters mild-visuospatial-language (MILD-VILA), mild-executive (MILD-EXE) and moderate-visuospatial (MOD-VISP) —included 29% of patients. Memory-indifferent clusters mild-diffuse (MILD-DIFF), moderate-language (MOD-LAN) and severe-diffuse (SEV-DIFF) —included 28% of patients. Cognitive clusters were associated with distinct demographical and neurobiological characteristics. In particular, the memory-spared MOD-VISP cluster was associated with younger age, APOE e4 negative genotype and prominent atrophy of the posterior cortex. Conclusions Using LCA, we identified eight distinct cognitive subtypes in a large sample of patients with AD dementia. Cognitive clusters were associated with distinct demographical and neurobiological characteristics.

Explaining Socioeconomic Inequalities in Childhood Blood Pressure and Prehypertension: The ABCD Study

Much remains to be understood about the socioeconomic inequalities in hypertension that continue to exist. We investigated the association of socioeconomic status with blood pressure and prehypertension in childhood. In a prospective cohort, 3024 five- to six-year–old children had blood pressure measurements and available information on potential explanatory factors, namely birth weight, gestational age, smoking during pregnancy, pregnancy-induced hypertension, familial hypertension, maternal body mass index, breastfeeding duration, domestic tobacco exposure, and body mass index. The systolic and diastolic blood pressures of children from mid-educated women were 1.0-mm Hg higher (95% CI, 0.4–1.7) and 0.9-mm Hg higher (95% CI, 0.3–1.4), and the blood pressures of children with low-educated women were 2.2-mm Hg higher (95% CI, 1.4–3.0) and 1.7-mm Hg higher (95% CI, 1.1–2.4) compared with children with high-educated women. Children with mid- (odds ratio, 1.50; 95% CI, 1.18–1.92) or low-educated mothers (odds ratio, 1.80; 95% CI, 1.35–2.42) were more likely to have prehypertension compared with children with high-educated mothers. Using path analyses, birth weight, breastfeeding duration, and body mass index were determined as having a role in the association of maternal education with offspring blood pressure and prehypertension. The socioeconomic gradient in hypertension appears to emerge from childhood as the results show a higher blood pressure and more prehypertension in children from lower socioeconomic status families. Socioeconomic disparities could be reduced by improving 3 factors in particular, namely birth weight, breastfeeding duration, and body mass index, but other factors might also play a role.

Smoking overrules many other risk factors for small for gestational age birth in less educated mothers.

BACKGROUND Although there is convincing evidence for the association between small for gestational age (SGA) and socioeconomic status (SES), it is not known to what extent explanatory factors contribute to this association. AIM To examine to what extent risk factors could explain educational inequalities in SGA. STUDY DESIGN In this study fully completed data were available for 3793 pregnant women of Dutch origin from a population-based cohort (ABCD study). Path-analysis was conducted to examine the role of explanatory factors in the relation of maternal education to SGA. RESULTS Low-educated pregnant women had a higher risk of SGA offspring compared to the high-educated women (OR 1.98, 95% CI 1.35-2.89). In path-analysis, maternal cigarette smoking and maternal height explained this association. Maternal age, hypertension, chronic disease, late entry into antenatal care, neighborhood income, underweight, environmental cigarette smoking, drug abuse, alcohol use, caffeine intake, fish intake, folic acid intake, anxiety, and depressive symptoms did not play a role in the association between maternal education and SGA birth. CONCLUSION Among a large array of potential factors, the elevated risk of SGA birth among low-educated women appeared largely attributable to maternal smoking and to a lesser extent to maternal height. To reduce educational inequalities more effort is required to include low-educated women especially in prenatal intervention programs such as smoking cessation programs instead of effort into reducing other SGA-risk factors, though these factors might still be relevant at the individual level.

Modeling the World Health Organization Disability Assessment Schedule II using non-parametric item response models

The World Health Organization Disability Assessment Schedule II (WHO‐DAS II) is a multidimensional instrument developed for measuring disability. It comprises six domains (getting around, self‐care, getting along with others, life activities and participation in society). The main purpose of this paper is the evaluation of the psychometric properties for each domain of the WHO‐DAS II with parametric and non‐parametric Item Response Theory (IRT) models. A secondary objective is to assess whether the WHO‐DAS II items within each domain form a hierarchy of invariantly ordered severity indicators of disability.

Pneumonia, Intake Problems, and Survival Among Nursing Home Residents With Variable Stages of Dementia in the Netherlands: Results From a Prospective Observational Study.

Objectives: We explored how pneumonia and intake problems affect survival in nursing home residents in variable stages of dementia. Methods: In a longitudinal observational study (372 residents) with up to 3.5 years of follow-up, we examined relationships between dementia severity, the development of pneumonia, intake problems, and mortality using joint modeling, Cox models, and mediation analyses. Dementia severity was measured semiannually with the Bedford Alzheimer Nursing Severity-Scale (BANS-S). Results: The median BANS-S score at baseline was 13 (range, 7 to 28). Pneumonia occurred in 103 (28%) and intake problems in 126 (34%) of 367 residents with complete registration of pneumonia and intake problems. Compared with dementia severity, incident pneumonia and, even more so, incident intake problems were more strongly associated with mortality risk. Pneumonia and intake problems both mediated the relationship between more severe dementia and mortality. Discussion: Developing pneumonia and intake problems affects survival, and this is not limited to advanced dementia. The occurrence of pneumonia and intake problems are important signals to consider a palliative care approach in nursing home residents with dementia, and an active focus on advance care planning is needed. Future studies should investigate whether this is also relevant for patients in primary care.

The Bedford Alzheimer nursing-severity scale to assess dementia severity in advanced dementia: a nonparametric item response analysis and a study of its psychometric characteristics.

The Bedford Alzheimer Nursing-Severity Scale (BANS-S) assesses disease severity in patients with advanced Alzheimers disease. Since Alzheimer is a progressive disease, studying the hierarchy of the items in the scale can be useful to evaluate the progression of the disease. Data from 164 Alzheimers patients and 186 patients with other dementia were analyzed using the Mokken Scaling Methodology to determine whether respondents can be ordered in the trait dementia severity, and to study whether an ordering between the items exist. The scalability of the scale was evaluated by the H coefficient. Results showed that the BANS-S is a reliable and medium scale (0.4≤H<0.5) for the Alzheimer group. All items with the exception of the item about mobility could be ordered. When later item was eliminated from the scale, the H coefficient decreased indicating that the scalability of the scale in the original form is more accurate than in the shorter version. For the other dementia group, the BANS-S did not fit any of the Mokken Scaling models because the scale was not unidimensional. In this group, a shorter version of the scale without the sleeping cycle item and the mobility item has better reliability and scalability properties than the original scale.

Factors Related to Rejection of Care and Behaviors Directed towards Others: A Longitudinal Study in Nursing Home Residents with Dementia

Aims: The aim of this study was to analyze factors related to rejection of care and behaviors directed towards others in nursing home residents with dementia. Methods: The relationship of lack of understanding, depression, psychosis and pain with rejection of care and behaviors directed towards others was explored using four assessments from the Minimum Data Set (MDS) within a period of 15 months on 1,101 residents with dementia in Dutch nursing homes. Presence of depressive symptoms was ascertained using a validated MDS scale, and presence of lack of understanding, rejection of care, psychosis and pain through the individual MDS items. A structural equation modeling approach and latent growth models were used to investigate the longitudinal relationship between changes in rejection of care and physical or verbal behaviors directed towards others, and changes in lack of understanding, pain, depression and psychotic symptoms. Results: Changes in lack of understanding predicted changes in rejection of care, and there was also a relationship between changes in depression and rejection of care. Changes of behaviors directed towards others were related to changes in lack of understanding and depression. Pain and behaviors directed towards others were unrelated, and psychosis was rather stable throughout. A mediation model suggested that the relationship of lack of understanding with behaviors directed towards others was mediated by rejection of care. Conclusion: These results indicate that lack of understanding and depression are important factors in development of rejection of care and behaviors directed towards others. The relationship between lack of understanding and behaviors directed towards others is mediated by rejection of care. Improvement in communication between residents and caregivers, and perhaps also effective treatment of depression may prevent or ameliorate these behaviors directed towards others.

Explaining Socioeconomic Inequalities in Childhood Blood Pressure and Prehypertension

Much remains to be understood about the socioeconomic inequalities in hypertension that continue to exist. We investigated the association of socioeconomic status with blood pressure and prehypertension in childhood. In a prospective cohort, 3024 five- to six-year–old children had blood pressure measurements and available information on potential explanatory factors, namely birth weight, gestational age, smoking during pregnancy, pregnancy-induced hypertension, familial hypertension, maternal body mass index, breastfeeding duration, domestic tobacco exposure, and body mass index. The systolic and diastolic blood pressures of children from mid-educated women were 1.0-mm Hg higher (95% CI, 0.4–1.7) and 0.9-mm Hg higher (95% CI, 0.3–1.4), and the blood pressures of children with low-educated women were 2.2-mm Hg higher (95% CI, 1.4–3.0) and 1.7-mm Hg higher (95% CI, 1.1–2.4) compared with children with high-educated women. Children with mid- (odds ratio, 1.50; 95% CI, 1.18–1.92) or low-educated mothers (odds ratio, 1.80; 95% CI, 1.35–2.42) were more likely to have prehypertension compared with children with high-educated mothers. Using path analyses, birth weight, breastfeeding duration, and body mass index were determined as having a role in the association of maternal education with offspring blood pressure and prehypertension. The socioeconomic gradient in hypertension appears to emerge from childhood as the results show a higher blood pressure and more prehypertension in children from lower socioeconomic status families. Socioeconomic disparities could be reduced by improving 3 factors in particular, namely birth weight, breastfeeding duration, and body mass index, but other factors might also play a role.