Adherence to fluid restrictions and dietary and medication guidelines as well as attendance at prescribed hemodialysis sessions of a hemodialysis regimen are essential for adequate management of end-stage renal disease. A literature review was conducted to determine the prevalence and consequences of nonadherence to the different aspects of a hemodialysis regimen and the methodological obstacles in research on nonadherence. Nonadherence to the prescribed regimen is a common problem in hemodialysis and is associated with increased morbidity and mortality. Research on nonadherence is associated with 2 major obstacles: inconsistencies in definitions and invalid measurement methods. Further research is needed to validate measurement methods and to establish clinically relevant operational definitions of nonadherence.

Medical education increasingly stresses that medical students should be prepared to take up multiple roles as a health professional. This requires the integrated acquisition of multiple competences such as clinical reasoning and decision making, communication skills and management skills. To promote such complex learning, instructional design has focused on the use of authentic, real-life learning tasks that students perform in a real or simulated task environment. The four-component instructional design model (4C/ID) model is an instructional design model that starts from the use of such tasks and provides students with a variety of learning tools facilitating the integrated acquisition of knowledge, skills and attitudes. In what follows, we guide the reader on how to implement educational programs based on the 4C/ID model and illustrate this with an example from general practice education. The developed learning environment is in line with the whole-task approach, where a learning domain is considered as a coherent, integrated whole and where teaching progresses from offering relatively simple, but meaningful, authentic whole tasks to more complex tasks. We describe the steps that were taken, from prototype over development to implementation, to build five learning modules (patient with diabetes; the young child with fever; axial skeleton; care for the elderly and physically undefined symptoms) that all focus on the integrated acquisition of the Canadian Medical Education Directives for Specialists roles in general practice. Furthermore, a change cycle for educational innovation is described that encompasses practice-based challenges and pitfalls about the collaboration between different stakeholders (students, developers and teachers) and the transition from traditional, fragmented and classroom-based learning to integrated and blended learning based on sound instructional design principles.

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Abstracts 55 years, to 69% in those aged over 85 years. Between 1986 and 1995, population-based mortality rates for out-ofhospital deaths fell by a third in men but only a quarter in women. Average annual falls were more marked in younger age groups (5.6% per annum in men and 3.7% in women aged 55-64), compared with those aged over 85 (2.5% in both men and women). Population-based out-of-hospital mortality rates were substantially higher in deprived socioeconomic groups compared with affluent groups, particularly below the age of 65. These inequalities persisted over time, because falls in mortality rates were broadly similar across all socio-economic groups. Conclusions: The majority of deaths attributable to acute myocardial infarction, and thus to coronary heart disease, occur without hospital admission, particularly in the elderly. In Scotland between 1986 and 1995, overall population-based out-of-hospital death rates fell substantially, more so in younger age groups than in the elderly and consistently more in men than in women. Socio-economic differentials in men hardly improved over this time. These continuing inequalities in age, gender and class must be more actively addressed in future coronary heart disease strategies. These findings are consistent with previous studies, and are cautiously generalisable to other countries with a similar burden of CHD.Cardiac cachexia is a complex, multifactorial process characterised by wasting and a loss of lean body mass. Autopsies performed on malnourished adults show that a loss of 40% of the total body weight includes a loss of 35% of the normal heart weight. No specific diagnostic criteria have yet been established, but can be defined on the basis of a documented non-intentional and non-oedematous weight loss of more than 7.5% of the pre-morbid normal weight occurring over a 6-month period. In this paper, which aims to describe the cardiac cachexia syndrome relevant to nursing interventions for patients with heart failure, two areas have been highlighted; drug treatment consequences and gastrointestinal effects. The malnutrition suffered by the majority of these patients is mainly due to anorexia, malabsorption and hypermetabolism. This paper states that the nurse can help these patients in a direct way with their choice of food and food intake, exercise and medicine intake. She can also support a favourable and pleasant environment. It is important for the nurse to be attentive and responsive and to have the intuition to meet the (un)expressed needs of the patient. It is also important for patients with heart failure that the nurse can cooperate with other healthcare professionals, such as dieticians, dental hygienists, physiotherapists and physicians. Due to the relatively short period of time that patients with heart failure reside in hospital and the large number of nurses involved in their care, difficulties can arise in meeting their needs in the area of malnutrition. Continuous contact with a heart failure nurse can create a better understanding of the rea...

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