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Background:Diagnosis of sinus venosus defects, not infrequently associated with complex anomalous pulmonary venous drainage, may be delayed requiring multimodality imaging.Methods:Retrospective review of all patients from February 2008 to January 2019.Results:Thirty-seven children were diagnosed at a median age of 4.2 years (range 0.5−15.5 years). In 32 of 37 (86%) patients, diagnosis was achieved on transthoracic echocardiography, but five patients (14%) had complex variants (four had high insertion of anomalous vein into the superior caval vein and three had multiple anomalous veins draining to different sites, two of whom had drainage of one vein into the high superior caval vein). In these five patients, the final diagnosis was achieved by multimodality imaging and intra-operative findings. The median age at surgery was 5.2 years (range 1.6−15.8 years). Thirty-one patients underwent double patch repair, four patients a Warden repair, and two patients a single-patch repair. Of the four Warden repairs, two patients had a high insertion of right-sided anomalous pulmonary vein into the superior caval vein, one patient had bilateral superior caval veins, and one patient had right lower pulmonary vein insertion into the right atrium/superior caval vein junction. There was no post-operative mortality, reoperation, residual shunt or pulmonary venous obstruction. One patient developed superior caval vein obstruction and one patient developed atrial flutter.Conclusion:Complementary cardiac imaging modalities improve diagnosis of complex sinus venosus defects associated with a wide variation in the pattern of anomalous pulmonary venous connection. Nonetheless, surgical treatment is associated with excellent outcomes.

OBJECTIVE: To evaluate a shared decision-making (SDM) intervention in orthopaedic hip and knee osteoarthritis care.METHODS: Using a pre- post intervention design study, we tested an intervention, that included a decision aid for patients (ptDA) and a SDM training course for residents in training and orthopaedic surgeons. The theory of planned behaviour was used for intervention development. Primary outcomes included patient reported decisional conflict, SDM, and satisfaction. Secondary outcomes were physicians' attitude and knowledge, and uptake of the ptDA.RESULTS: 317 patients were included. The intervention improved physicians' knowledge about SDM but had no effect on the primary outcomes. 19 eligible patients used the ptDA (17%). SDM was higher for middle educated patients compared to lower educated (mean difference 9.91, p=0.004), patients who saw surgeons instead of residents (mean difference 5.46, p=0.044) and when surgery was chosen and desired by patients compared to situations where surgery was desired but not chosen (mean difference 15.39, p=0.036).CONCLUSION: Our multifaceted intervention did not improve SDM and ptDA uptake was low.PRACTICE IMPLICATIONS: In orthopaedic hip and knee osteoarthritic care other ways should be explored to successful implement SDM. Since residents received lower SDM scores, special focus should go to this group.

There is a need for culturally competent health care providers (HCPs) to provide care to deaf signers, who are members of a linguistic and cultural minority group. Many deaf signers have lower health literacy levels due to deprivation of incidental learning opportunities and inaccessibility of health-related materials, increasing their risk for poorer health outcomes. Communication barriers arise because HCPs are ill-prepared to serve this population, with deaf signers reporting poor-quality interactions. This has translated to errors in diagnosis, patient nonadherence, and ineffective health information, resulting in mistrust of the health care system and reluctance to seek treatment. Sign language interpreters have often not received in-depth medical training, compounding the dynamic process of medical interpreting. HCPs should thus become more culturally competent, empowering them to provide cultural- and language-concordant services to deaf signers. HCPs who received training in cultural competency showed increased knowledge and confidence in interacting with deaf signers. Similarly, deaf signers reported more positive experiences when interacting with medically certified interpreters, HCPs with sign language skills, and practitioners who made an effort to improve communication. However, cultural competency programs within health care education remain inconsistent. Caring for deaf signers requires complex, integrated competencies that need explicit attention and practice repeatedly in realistic, authentic learning tasks ordered from simple to complex. Attention to the needs of deaf signers can start early in the curriculum, using examples of deaf signers in lectures and case discussions, followed by explicit discussions of Deaf cultural norms and the potential risks of low written and spoken language literacy. Students can subsequently engage in role plays with each other or representatives of the local signing deaf community. This would likely ensure that future HCPs are equipped with the knowledge and skills necessary to provide appropriate care and ensure equitable health care access for deaf signers.

Introduction Health professions educators risk misunderstandings where terms and concepts are not clearly defined, hampering the field’s progress. This risk is especially pronounced with ambiguity in describing roles. This study explores the variety of terms used by researchers and educators to describe “faculty”, with the aim to facilitate definitional clarity, and create a shared terminology and approach to describing this term. Methods The authors analyzed journal article abstracts to identify the specific words and phrases used to describe individuals or groups of people referred to as faculty. To identify abstracts, PubMed articles indexed with the Medical Subject Heading “faculty” published between 2007 and 2017 were retrieved. Authors iteratively extracted data and used content analysis to identify patterns and themes. Results A total of 5,436 citations were retrieved, of which 3,354 were deemed eligible. Based on a sample of 594 abstracts (17.7%), we found 279 unique terms. The most commonly used terms accounted for approximately one-third of the sample and included faculty or faculty member/s (n = 252; 26.4%); teacher/s (n = 59; 6.2%) and medical educator/s (n = 26; 2.7%) were also well represented. Content analysis highlighted that the different descriptors authors used referred to four role types: healthcare (e.g., doctor, physician), education (e.g., educator, teacher), academia (e.g., professor), and/or relationship to the learner (e.g., mentor). Discussion Faculty are described using a wide variety of terms, which can be linked to four role descriptions. The authors propose a template for researchers and educators who want to refer to faculty in their papers. This is important to advance the field and increase readers’ assessment of transferability. Supplementary Information The online version of this article (10.1007/s40037-021-00683-8) contains supplementary material, which is available to authorized users.

Phenomenon: In South Africa, as with many other developing countries, a call has been made for institutions of higher learning to participate in more research and set the pace for societal transformation. At the Faculty of Health Sciences (FoHS), University of the Free State (UFS), numerous strategic efforts are focused on supporting and stimulating research. An essential prerequisite for the success of these vital efforts is to be aware of the research culture within the academic faculties. A peculiarity of medical colleges in South Africa is that medical faculties are in partnership with the government through the academic training hospitals; hence, staff appointment occurs through a joint structure with both the provincial Department of Health and the National Health Laboratory Services. So far, no known study has investigated research culture in this context (joint staff appointment). Approach: This study included elements of case study evaluation and improvement-oriented evaluation. We distributed to 242 educators a structured questionnaire to obtain perceptions of aspects of research, research processes, and existing research culture in the FoHS, UFS. Suggestions on how to improve the research culture also were obtained. The structured questionnaire was self-administered, consisted of closed and open-ended questions grouped into five main sections, and was distributed electronically and manually (hard copy) to participants. Findings: One-hundred-eleven questionnaires were returned (46% response rate). Motivation to do research varied by school and included career advancement (77%, School of Allied Health Professions); change the situation (80%, Academic support); develop individual skillset (67%, School of Nursing) and improve patient care (62%, School of Medicine). Perceived factors affecting research culture included limited funding and allocated time for research, minimal leadership support for research, and absence of research-related support structures as well as minimal teamwork/collaboration. Frustration was the most reported (negative) emotion (25%). Participants suggested that encouraging teamwork among staff, reducing workload to allow time for research, establishing a mentorship program, providing training on deficient skills, and more support from leadership would improve research culture. Insights: This present study reveals some of the factors that impact negatively on research, research culture, and productivity in a medical college in a resource-limited setting. While the benefits of joint staff appointment cannot be overemphasized, our findings highlight that the complex interplay between employers/stakeholders result in poorly executed joint appointment scheme/models (i.e., competitive approach) and creates numerous challenges that negatively impact research productivity and research culture. Recommendations suggested herein can be implemented by the FoHS and other medical colleges in similar contexts to improve research productivity and foster an enabling research culture.

Background: Patients with locally advanced rectal cancer are often considered for neoadjuvant chemoradiotherapy before resection. This presurgical treatment can have negative effects on physical fitness, muscle mass, and treatment compliance, which can negatively influence clinical outcomes. Objective: The aim of this study was to evaluate physical fitness and skeletal muscle mass before and after neoadjuvant chemoradiotherapy in single subjects with locally advanced rectal cancer. Design: An observational longitudinal study of single subjects. Methods: Routine care data were retrospectively analyzed. Data consisted of tumor characteristics, clinical data (eg, side effects and toxicity of the neoadjuvant chemoradiotherapy, loss of body mass), data on performance-based physical fitness, and computed tomography-derived skeletal muscle mass. An independent-samples t test or its nonparametric equivalent was performed on outcome measures to test for significant differences between T-0 and T-1. For comparing several subgroups in this cohort, the Mann-Whitney U test was performed and correlations were studied using the Pearson or Spearman correlation coefficient, as appropriate. Results: Data from 25 single subjects were available. Aerobic capacity (n = 25, P = .033) and skeletal muscle mass (n = 16, P = .005) were significantly reduced after neoadjuvant chemoradiotherapy. Although not statistically significant, a large number of patients demonstrated a decrease in muscle strength and functional mobility after completing neoadjuvant chemoradiotherapy. In 14 patients (56%), adverse events, dose-limiting toxicity, or early termination of treatment occurred. Conclusions: Aerobic capacity and skeletal muscle mass decreased following neoadjuvant chemoradiotherapy, with large interindividual differences concerning the changes in physical fitness and muscle mass. This between-subject variability indicates the importance of a personalized treatment approach.

IntroductionOver the past year, there has been a worldwide increase in the focus on systemic discrimination and inequitable practices within different societies, particularly concerning race and ethnicity. The inherent (experience of) inequity in racism is notonly limited to individuals but also found in different domains of societal structures, including healthcare and academia. In academia and healthcare organisations, junior Black and Minority Ethnic (BAME) doctors and students regularly find themselves caught between the leaky pipeline phenomenon and hierarchically dependent positions in academic healthcare settings. Voicing their experiences after such encounters is neither an option nor a choice they can do without repercussions. The prejudices, stigmas, implicit biases present within these environments result in segregated practices, where BAME doctors become the ‘other’ doctor (otherism), and based on their religion, ethnicity, migrant background or physical features are boxed into a specific group or category.Reflections & recommendationsThe outcome of this exercise (re-) emphasised that more improvement in the Dutch healthcare systems concerning stigmas and biases towards race and ethnicity are needed to promote the inclusion of future BAME doctors and students. A pivotal turn is urgently needed to repair the racial stigmas and biases that have distorted the image of BAME doctors/students, limiting their academic and professional progress. By structurally implementing focused strategies to promote inclusivity, the current gap within healthcare and the participation between non- BAME and BAME-doctors/students can be bridged, inevitably leading to better healthcare services, safer learning environments and a balanced representation of our multicultural societies in healthcare.We argue that increased self-reflection from such critical inquiry will ultimately result in clear and objective understandings of (pre) existent inequitable practices in our societies.

Vertebral fracture (VF) locations are bimodally distributed in the spine. The association between VF and bone attenuation (BA) measured on chest CT scans varied according to the location of VFs, indicating that other factors than only BA play a role in the bimodal distribution of VFs.INTRODUCTION: Vertebral fractures (VFs) are associated with low bone mineral density but are not equally distributed throughout the spine and occur most commonly at T7-T8 and T11-T12 ("cVFs") and less commonly at T4-T6 and T9-T10 ("lcVF"). We aimed to determine whether associations between bone attenuation (BA) and VFs vary between subjects with cVFs only, with lcVFs only and with both cVFs and lcVFs.METHODS: Chest CT images of T4-T12 in 1237 smokers with and without COPD were analysed for prevalent VFs according to the method described by Genant (11,133 vertebrae). BA (expressed in Hounsfield units) was measured in all non-fractured vertebrae (available for 10,489 vertebrae). Linear regression was used to compare mean BA, and logistic regression was used to estimate the association of BA with prevalent VFs (adjusted for age and sex).RESULTS: On vertebral level, the proportion of cVFs was significantly higher than of lcVF (5.6% vs 2.0%). Compared to subjects without VFs, BA was 15% lower in subjects with cVFs (p < 0.0001), 25% lower in subjects with lcVFs (p < 0.0001) and lowest in subjects with cVFs and lcVFs (- 32%, p < 0.0001). The highest ORs for presence of VFs per - 1SD BA per vertebra were found in subjects with both cVFs and lcVFs (3.8 to 4.6).CONCLUSIONS: The association between VFs and BA differed according to VF location. ORs increased from subjects with cVFs to subjects with lcVFs and were highest in subjects with cVFs and lcVFs, indicating that other factors than only BA play a role in the bimodal VF distribution.TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT00292552.

BackgroundThis study examined the associations between accelerometer-derived sedentary time (ST), lower intensity physical activity (LPA), higher intensity physical activity (HPA) and the incidence of depressive symptoms over 4 years of follow-up.MethodsWe included 2082 participants from The Maastricht Study (mean ± s.d. age 60.1 ± 8.0 years; 51.2% men) without depressive symptoms at baseline. ST, LPA and HPA were measured with the ActivPAL3 activity monitor. Depressive symptoms were measured annually over 4 years of follow-up with the 9-item Patient Health Questionnaire (PHQ-9). Cox regression analysis was performed to examine the associations between ST, LPA, HPA and incident depressive symptoms (PHQ-9 ⩾ 10). Analyses were adjusted for total waking time per day, age, sex, education level, type 2 diabetes mellitus, body mass index, total energy intake, smoking status and alcohol use.ResultsDuring 7812.81 person-years of follow-up, 203 (9.8%) participants developed incident depressive symptoms. No significant associations [Hazard Ratio (95% confidence interval)] were found between sex-specific tertiles of ST (lowest v. highest tertile) [1.13 (0.76–1.66], or HPA (highest v. lowest tertile) [1.14 (0.78–1.69)] and incident depressive symptoms. LPA (highest v. lowest tertile) was statistically significantly associated with incident depressive symptoms in women [1.98 (1.19–3.29)], but not in men (p-interaction ConclusionsWe did not observe an association between ST or HPA and incident depressive symptoms. Lower levels of daily LPA were associated with an increased risk of incident depressive symptoms in women. Future research is needed to investigate accelerometer-derived measured physical activity and ST with incident depressive symptoms, preferably stratified by sex.

Nicolaides–Baraitser syndrome is a rare, neuro-developmental disorder caused by heterozygous pathogenic variants in the SMARCA2 gene, involved with chromatin regulation. Cardinal features include intellectual disability, short stature, microcephaly, triangular facies, sparse hair, brachydactyly, prominent interphalangeal joints and seizures. Genetic testing demonstrated a loss within SMARCA2 at 9p24.3 inclusive of basepairs 2094861_2141830 (hg19) in our patient. This case highlights a child with Nicolaides–Baraiter syndrome, a SMARCA2 gene deletion and a novel association of hypertrophic obstructive cardiomyopathy.

11020 Background: Despite proposed advantages of global oncology curricular harmonization including physician mobility and improving the quality of care the challenges and unintended consequences require greater study. The aim of this study was to problematize the concept and implementation of global oncology curricula and their relationship to local contexts of power and culture. Methods: Fourteen international participants involved in the development and implementation of global oncology curricula completed in-depth, one-on-one semi-structured interviews lasting 40-60 minutes. Snowball sampling was employed. The participant sample was representative of different geographic regions, genders and professional scopes of practice to ensure diverse perspectives were sought. Through iterative analyses, using an abductive approach, the study team discussed and reviewed the data and made revisions through collaborative analysis to enhance comprehensiveness and to improve credibility. In the final analysis the meaning and implication of the themes were discussed yielding a conceptual analysis. Results: Our data have articulated 5 key challenges for global curricula including 1) Ambiguous or conflicting perspectives on the purpose and scope of Global Oncology Curricula 2) Insufficient representation of diverse perspectives and realities in the creation of the final curricula 3) A rigid conceptualization of competency requirements 4) A mismatch between the curricular requirements and local context and 5) The influence of power relationships and decision makers. Leveraging the strengths of diversity including fostering representation, addressing power differentials and factoring local contexts may be an approach to mitigating these challenges. Conclusions: Global oncology curricula may serve important advocacy roles within the healthcare system. Leveraging diversity may positively impact the common challenges in the construction and implementation of global oncology curricula.

BackgroundTotal Knee Arthroplasty (TKA) remains the gold standard for treatment of debilitating symptoms of knee osteoarthritis (OA). Even though providing satisfactory results for the majority of patients, some studies report dissatisfaction after TKA to be as high as 20%. Among other things, pain catastrophising and self-efficacy are thought to compromise results of TKA. Implant manufacturers keep improving upon their designs in an attempt to improve functional outcomes. One of these novel knee systems is the Attune. To our knowledge, there are no clinical follow-up studies reporting results of the uncemented version. The main objective of this multicentre prospective observational study is to evaluate revision rate, complications, radiographic outcomes (i.e. alignment and radiolucent lines) and patient reported outcomes of the uncemented Attune mobile bearing TKA. Secondary objectives are (1) to assess physical function, return to sport and return to work after TKA and (2) to evaluate the long-term effect of preoperative psychological factors on satisfaction after TKA.MethodsAll patients presenting in the participating centres with knee pathology warranting joint replacement therapy will be considered for inclusion, an absolute indication for cemented fixation is the only exclusion criterium. Evaluation of clinical and radiographic performance (e.g. radiolucent lines) is done at 6 weeks, 6 months, 1 year, 5 years and 10 years after surgery using validated patient reported outcome measures. Cumulative revision rates are calculated after 5 and 10 years using Kaplan–Meier methods. Physical function is assessed with performance based measurements before and 1 year after surgery. Return to sports is assessed using the Tegner and University of California Los Angeles (UCLA) activity rating scale before and 1 year after surgery. Return to work is evaluated by inviting patients of working age to complete a short questionnaire 1 year after surgery. Psychologic factors are assessed using questionnaires for pain catastrophising, pain self-efficacy and mental health before, 5 years and 10 years after surgery. Preoperative psychologic scores are correlated to functional outcomes.DiscussionThe current study aims to report the clinical performance of a novel implant and can help provide insight in factors that play a role in satisfaction after TKA.Trial registrationClinicalTrials.gov identifier: NCT04247672 (January 30, 2020)

Educators use entrustment, a common framework in competency-based medical education, in multiple ways, including frontline assessment instruments, learner feedback tools, and group decision making within promotions or competence committees. Within these multiple contexts, entrustment decisions can vary in purpose (i.e., intended use), stakes (i.e., perceived risk or consequences), and process (i.e., how entrustment is rendered). Each of these characteristics can be conceptualized as having 2 distinct poles: (1) purpose has formative and summative, (2) stakes has low and high, and (3) process has ad hoc and structured. For each characteristic, entrustment decisions often do not fall squarely at one pole or the other, but rather lie somewhere along a spectrum. While distinct, these continua can, and sometimes should, influence one another, and can be manipulated to optimally integrate entrustment within a program of assessment. In this article, the authors describe each of these continua and depict how key alignments between them can help optimize value when using entrustment in programmatic assessment within competency-based medical education. As they think through these continua, the authors will begin and end with a case study to demonstrate the practical application as it might occur in the clinical learning environment.

An overview of the experiences with deployment of undergraduate medical students in a Dutch university center during the COVID-19 pandemic is provided from organisational and educational perspectives. Medical students' and specialists' experiences during the first peak of COVID-19 underscore the preliminary suggestion that students can be given more enhanced (yet supervised) responsibility for patient care early in their practicums., Highlights • Medical students can make significant contributions to healthcare during COVID-19. • Participation in clinical care by medical students is always voluntary. • Adequate preparatory teaching and training, as well as clinical supervision, are prerequisite. • Students perceive the deployment during COVID-19 contributory to learning in the different competency domains.

Introduction When medical education programs have difficulties recruiting or retaining clinical teachers, they often introduce incentives to help improve motivation. Previous research, however, has shown incentives can unfortunately have unintended consequences. When and why that is the case in the context of incentivizing clinical teachers remains unclear. The purposes of this study, therefore, were to understand what values and motivations influence teaching decisions; and to delve deeper into how teaching incentives have been perceived.Methods An interpretive description methodology was used to improve understanding of the development and delivery of teaching incentives. A purposeful sampling strategy identified a heterogenous sample of clinical faculty teaching in undergraduate and postgraduate contexts. Sixteen semi-structured interviews were conducted and transcripts were analyzed using an iterative process to develop a thematic structure that accounts for general trends and individual variations.Results Clinicians articulated interrelated and dynamic personal and environmental factors that had linear, dual-edged and inverted U-shaped impacts on their motivations towards teaching. Barriers were frequently rationalized away, but cumulative barriers often led to teaching attrition. Clinical teachers were motivated when they felt valued and connected to their learners, peers, leadership, and/or the medical education community. While incentives aimed at producing these connections could be perceived as supportive, they could also negatively impact motivation if they were impersonal, inequitable, inefficient, or poorly framed.Discussion/Conclusion These findings reinforce the literature suggesting that it is necessary to proceed with caution when labeling any particular factor as a motivator or barrier to teaching. They take us deeper, however, towards understanding how and why clinical teachers' perceptions are unique, dynamic and fluid. Incentive schemes can be beneficial for teacher recruitment and retention, but must be designed with nuance that takes into account what makes clinicians feel valued if the strategy is to do more good than harm.

Background Primary anastomosis (PA) in left-sided colorectal cancer (CRC) surgery in elderly patients is disputed. The aim of our study was to evaluate the differences in postoperative outcomes after left-sided CRC surgery in elderly patients in The Netherlands, comparing patients with PA and those who underwent end-ostomy (EO). Method Patients aged ≥ 75 years with stage I–III left-sided CRC, diagnosed and surgically treated in 2015–2017 were selected from the Netherlands Cancer Registry (n = 3286). Postoperative outcomes, short-term (30-, 60-, and 90-day) mortality and 3-year overall and relative survival were analyzed, stratified by surgical resection with PA versus EO. Propensity score matching (PSM) and multivariable logistic regression analysis were conducted. Results Patients with higher age, higher American Society of Anesthesiologists classification and higher tumor stage, a perforation, ileus or tumor located in the proximal rectum, and after open or converted surgery were more likely to receive EO. No difference in anastomotic leakage was seen in PA patients with or without defunctioning stoma (6.2% vs. 7.0%, p = 0.680). Postoperative hospital stay was longer (7.0 vs. 6.0 days, p p = 0.03) in EO patients. Sixty-day mortality (2.9% vs. 6.4%, p p p Conclusion There are significant differences between elderly patients after left-sided CRC surgery with PA versus EO in terms of postoperative length of stay, short-term survival, 3-year overall survival, and relative survival at disadvantage of EO patients. This information could be important for decision making regarding surgical treatment in the elderly.

Introduction While the popularity of international care is rising, the complexity of international care compromises patient safety. To identify risks and propose solutions to improve international care, this study explores experiences of healthcare workers with international handovers in a European border region. Methods A cross-sectional survey design was used to reach out to 3000 healthcare workers, working for hospitals or emergency services in three neighboring countries in the Meuse-Rhine Euregion. In total, 846 healthcare workers completed the survey with 35 closed- and open-ended questions about experiences with international patient handover. Results One-third of respondents had been involved in international handover in the previous month. The handovers occurred in planned and acute care settings and were supported by numerous, yet varying standardized procedures. Healthcare workers were trained for this in some, but not all settings. Respondents mentioned 408 risks and proposed 373 solutions, which were inductively analyzed. Six identified themes classify the level on which risks and accompanying solutions can be found: awareness, professional competencies, communication between professionals, loss of information, facilities and support, and organizational structure. Discussion This study gives insight in international patient handovers in a European border region. Among the biggest risks experienced are procedural differences, sharing patient information, unfamiliarity with foreign healthcare systems, and not knowing roles and responsibilities of peers working across the border. Standardization of procedures, harmonization of systems, and the possibility for healthcare workers to get to know each other will contribute to reach common ground and move towards optimized and patient-safer cross-border care.

Approximately one in five professional cycling athletes will eventually develop a sport-related vascular problem. However, detecting such flow limitation is a diagnostic challenge as the sensitivity of the currently available standard diagnostic tools is limited.Here we present an athlete with exercise-induced pain and weakness of the left leg. During the physical examination, pulsations of the femoral artery were palpable but less prominent. He was analyzed in an ongoing research project aimed at improving methods detecting sport-related leg flow limitations.During functional testing, the ankle-brachial index of the left leg was moderately lowered. However, results of near-infrared spectroscopy and pedal power measurements were largely abnormal suggesting a severe flow limitation.Combining post-exercise ankle-brachial index, near-infrared spectroscopy, and pedal power measurements as routine diagnostic functional testing suggested a severe arterial flow inflow limitation. Conventional diagnostics encompassing duplex-Doppler echography and magnetic resonance angiography confirmed a femoral artery occlusion.https://www.trialregister.nl/ identifier is Trial NL8557.

Context The trajectory towards becoming a medical professional is strongly situated within the clinical workplace. Through participatory engagement, medical trainees learn to address complex health care issues through collaboration with the interprofessional health care team. To help explain learning and teaching dynamics within the clinical workplace, many scholars have relied on socio‐cultural learning theories. In the field of medical education, this research has largely adopted a limited interpretation of a crucial dimension within socio‐cultural learning theory: the expert who guides the trainee into the community is almost exclusively from the same profession. We contend that this narrow interpretation is not necessary. This limited focus is one we choose to maintain—be that choice intentional or implicit. In this cross‐cutting edge paper, we argue that choosing an interprofessional orientation towards workplace learning and guidance may better prepare medical trainees for their future role in health care practice. Methods By applying Communities of Practice and Landscapes of Practice , and supported by empirical examples, we demonstrate how medical trainees are not solely on a trajectory towards the Community of Physician Practice (CoPP) but also on a trajectory towards various Landscapes of Healthcare Practice (LoHCP). We discuss some of the barriers present within health care organisations and professions that have likely inhibited adoption of the broader LoHCP perspective. We suggest three perspectives that might help to deliberately and meaningfully incorporate the interprofessional learning and teaching dynamic within the medical education continuum. Conclusion Systematically incorporating Landscapes of Competence, Assessment, and Guidance in workplace‐based education—in addition to our current intraprofessional approach—can better prepare medical trainees for their roles within the LoHCP. By advocating and researching this interprofessional perspective, we can embark on a journey towards fully harnessing and empowering the health care team within workplace‐based education., Using a Landscapes of Health Care Practices perspective, the authors describe how medical education should be feeding both and intra‐ and interprofessional perspectives on effective workplace learning.

Background: Preoperative education is part of the informed consent process and should enable patients to make an informed decision. Aim of this study was to gain a more detailed insight in the perceptions and experiences of the informed consent process of young adults undergoing bariatric surgery.Methods: Fifty-five young adults, aged 18-25 years, who underwent bariatric surgery, were invited to participate in a semistructured interview. The interview covered three main topics: education of specific informed consent domains, perioperative expectations and experiences, and personal (un)certainties related to undergoing bariatric surgery.Results: Twenty-seven patients participated in a semistructured interview. Mean age was 23.1 +/- 1.6 years. All consent domains were remembered by the patients, but 24/27 patients could not recall one or more complications. Inadequate weight loss was not recalled by 6/27 patients. Common remarks were that the preoperative education focused mainly on the positive results. Negative effects were inadequately educated.Conclusions: Physicians should educate patients more about the negative effects of a treatment and should focus more on specific age-related problems and social interactions. Improved preoperative education, including possible outcome scenarios to assess risks and lifetime consequences, should be developed to improve informed consent in these patients.

Background: Outpatient joint arthroplasty (OJA) has gained increasing popularity and success in a well-defined population. Safety concerns, in terms of complications and readmissions, however still exist.Patients and Methods: This retrospective study included 525 patients (90 primary THAs, 277 primary TKAs, and 158 primary UKAs), initially planned for OJA. All complications and readmissions were evaluated for timing and cause (surgical vs medical) within a 90-day followup. Complications and readmissions were compared by the length of stay (LOS): same-day discharge (SDD) vs >= 1 day. Differences were assessed by the log-rank test. Complications and readmission risk were assessed using multivariable logistic regression analysis.Results: The complication rate was 9.9% at 30 days and 15% at 90 days. The readmission rate was 2.5% at 30 days and 4.2% at 90 days. The majority of surgical complications and readmissions were the result of wound discharge (43% and 56%, respectively). Overall, we did not observe different rates between SDD and LOS >= 1. Following THA, but not TKA or UKA, the 90-day complication rate was significantly lower in patients that underwent SDD compared with LOS >= 1. The risk of complications was positively associated with TKA (vs THA and UKA), ASA III (vs ASA I), and Charnley C (vs Charnley A). The risk of readmissions was negatively associated with a BMI ranging from 25-29.9 kg/m(2) (vs BMI

Background Training residents in delivering high-value, cost-conscious care (HVCCC) is crucial for a sustainable healthcare. A supportive learning environment is key. Yet, stakeholders’ attitudes toward HVCCC in residents’ learning environment are unknown. Objective We aimed to measure stakeholders’ HVCCC attitudes in residents’ learning environment, compare these with resident perceptions of their attitudes, and identify factors associated with attitudinal differences among each stakeholder group. Design We conducted a cross-sectional survey across the Netherlands between June 2017 and December 2018. Participants Participants were 312 residents, 305 faculty members, 53 administrators, and 1049 patients from 66 (non)academic hospitals. Main Measures Respondents completed the Maastricht HVCCC Attitude Questionnaire (MHAQ), containing three subscales: (1) high-value care, (2) cost incorporation, (3) perceived drawbacks. Additionally, resident respondents estimated the HVCCC attitudes of other stakeholders, and answered questions on job demands and resources. Univariate and multivariate analyses were used to analyze data. Key Results Attitudes differed on all subscales: faculty and administrators reported more positive HVCCC attitudes than residents (p ≤ 0.05), while the attitudes of patients were less positive (p ≤ 0.05). Residents underestimated faculty’s (p < 0.001) and overestimated patients’ HVCCC attitudes (p < 0.001). Increasing age was, among residents and faculty, associated with more positive attitudes toward HVCCC (p ≤ 0.05). Lower perceived health quality was associated with less positive attitudes among patients (p < 0.001). The more autonomy residents perceived, the more positive their HVCCC attitude (p ≤ 0.05). Conclusions Attitudes toward HVCCC vary among stakeholders in the residency learning environment, and residents misjudge the attitudes of both faculty and patients. Faculty and administrators might improve their support to residents by more explicitly sharing their thoughts and knowledge on HVCCC and granting residents autonomy in clinical practice.

The importance of successful interprofessional collaboration for effective patient care is generally acknowledged. Research into interprofessional collaboration has thus far been mainly situated in the civilian context and has mostly indicated barriers that prevent successful interprofessional collaboration. However, military interprofessional healthcare teams (MIHTs) seem to be exceptionally successful. Building on the overarching finding of the studies within this special edition—i.e., that MIHTs’ readiness and excellence are in part due to healthcare professionals’ “shared understanding” of what is needed to effectively serve on an MIHT—this commentary uses the theory of Landscape of Practice as a lens to further explain the processes through which healthcare professionals attain this shared understanding. Used within the fields of Health Professions Education and workplace learning, Landscapes of Practice (LoP) helps to explain how learning occurs within practice. It highlights how, by engaging within the various working environments belonging to a profession, social interactions between the various professionals within that environment form the conduit for learning. LoP highlights that the outcome of this learning process is “knowledgeability,” i.e., understanding of how to engage within the field and with its players, resulting in being an acknowledged member of the field. Fostered through a process called “identification,” professionals learn to see how their professional practice aligns with that of others and how to effectively collaborate with others. The commentary explains how the findings of the separate studies within this special edition strongly resonate with knowledgeability and identification. It is concluded that civilian interprofessional healthcare teams may benefit from incorporating characteristics of MIHTs in their training programs.

Using hidden Markov models (HMM), the current study looked at how learners’ metacognitive monitoring is related to their physiological reactivity in the context of collaborative learning. The participants (N = 12, age 16–17 years, three females and nine males) in the study were high school students enrolled in an advanced physics course. The results show that during collaborative learning, the students engaged in monitoring in each self-regulated learning phase such as task understanding, planning and goal setting, task enactment, adaptation and reflection. The results of the HMM indicated that the learners’ physiological reactivity was low when monitoring occurred. The associations between the states based on the HMM provide insights not only into how learners engage in metacognitive monitoring but also about their level of physiological reactivity in each state. In conclusion, exploring aspects of metacognitive monitoring in collaborative learning can be done with the help of physiological reactions.

Background Moderate to vigorous physical activity (MVPA) can help to prevent depression, but identification of the most important psycho-biological pathways involved is unclear. The improvement of cardio-respiratory fitness (CRF) in response to MVPA can vary markedly, we therefore examined the association between CRF and the incidence of depressive symptoms. Methods We used data from The Maastricht Study, a large population-based prospective-cohort study. CRF was estimated at baseline from a graded submaximal exercise protocol and MVPA was measured with accelerometry. Depressive symptoms were assessed using the validated Dutch version of the 9-item Patient Health Questionnaire, both at baseline and during annual follow-up over five years. Cox proportional hazards models were used. Results A total of 1,730 individuals without depressive symptoms at baseline were included in the analysis. During the 5-year follow-up, n = 166 (9.6%) of individuals developed depressive symptoms. Compared to individuals with a low CRF, those with a moderate-to-high CRF had a significantly lower risk of developing depressive symptoms, independent of MVPA (medium CRF: HR = 0.49 (95%CI = 0.33–0.72); high CRF: HR = 0.48 (95% CI = 0.30–0.75). These associations were adjusted for age, sex, level of education, diabetes status, smoking status, alcohol use, energy intake, waist circumferences and antidepressant medications. Limitations PHQ-9 is a validated screening instrument, but it is not a diagnostic tool of depression. Conclusions Higher CRF was strongly associated with a lower risk of incident depressive symptoms over 5-year follow-up, independent of the level of MVPA at baseline, suggesting that interventions aimed at improving CRF could reduce the risk of depression.

Context A wellness crisis exists among physicians and medical trainees. High rates of burnout, depression, stress and other states of impaired wellness have driven a sense of urgency to create solutions, and the medical education community has mobilised impressively. However, we argue-and data suggest-that this rush to find solutions has outpaced our efforts to more fully understand the nature of impaired wellness in medicine. This, we believe, has led to the implementation of solutions informed by limited understanding of the problems we intend to solve. Methods In this paper, we explore three contributors to this situation: (i) shaky definitions and conceptualisations of wellness, (ii) the predominance of deductive, quantitative research informing our understanding and current solutions, and (iii) the reliance on a 'disease-focused' approach to addressing impaired wellness in physicians and trainees. We discuss how these contributors have led to the current state of the science of wellness in medicine: one characterised by an expanding array of solutions built upon narrow conceptualisations of wellness and how it can be impaired. Discussion Moving beyond the current state of the science on wellness in medicine will require three critical developments: (i) consistent use of clear definitions of wellness; (ii) expanding our methodologies to include those utilising direct interaction with participants; and (iii) moving beyond solutions informed by a disease-model approach. We propose a different way of thinking about wellness: one based on what we view as an inherent-and potentially unavoidable-risk of experiencing impairment during a career in medicine. We argue that efforts to extinguish and eliminate all states of impaired wellness may also eliminate opportunities to develop constructive coping mechanisms and future resilience, and that wellness may best be conceptualised as healthy and authentic engagement with the inevitable adversity of a career in medicine.

Background Several studies have shown that conceptions of teachers on teaching and learning can influence the teaching practices and behavior in higher education. This association is also found in undergraduate medical education but not yet established in postgraduate medical setting. An instrument, Conceptions of Learning and Teaching (COLT) was developed to measure conception of teachers in undergraduate medical education. COLT is a 3-factor 18-item questionnaire. The objective of this study is to evaluate if COLT is valid for postgraduate medical education. Methods We invited postgraduate clinical faculty from 3 hospitals in the Netherlands to fill out the COLT. Confirmatory and exploratory factor analysis were performed to evaluate the fit of the postgraduate clinical faculty data to the COLT. Analysis of variance was done to evaluate if there was difference among the 3 hospitals in terms of the response by the clinical faculty. Results Confirmatory factor analysis showed that the postgraduate faculty data had a 2 factor structure after removal of five items. These factors were Teacher Centeredness (TC) and combined Appreciation of Active Learning and Orientation to Professional Practice (A-P) and were considered as comparable to the factors in the original COLT, expressing the post-graduate learning and teaching setting. As several items were removed, the fit was suboptimal, yet did suggest validity for use of the COLT for postgraduate medical education. Conclusion The modified COLT can be used to measure conceptions of teaching and learning in postgraduate medical education. We recommend further study to improve the factor structure of the modified COLT.

European civic integration programs claim to provide newcomers with necessary tools for successful participation. Simultaneously, these programs have been criticized for being restrictive, market-driven, and for working towards an implicit goal of limiting migration. Authors have questioned how these programs discursively construct an offensive image of the Other and how colonial histories are reproduced in the constructions seen today. The Dutch civic integration program is considered a leading example of a restrictive program within Europe. Research has critically questioned the discourses within its policies, yet limited research has moved beyond policy to focus on discourse in texts in practice. This study presents a critical discourse analysis of texts used in practice within the civic integration program and demonstrates that they participate in multiple discursive constructions: the construction of the Dutch nation state and its citizens as inherently modern, the construction of the Other as Unmodern and thus a threat, and the construction of the hierarchical relationship between the two. The civic integration program has been left out of discussions on decolonization to date, contributing to it remaining a core practice of othering. This study applies post-colonial theories to understand the impacts of current discourse, and forwards possibilities for consideration of decolonized alternatives.

Background:Factors that facilitate transfer of training in paediatric echocardiography remain poorly understood. This study assessed whether high-variation training facilitated successful transfer in paediatric echocardiography.Methods:A mixed-methods study of transfer of technical and interpretive skill application amongst postgraduate trainees. Trainees were randomised to a low or high-variation training group. After a period of 8 weeks intensive echocardiography training, we video-recorded how trainees completed an echocardiogram in a complex cardiac lesion not previously encountered. Blinded quantitative analysis and scoring of trainee performance (echocardiogram performance, report, and technical proficiency) were performed using a validated assessment tool by a blinded cardiologist and senior cardiac physiologist. Qualitative interviews of the trainees were recorded to ascertain trainee experiences during the training and transfer process.Results:Sixteen trainees were enrolled in the study. For the cumulative score for all three components tested (echocardiogram performance, report, and technical proficiency), χ2 = 8.223, p = .016, which showed the high-variation group outperformed the low-variation group. Two common themes which assisted in the transfer emerged from interviews are as follows: (1) use of strategies described in variation theory to describe abnormal hearts, (2) the use of formative live feedback from trainers during hands-on training.Conclusion:Training strategies exposing trainees to high-variation training may aid transfer of paediatric echocardiography skills.

As we witness an alarming change in the delivery of healthcare worldwide, there is a need for transformational leadership that can inspire and empower healthcare professionals, and patients alike. Due to the lack of economic, infrastructural and human resources especially in developing countries, the organisation and delivery of healthcare services is even more challenging. Hence, the focus of leadership development in resource-limited environments should be to facilitate knowledge building, interprofessional collaboration, empowerment and inclusion.In this paper, we use two exemplary cases to illustrate the impact of, and the challenges facing leadership capacity building in non-Western contexts with special reference to India and Curaçao. These cases demonstrate that there is a place for validated medical leadership models in developing countries with promising outcomes for the collective health status of communities at large. Such models, however, need to be contextualised to fit the individual country's economic and sociopolitical context. Also, the stakeholders should be prepared to create healthy professional cultures that embrace respect (for self and others) and focus on effective communication practices within their local environments.

BackgroundCross-border healthcare is complex, increasingly frequent and causes potential risks for patient safety. In this context, cross-border handovers or the transfer of patients from one country to another deserves particular attention. Although general handover has been the topic of extensive research, little is known about the challenges of handover across national borders, especially as perceived by stakeholders. In this study, we aimed to gain insight into healthcare professionals’ perspectives on cross-border handover and ways to support this.MethodsWe conducted semistructured interviews with healthcare professionals (physicians, nurses, paramedics and administrative staff) in a European border region to investigate their perspectives on cross-border handover. The interviews were aimed to investigate settings of acute and planned handover. Informed by the theory of planned behaviour (TPB), interviews focused on participant perspectives. We summarised all interviews and inductively identified healthcare professionals’ perspectives. We used elements of the TPB as sensitising concepts.ResultsForty-three healthcare professionals participated. Although respondents had neutral to positive attitudes, they often did not know very well what was expected of them or what influence they could have on improving cross-border handover. Challenges covered five themes: information transfer, language barriers, task division and education, policy and financial structures and cultural differences. To overcome these challenges, we proposed strategies such as providing tools and protocols, discussing and formalising collaboration, and organising opportunities to meet and get to know each other.ConclusionHealthcare professionals involved in cross-border handovers face specific challenges. It is necessary to take measures to come to a shared understanding while paying special attention to the above-mentioned challenges. Meeting in person around meaningful activities (eg, training and case discussions) can facilitate sharing ideas and community building.

Aim There is an ongoing debate as to whether or not the efficacy of sacral neuromodulation (SNM) is optimized by maximizing the total number of active electrode poles (AEPs) during lead placement because there are more programming options. However, this is at the cost of increased operating time. The aims of this study were to establish if a higher number of AEPs improves SNM efficacy during the trial period and after permanent implantable pulse generator (IPG) placement and if there is there a correlation between number of AEPs and battery life of the first placed IPG. Method This was a single centre retrospective cohort study of new patients with faecal incontinence who underwent SNM between 2000 and 2018. Exclusion criteria were sphincter defect > 30%, rectocele/enterocele Grade 3 or higher and incomplete records. Results In all, 288/456 (63%) patients (women 91%; mean age 58.5 ± 11.7 years) were eligible for analysis. The number of AEPs during lead placement was two (n = 42, 14.5%), three (n = 82, 28.5%) and four (n = 164, 57%). There was no association between the number of AEPs during tined lead placement and long‐term efficacy. Neither the success rate of the trial phase nor the battery life after first placed IPG was influenced by the number of AEPs. Conclusion In this study, the number of AEPs does not seem to influence long‐term efficacy of SNM success rate during the trial phase or the battery life of the first placed IPG. However, we also suggest that at the very least there should be two AEPs at lead placement.

Background: In recent decades, the use of near-infrared light and fluorescence-guidance during open and laparoscopic surgery has exponentially expanded across various clinical settings. However, tremendous variability exists in how it is performed. Objective: In this first published survey of international experts on fluorescence-guided surgery, we sought to identify areas of consensus and nonconsensus across 4 areas of practice: fundamentals; patient selection/preparation; technical aspects; and effectiveness and safety. Methods: A Delphi survey was conducted among 19 international experts in fluorescence-guided surgery attending a 1-day consensus meeting in Frankfurt, Germany on September 8(th), 2019. Using mobile phones, experts were asked to anonymously vote over 2 rounds of voting, with 70% and 80% set as a priori thresholds for consensus and vote robustness, respectively. Results: Experts from 5 continents reached consensus on 41 of 44 statements, including strong consensus that near-infrared fluorescence-guided surgery is both effective and safe across a broad variety of clinical settings, including the localization of critical anatomical structures like vessels, detection of tumors and sentinel nodes, assessment of tissue perfusion and anastomotic leaks, delineation of segmented organs, and localization of parathyroid glands. Although the minimum and maximum safe effective dose of ICG were felt to be 1 to 2 mg and >10 mg, respectively, there was strong consensus that determining the optimum dose, concentration, route and timing of ICG administration should be an ongoing research focus. Conclusions: Although fluorescence imaging was almost unanimously perceived to be both effective and safe across a broad range of clinical settings, considerable further research remains necessary to optimize its use.

Background: The majority of patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are admitted to the Intensive Care Unit (ICU) for mechanical ventilation. The role of multi-organ failure during ICU admission as driver for outcome remains to be investigated yet.Design and setting: Prospective cohort of mechanically ventilated critically ill with SARS-CoV-2 infection.Participants and methods: 94 participants of the MaastrICCht cohort (21% women) had a median length of stay of 16 days (maximum of 77). After division into survivors (n = 59) and non-survivors (n = 35), we analysed 1555 serial SOFA scores using linear mixed-effects models.Results: Survivors improved one SOFA score point more per 5 days (95% CI: 4-8) than non-survivors. Adjustment for age, sex, and chronic lung, renal and liver disease, body-mass index, diabetes mellitus, cardiovascular risk fac-tors, and Acute Physiology and Chronic Health Evaluation II score did not change this result. This association was stronger for women than men (P-interaction = 0.043).Conclusions: The decrease in SOFA score associated with survival suggests multi-organ failure involvement dur -ing mechanical ventilation in patients with SARS-CoV-2. Surviving women appeared to improve faster than sur-viving men. Serial SOFA scores may unravel an unfavourable trajectory and guide decisions in mechanically ventilated patients with SARS-CoV-2.(c) 2020 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Aim The purpose of this research was to investigate students' approaches to learning and use of cognitive strategies in a collaborative learning environment with team-based learning. Method In a mixed-methods study, 263 medical students from 6 different semesters answered the R-SPQ-2F Questionnaire and MSLQ's items that measure elaboration and rehearsal strategies. ANOVA was used to compare differences between semesters, and Pearson's correlation to investigate how approaches to learning, cognitive strategies, and academic achievement correlate. Focus groups elucidated which elements in the collaborative learning environment enhanced or hindered deep approach to learning or elaboration strategies and why. Results Students took a deep approach to learning and sometimes a surface approach. They used elaboration and rehearsal strategies. First semester's students had significantly higher deep approach than fifth and sixth semesters' students. Elaboration strategies significantly correlated with final grade. Commitment to the group, case discussions, feeling challenged by teachers, and patients' visits were perceived to enhance deep approach to learning and use of elaboration strategies, while overload in course activities hindered deep approach to learning. Conclusions Particular elements of the learning environment triggered students to take deep approach to learning and use elaboration strategies, and this positively correlated to academic achievement.

Academic writing is a complex competence in higher education. To develop this competence, teachers' written feedback is vital, especially if it contains feed-up, feed-back and feed-forward information. However, academic writing does not always improve after provision of written feedback. The purpose of this study was to explore if peer-to-peer dialogue between students about teachers' written feedback does enhance students' understanding of written feedback. Sixty-three second-year university students participated in a pre-test-post-test design with mixed methods. Questionnaire data showed that peer-to-peer dialogue increased students' understanding of feed-up, feed-back and feed-forward information. Focus group data demonstrated that the dialogue helped students to understand the assessment criteria better (feed up) and offered suggestions for improvement (feed forward). High quality teachers' written feedback was perceived as an important condition. Peer-to-peer dialogue among students about teachers' written feedback seems promising in enhancing students' understanding on how to improve their academic writing assignments.

The concept of quality culture has gained increased attention in health professions education, drawing on insights that quality management processes and positive work-related attitudes of staff in synergy lead to continuous improvement. However, the directions that guide institutions from quality culture theory to educational practice have been missing so far. A prospective qualitative case study of three health professions education programmes was conducted to explore how a quality culture can be enhanced according to the experiences and perspectives of educational leaders. The data collection was structured by an appreciative inquiry approach, supported with vignette-based interviews. A total of 25 participants (a selection of course coordinators, bachelor coordinators and directors of education) reflected on quality culture themes to learn about the best of what is (Discover), envision positive future developments (Dream), identify actions to reach the desired future (Design), and determine how to support and sustain improvement actions (Destiny) within their own educational setting. The results are presented as themes subsumed under these four phases. The experiences and perspectives of educational leaders reveal that peer learning in teams and communities, attention to professional development, and embedding support- and innovation networks, are at the heart of quality culture enhancement. An emphasis on human resources, (inter)relations and contextual awareness of leaders stood out as quality culture catalysts. Educational leaders are therefore encouraged to especially fuel their networking, communication, coalition building, and reflection competencies.

Realistic models to understand the developmental appearance of the pelvic nervous system in mammals are scarce. We visualized the development of the inferior hypogastric plexus and its preganglionic connections in human embryos at 4–8 weeks post‐fertilization, using Amira 3D reconstruction and Cinema 4D‐remodelling software. We defined the embryonic lesser pelvis as the pelvic area caudal to both umbilical arteries and containing the hindgut. Neural crest cells (NCCs) appeared dorsolateral to the median sacral artery near vertebra S1 at ~5 weeks and had extended to vertebra S5 1 day later. Once para‐arterial, NCCs either formed sympathetic ganglia or continued to migrate ventrally to the pre‐arterial region, where they formed large bilateral inferior hypogastric ganglionic cell clusters (IHGCs). Unlike more cranial pre‐aortic plexuses, both IHGCs did not merge because the 'pelvic pouch', a temporary caudal extension of the peritoneal cavity, interposed. Although NCCs in the sacral area started to migrate later, they reached their pre‐arterial position simultaneously with the NCCs in the thoracolumbar regions. Accordingly, the superior hypogastric nerve, a caudal extension of the lumbar splanchnic nerves along the superior rectal artery, contacted the IHGCs only 1 day later than the lumbar splanchnic nerves contacted the inferior mesenteric ganglion. The superior hypogastric nerve subsequently splits to become the superior hypogastric plexus. The IHGCs had two additional sources of preganglionic innervation, of which the pelvic splanchnic nerves arrived at ~6.5 weeks and the sacral splanchnic nerves only at ~8 weeks. After all preganglionic connections had formed, separate parts of the inferior hypogastric plexus formed at the bladder neck and distal hindgut., The umbilical arteries separate the lesser pelvis from the abdomen. Development of the inferior hypogastric plexus is divided into migration of neural crest cells (blue dots) to para‐ and pre‐arterial positions, followed by association of the ganglionic cell cluster with the superior hypogastric nerve, then the pelvic splanchnic nerves, and finally the sacral splanchnic nerves. Only thereafter nerves and ganglionic cells extend from this plexus along the bladder wall and the caudal hindgut.

Background: The Observational Clinical Human Reliability Assessment (OCHRA) can be used to score errors during surgical procedures. To construct an OCHRA-checklist, steps, substeps, and hazards of a surgical procedure need to be defined. A step-by-step framework was developed to segment surgical procedures into steps, substeps, and hazards. The first aim of this study was to investigate if the step-by-step framework could be used to construct an accurate Lichtenstein open inguinal hernia repair (LOIHR) stepwise description. The second aim was to investigate if the OCHRA-checklist based on this stepwise description was accurate and useful for surgical training and assessment.Materials and methods: Ten expert surgeons rated statements regarding the accuracy of the LOIHR stepwise description, the accuracy, and the usefulness of the LOIHR OCHRA-checklist (eight, seven, and six statements, respectively) using a 5-point Likert scale. One-sample Wilcoxon signed-rank test was used to compare the outcomes to the neutral value of 3.Results: The accuracy of the stepwise description and the accuracy and usefulness of the OCHRA-checklist were rated statistically significantly higher than the neutral value of 3 (median 4.75 [5.00-4.00] with p = .009, median 5.00 [5.00-4.00] with p = .012, median 4.00 [5.00-4.00] with p = .047, respectively). The experts rated the OCHRA-checklist to be useful for the training (5.00 [5.00-4.00], p = .009), and assessment (4.50 [5.00-4.00], p = .010) of surgical residents.Conclusion: This preliminary study showed that the stepwise LOIHR description constructed using the step-bystep framework was found to be accurate. The LOIHR OCHRA-checklist developed using the stepwise description was also accurate, and particularly useful for the training and assessment of proficiency of surgical residents.

Background In 80% to 90% of the patients intra-abdominal adhesions occur after abdominal surgery, which can cause small-bowel obstruction, chronic abdominal pain, female infertility and difficulty during reoperation. A novel crosslinked hyaluronic acid gel is evaluated regarding its anti-adhesive capacities in an ischemic button model in rats. Method 51 adult, male Wistar rats from a registered breeder, received eight ischemic buttons each and were treated with hyaluronic acid gel (HA, HyaRegen©), hyaluronic acid carboxymethylcellulose (HA-CMC, Seprafilm©) or no anti-adhesive barrier. After 14 days, the animals were sacrificed and adhesions were scored macroscopically. The number of buttons and organs involved in adhesions were recorded. Per animal, one button with adhesions and one without adhesions was explanted for qPCR analysis. Mann-Whitney U, Fisher’s exact and Wilcoxon signed rank test were used for data analysis. A p-value of 0.05 was considered significant. Results Macroscopic evaluation of adhesion formation did not differ between the groups. The number of organs involved in adhesions in the HA gel group was significantly lower compared to HA-CMC (p = .041) and the control group (p = .012). A significantly, 1.36-fold higher clec10a (p = 0.25), 1.80-fold higher cd163 (p = 0.003) and 5.14-fold higher mmp1 expression (p = 0.028) was found in ischemic buttons with adhesions compared to buttons without adhesions. Conclusion HA gel application reduces the number of organs involved in adhesions in an ischemic button model, but no overall reduction in adhesion formation was encountered. Macrophage subtype 2 polarization and high mmp1 expression are associated with adhesion formation. Further investigation is needed in the exact pathophysiologic process of adhesion formation and the role of macrophage polarization.

Objective. To determine the discourses on professional identity in pharmacy education over the last century in North America and which one(s) currently dominate.Methods. A Foucauldian critical discourse analysis using archival resources from the American Journal of Pharmaceutical Education (AJPE) and commissioned education reports was used to expose the identity discourses in pharmacy education.Results. This study identified five prominent identity discourses in the pharmacy education literature: apothecary, dispenser, merchandiser, expert advisor, and health care provider. Each discourse constructs the pharmacist's professional identity in different ways and makes possible certain language, subjects, and objects. The health care provider discourse currently dominates the literature. However, an unexpected finding of this study was that the discourses identified did not shift clearly over time, but rather piled up, resulting in students being exposed to incompatible identities.Conclusion. This study illustrates that pharmacist identity constructs are not simple, self-evident, or progressive. In exposing students to incompatible identity discourses, pharmacy education may be unintentionally impacting the formation of a strong, unified healthcare provider identity, which may impact widespread practice change.

BackgroundMental health problems can lead to costs and benefits in other sectors (e.g. in the education sector) in addition to the healthcare sector. These related costs and benefits are known as intersectoral costs and benefits (ICBs). Although some ICBs within the education sector have been identified previously, little is known about their extensiveness and transferability, which is crucial for their inclusion in health economics research.ObjectivesThe aim of this study was to identify ICBs in the education sector, to validate the list of ICBs in a broader European context, and to categorize the ICBs using mental health as a case study.MethodsPreviously identified ICBs in the education sector were used as a basis for this study. Additional ICBs were extracted from peer-reviewed literature in PubMed and grey literature from six European countries. A comprehensive list of unique items was developed based on the identified ICBs. The list was validated by surveying an international group of educational experts. The survey results were used to finalize the list, which was categorized according to the care atom.ResultsAdditional ICBs in the education sector were retrieved from ninety-six sources. Fourteen experts from six European countries assessed the list for completeness, clarity, and relevance. The final list contained twenty-four ICBs categorized into input, throughput, and output.ConclusionBy providing a comprehensive list of ICBs in the education sector, this study laid further foundations for the inclusion of important societal costs in health economics research in the broader European context.

PurposeA lack of quality measures aligned with residents' work led to the development of resident-sensitive quality measures (RSQMs). This study sought to describe how often residents complete RSQMs, both individually and collectively, when they are implemented in the clinical environment.MethodDuring academic year 2017-2018, categorical pediatric residents in the Cincinnati Children's Hospital Medical Center pediatric emergency department were assessed using RSQMs for acute asthma exacerbation (21 RSQMs), bronchiolitis (23 RSQMs), and closed head injury (19 RSQMs). Following eligible patient encounters, all individual RSQMs for the illnesses of interest were extracted from the health record. Frequencies of 3 performance classifications (opportunity and met, opportunity and not met, or no opportunity) were detailed for each RSQM. A composite score for each encounter was calculated by determining the proportion of individual RSQMs performed out of the total possible RSQMs that could have been performed.ResultsEighty-three residents cared for 110 patients with asthma, 112 with bronchiolitis, and 77 with closed head injury during the study period. Residents had the opportunity to meet the RSQMs in most encounters, but exceptions existed. There was a wide range in the frequency of residents meeting RSQMs in encounters in which the opportunity existed. One closed head injury measure was met in all encounters in which the opportunity existed. Across illnesses, some RSQMs were met in almost all encounters, while others were met in far fewer encounters. RSQM composite scores demonstrated significant range and variation as well-asthma: mean = 0.81 (standard deviation [SD] = 0.11) and range = 0.47-1.00, bronchiolitis: mean = 0.62 (SD = 0.12) and range = 0.35-0.91, and closed head injury: mean = 0.63 (SD = 0.10) and range = 0.44-0.89.ConclusionsIndividually and collectively, RSQMs can distinguish variations in the tasks residents perform across patient encounters.

Introduction and hypotheses valuation of surgical skills, both technical and nontechnical, is possible through observations and video analysis. Besides technical failures, adverse outcomes in surgery can also be related to hampered communication, moderate teamwork, lack of leadership, and loss of situational awareness. Even though some surgeons are convinced about nontechnical skills being an important part of their professionalisation, there is paucity of data about a possible relationship between nontechnical skills and surgical outcome. In robot-assisted surgery, the surgeon sits behind the console and is at a remote position from the surgical field and team, making communication more important than in open surgery and conventional laparoscopy. A lack of structured research makes it difficult to assess the value of the different analysis methods for nontechnical skills, particularly in robot-assisted surgery. Our hypothesis includes the following: (1) introduction of robot-assisted surgery leads to an initial decay in nontechnical skills behaviour during the learning curve of the team, (2) nontechnical skills behaviour is more explicitly expressed in experienced robot-assisted surgery teams than in experienced open surgery teams, and (3) introduction of robot-assisted surgery leads to the development of different forms of nontechnical skills behaviour compared with open surgery. Design This study is a prospective, observational, multicentre, nonrandomised, case-control study including bladder cancer patients undergoing either an open radical cystectomy or a robot-assisted radical cystectomy at the Catharina Hospital Eindhoven, the Netherlands, or at the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital Amsterdam. All patients are eligible for inclusion; there are no exclusion criteria. The Catharina Hospital Eindhoven, the Netherlands, performs on average 35 radical cystectomies a year. The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital Amsterdam, performs on average 100 radical cystectomies a year. Protocol overview The choice of treatment is at the discretion of the patient and the surgeon. Patient results will be obtained prospectively. Pathology results as well as complications occurring within 90 d following surgery will be registered. Surgical complications will be registered according to the Clavien-Dindo system. Measurements Nontechnical skills will be observed using five different methods: (1) NOTSS: Nontechnical Skills for Surgeons; (2) Oxford NOTECHS II: a modified theatre team nontechnical skills scoring system; (3) OTAS: Observational Teamwork Assessment for Surgery; (4) Interpersonal and Cognitive Assessment for Robotic Surgery (ICARS): evaluation of nontechnical skills in robotic surgery; and (5) analysis of human factors. Technical skills in robot-assisted radical cystectomy will be analysed using two different methods: (1) GEARS: Global Evaluative Assessment of Robotic Skill and (2) GERT: Generic Error Rating Tool. Safety criteria and reporting Formal ethical approval has been provided by Medical research Ethics Committees United (MEC-U), The Netherlands (reference number W19.048). We hope to present the results of this study to the scientific community at conferences and in peer-reviewed journals. Statistical analysis Frequency statistics will be calculated for patient demographical data, and a Shapiro-Wilk test with p > 0.05 will be used to define normal distribution. Univariate analysis will be conducted to test for statistically significant differences in observation scores between open radical cystectomy and robot-assisted radical cystectomy cohorts across all variables, using independent sample t tests and Mann-Whitney U testing, as appropriate. A variable-selection strategy will be used to create multivariate models. Binary logistic regression will be conducted to calculate odds ratios and 95% confidence intervals for significant predictors on univariate analysis and clinically relevant covariates. Statistical significance is set at p, This study uses a structured approach to the analysis of nontechnical skills (NTS) using extracorporeal videos of both open radical cystectomy and robot-assisted radical cystectomy surgeries, in order to obtain detailed data on NTS during open and minimally invasive surgery.

Background and purpose — Hip resurfacing arthroplasty (HRA) was designed for the highly active patient because of the various theoretical advantages compared with stemmed total hip arthroplasty (THA), but has shown high failure rates. Physical activity (PA) after arthroplasty is frequently determined with the use of questionnaires, which are known for their subjective nature, recall bias, and ceiling effect. These disadvantages are not applicable to physical activity monitoring (AM) using sensors. We compared objectively measured PA at long-term follow-up in a matched cohort of HRA and stemmed THA subjects. Patients and methods — We compared 2 groups of 16 patients (12 males) in each group, one having received unilateral HRA (median age 56 years at surgery) and a matched group having received unilateral stemmed THA with a small diameter femoral head (28 mm) on conventional polyethylene (median age 60 years at surgery) with osteoarthritis as indication for surgery, 10 years after surgery. Groups were matched by sex, age at surgery, and BMI. The daily habitual PA was measured over 4 consecutive days in daily living using a 3-axis accelerometer, gyroscope, and magnetometer. Both quantitative parameters (time standing, sitting, walking, number of steps, and sit–stand transfers) and qualitative parameters (walking cadence) were determined. Results — The AM was worn for a median 13 (11–16) hours per day. The median daily step count was 5,546 (2,274–9,966) for the HRA group and 4,583 (1,567–11,749) for the stemmed THA-group with 39 (21–74) versus 37 (24–62) daily sit–stand transfers respectively. The other PA parameters were also similar in both groups. Interpretation — We found similar median PA levels and also identical ranges. While short-term effects may exist, ageing and related behavioral adaptations or other effects seem to render the theoretical activity benefits from HRA irrelevant at longer follow-up.

Background Therapeutic drug monitoring (TDM) of antiepileptic drugs (AEDs) can serve as a valuable tool in optimising and individualising epilepsy treatment, especially in vulnerable groups such as pregnant women, the elderly and children. Unfortunately, TDM is often performed suboptimally due to limitations in blood collection. Therefore, we investigated volumetric absorptive micro sampling (VAMS) – a new home-sampling technique. We aimed to evaluate VAMS to determine and quantify the different AEDs and concentrations of 16 different AEDs in whole blood collected by VAMS. Methods Patient blood samples (n = 138) were collected via venepunctures at the Academic Centre for Epileptology Kempenhaeghe. AED concentrations were determined, and these concentrations were used to compare the VAMS method (whole blood) with the conventional method (serum). In addition, the recovery was examined as well as the impact of haematocrit. Finally, AED-spiked blood was used to test the stability of the AEDs inside the micro-sampler devices over a period of time and whether temperature had an effect on the stability. Results VAMS allows for an accurate detection of 16 different AEDs within 2 days after sampling. Deviation in recovery was less than 10% and high correlations were found between VAMS and conventional sampling. Moreover, haematocrit does not have an effect with values between 0.3 and 0.5 (L/L). Finally, although storage temperature of VAMS does affect some AEDs, most are unaffected. Conclusions VAMS enables an accurate detection of a wide variety of AEDs within 2 days after sampling.

Background Preoperative exercise training (PET) studies show promising results in various patient populations. However, the lack of standardised programmes and uniformity in practice guidelines are barriers for implementation. Aim of this study was to assess the current opinions of pulmonologists and cardiothoracic surgeons on the clinical applicability of PET in patients scheduled for lung cancer surgery. Methods Dutch pulmonologists and cardiothoracic surgeons were asked to complete a 29-question survey regarding PET as an additional option to further optimise the health status of patients scheduled for lung cancer surgery. Results In total, 47 respondents (63% response rate), including 30 pulmonologists and 11 cardiothoracic surgeons and 6 residents in training completed the survey. A vast majority of the respondents had a positive attitude towards PET. Home-based exercise was considered less useful, as well as unsupervised exercise. Patient's motivation, improvements in physical capacity and quality of life, and lifestyle adjustments are important factors for the success of PET. The programme should at least contain inspiratory muscle training (95.7%), lifestyle interventions (95.7%), and supervised exercise training (91.5%). Cardiac and pulmonary risk assessment and medication assessment and optimisation were found less important. Conclusion Among pulmonologists and cardiothoracic surgeons, there is a tendency that PET can be a valuable addition to the perioperative care of lung surgery patients. Points of discussion are the contents of PET programmes, and there seems to be a lack of awareness among chest physicians.

Introduction Portfolio-based assessments require that learners’ competence development is adequately reflected in portfolio documentation. This study explored how students select and document performance data in their portfolios and how they perceive these data to be representative for their competence development. Methods Students uploaded performance data in a competency-based portfolio. During one clerkship period, twelve students also recorded an audio diary in which they reflected on experiences and feedback that they perceived to be indicants of their competence development. Afterwards, these students were interviewed to explore the extent to which the performance documentation in the portfolio corresponded with what they considered illustrative evidence of their development. The interviews were analyzed using thematic analysis. Results Portfolios provide an accurate but fragmented picture of student development. Portfolio documentation was influenced by tensions between learning and assessment, student beliefs about the goal of portfolios, student performance evaluation strategies, the learning environment and portfolio structure. Discussion This study confirms the importance of taking student perceptions into account when implementing a competency-based portfolio. Students would benefit from coaching on how to select meaningful experiences and performance data for documentation in their portfolios. Flexibility in portfolio structure and requirements is essential to ensure optimal fit between students’ experienced competence development and portfolio content. Electronic supplementary material The online version of this article (10.1007/s40037-020-00571-7) contains supplementary material, which is available to authorized users.

PurposeInternationally, health professions education scholarship units (HPESUs) are often developed to promote engagement in educational scholarship, yet little is known about how HPESUs change over time or what factors support their longevity. In hopes of helping HPESUs thrive, this study explored factors that shaped the evolution of 8 HPESUs over the past 14 years.MethodThis study involved retrospective case-study analysis of the 8 American, Canadian, and Dutch HPESUs profiled in a 2004 publication. First, the research team summarized key elements of HPESUs from the 2004 articles, then conducted semistructured interviews with the current unit directors. In the first set of questions, directors were asked to reflect on how the unit had changed over time, what successes the unit enjoyed, what enabled these successes, what challenges the unit encountered, and how these challenges were managed. In the second set of questions, questions were tailored to each unit, following up on unique elements from the original article. The team used Braun and Clarke's 6-phase approach to thematic analysis to identify, analyze, and report themes.ResultsThe histories of the units varied widely-some had grown by following their original mandates, some had significant mission shifts, and others had nearly disappeared. Current HPESU directors identified 3 key factors that shaped their HPESU's longitudinal development: the people working within and overseeing the HPESU (the need for a critical mass of scholars, a pipeline for developing scholars, and effective leadership), institutional structures (issues of centralization, unit priorities, and clear messaging), and funding (the need for multiple funding sources).ConclusionsStudy findings offer insights that may help current HPESU directors to strategically plan for their unit's continued development. Tactically harnessing the factors identified could help directors ensure their HPESU's growth and contend with the challenges that threaten the unit's success.

Aims: Mentorship during residency guides and supports professional and personal development. Despite this, mentorship programmes within many postgraduate medicine programmes, including radiation oncology, are not standard. The objective of this qualitative study was to carry out a needs assessment to determine the perceived mentorship needs and experiences of radiation oncology residents and faculty.Materials and methods: Radiation oncology residents and faculty from a single university were invited to participate in semi-structured interviews in September 2017. Interviews were audiotaped and transcribed verbatim. An inductive thematic analysis was carried out using NVivo Pro version 11. Data collection occurred until saturation. Codes were derived and a systematic framework was applied to yield emergent themes. Trustworthiness was verified through triangulation and member checking.Results: Twenty interviews (10 residents and 10 faculty) took place between October and December 2017, at which point thematic saturation was achieved. Four major themes emerged: (i) the perceived experiences of residents and faculty with mentorship, (ii) the evolution of mentorship needs during residency training, (iii) the mechanisms of creating mentorship relationships and (iv) peer mentorship.Conclusions: In this study, the perceptions of mentorship from the perspective of radiation oncology residents and faculty were explored. Important areas of alignment and discordance were discovered. These insights will inform the development and implementation of a mentorship programme that can be adapted for use by other oncology training programmes. (C) 2019 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.