Search

Standardized narratives or "profiles" can facilitate identification of poor professional behaviour of medical students. If unprofessional behaviour is identified, educators can help the student to improve their professional performance. In an earlier study, based on opinions of frontline teachers from one institution, the authors identified three profiles of medical students' unprofessional behaviour: (1) "Poor reliability," (2) "Poor reliability and poor insight," and (3) "Poor reliability, poor insight and poor adaptability." The distinguishing variable was "Capacity for self-reflection and adaptability." The current study used Nominal Group Technique and thematic analysis to refine these findings by synthesizing experts' opinions from different medical schools, aiming to develop a model of unprofessional behaviour profiles in medical students. Thirty-one experienced faculty, purposively sampled for knowledge and experience in teaching and evaluation of professionalism, participated in five meetings at five medical schools in the Netherlands. In each group, participants generated ideas, discussed them, and independently ranked these ideas by allocating points to them. Experts suggested ten different ideas, from which the top 3 received 60% of all ranking points: (1) "Reflectiveness" and "adaptability" are two distinct distinguishing variables (25%), (2) The term "reliability" is too narrow to describe unprofessional behaviour (22%), and (3) Profiles are dynamic over time (12%). Incorporating these ideas yielded a model consisting of four profiles of medical students' unprofessional behaviour ("accidental behaviour," "struggling behaviour," "gaming-the-system behavior" and "disavowing behavior") and two distinguishing variables ("reflectiveness" and "adaptability"). The findings could advance educators' insight into students' unprofessional behaviour, and provide information for future research on professionalism remediation.

Purpose: Professional Identity Formation (PIF) is crucial for high-quality patient care and physician well-being. Few empirical studies examined PIF in residency from the perspective of supervisors. In GP residency, residents are supervised with an 'end in mind' that remains unexplored. To encourage supervisors to reflect on their teaching behaviours, this study investigated GP clinical supervisors' perceptions of PIF outcomes in GP residency. Methods: Applying qualitative description, focus group interviews were conducted between spring and autumn 2019. Using a semi-structured interview guide, supervisors' perceptions of PIF outcomes were explored. In an iterative coding process applying constant comparison, a thematic analysis was performed of focus group transcripts. Results: We conducted eight focus groups with 55 supervisors at four training institutes across the Netherlands. Half of the supervisors were female. GP supervisors tend to address the 'poor GP' when prompted to address the 'good GP'. PIF outcomes in GP residency should revolve around taking ownership in patient care, self-care and the persistence of GP as a profession. Conclusion: PIF can be challenged by a lack of positive language. Supervisors' strong beliefs regarding ideals of the profession potentially compromise PIF when they do not resonate with residents' beliefs, resulting in poor educational alliance. [ABSTRACT FROM AUTHOR]

Background: Recognition of poor performance in General Practice trainees is important because underperformance compromises patients' health and safety. However, in General Practice, research on persistent underperformance while in training and its ultimate consequences is almost completely lacking. We aim to explore the unprofessional behaviours of residents in General Practice who were dismissed from training and who litigated against dismissal. Methods: We performed a structured analysis using open-source data from all General Practice cases before the Conciliation Board of the Royal Dutch Medical Association between 2011 and 2020. Anonymised law cases about residents from all Dutch GP training programmes were analysed in terms of the quantitative and qualitative aspects related to performance. Results: Between 2011 and 2020, 24 residents who were dismissed from training challenged their programme director's decision. Dismissed residents performed poorly in several competencies, including communication, medical expertise and most prominently, professionalism. Over 90% of dismissed residents failed on professionalism. Most lacked self-awareness and/or failed to profit from feedback. Approximately 80% failed on communication, and about 60% on medical expertise as well. A large majority (more than 80%) of dismissed residents had previously participated in some form of remediation. Conclusions: Deficiencies in both professionalism and communication were the most prevalent findings among the dismissed General Practice residents. These two deficiencies overlapped considerably. Dismissed residents who challenged their programme director's decision were considered to lack self-awareness, which requires introspection and the appreciation of feedback from others. [ABSTRACT FROM AUTHOR]

Background: In the Netherlands, 2 to 10% of the residents terminate training prematurely. Infrequently, termination of training is by dismissal. Incidentally, residents may disagree, dispute and challenge these decisions from the programme directors. Resident dismissal is always a difficult decision, most commonly made after, repeated assessments, and triangulation of the resulting assessment data and one or more remediation attempts. Nevertheless, the underlying reasons for dismissal and the policies for remediation and dismissal may differ between training programmes. Such differences may however impact the chance of remediation success, the chance of dismissal and subsequent residents' appeals. Method: We included a total of 70 residents from two groups (community-based and hospital-based specialties) during 10 years of appeals. Subsequently, we compared these groups on factors potentially associated with the outcome of the conciliation board decision regarding the residents' dismissal. We focused herein on remediation strategies applied, and reasons reported to dismiss residents. Results: In both groups, the most alleged reason to dismiss residents was lack of trainability, > 97%. This was related to deficiencies in professionalism in community-based practice and medical expertise in hospital-based specialties respectively. A reason less frequently mentioned was endangerment of patient care, < 26%. However, none of these residents accused of endangerment, actually jeopardized the patients' health, probably due to the vigilance of their supervisors. Remediation strategies varied between the two groups, whereas hospital-based specialties preferred formal remediation plans in contrast to community-based practice. A multitude of remediation strategies per competency (medical expertise, professionalism, communication, management) were applied and described in these law cases. Discussion: Residents' appeals in community-based practice were significantly less likely to succeed compared to hospital-based specialties. Hypothesised explanatory factors underlying these differences include community-based practices' more prominent attention to the longitudinal assessment of professionalism, the presence of regular quarterly progress meetings, precise documentation of deficiencies, and discretion over the timing of dismissal in contrast to dismissal in the hospital-based specialties which is only formally possible during scheduled formal summative assessment meetings. [ABSTRACT FROM AUTHOR]

Background: It is important that healthcare professionals recognise cognitive dysfunction in hospitalised older patients in order to address associated care needs, such as enhanced involvement of relatives and extra cognitive and functional support. However, studies analysing medical records suggest that healthcare professionals have low awareness of cognitive dysfunction in hospitalised older patients. In this study, we investigated the prevalence of cognitive dysfunction in hospitalised older patients, the percentage of patients in which cognitive dysfunction was recognised by healthcare professionals, and which variables were associated with recognition. Methods: A multicentre, nationwide, cross-sectional observational study was conducted on a single day using a flash mob study design in thirteen university and general hospitals in the Netherlands. Cognitive function was assessed in hospitalised patients aged ≥ 65 years old, who were admitted to medical and surgical wards. A Mini-Cog score of < 3 out of 5 indicated cognitive dysfunction. The attending nurses and physicians were asked whether they suspected cognitive dysfunction in their patient. Variables associated with recognition of cognitive dysfunction were assessed using multilevel and multivariable logistic regression analyses. Results: 347 of 757 enrolled patients (46%) showed cognitive dysfunction. Cognitive dysfunction was recognised by attending nurses in 137 of 323 patients (42%) and by physicians in 156 patients (48%). In 135 patients (42%), cognitive dysfunction was not recognised by either the attending nurse or physician. Recognition of cognitive dysfunction was better at a lower Mini-Cog score, with the best recognition in patients with the lowest scores. Patients with a Mini-Cog score < 3 were best recognised in the geriatric department (69% by nurses and 72% by physicians). Conclusion: Cognitive dysfunction is common in hospitalised older patients and is poorly recognised by healthcare professionals. This study highlights the need to improve recognition of cognitive dysfunction in hospitalised older patients, particularly in individuals with less apparent cognitive dysfunction. The high proportion of older patients with cognitive dysfunction suggests that it may be beneficial to provide care tailored to cognitive dysfunction for all hospitalised older patients. [ABSTRACT FROM AUTHOR]

How do the educational trajectories of young people develop differently at the transition between lower and upper secondary education and training--even amongst students labelled as disadvantaged with regard to social background, gender or ethnicity? The aim of the article is to understand the role of decision-making in the emergence of educational trajectories. Based on the analysis of qualitative interviews with students from schools in disadvantaged areas, patterns of educational trajectories are discerned with regard to the ruptures they involve, the destinations they take and the degree of choice young people have. The in-depth analysis of exemplary cases, however, reveals that even within similar patterns of trajectories decision-making processes occur in different ways. Therefore, constellations of decision-making are elaborated which cross-cut the patterns of educational trajectories. The fact that both institutional structures of different education systems and individual biographical orientations do make a difference reveals the complexity of educational trajectories in the interplay of structure and agency.

Organ donation after euthanasia is performed in Belgium, the Netherlands, Canada and Spain. Directed deceased organ donation is currently possible under strict conditions in a limited number of countries, while it is currently not possible to opt for directed donation following euthanasia. While organ donation after euthanasia is a deceased donation procedure, directed organ donation after euthanasia could be seen as a deceased donation procedure with a living donation consent process. Therefore, directed organ donation after euthanasia is feasible on medical and ethical grounds. Strict safeguards should be in place, including the requirement of a pre-existing familial or personal relationship with the proposed recipient, without any evidence of coercion or financial gain. [ABSTRACT FROM AUTHOR]

Supporting the development of a professional identity is a primary objective in postgraduate education. Few empirical studies have explored professional identity formation (PIF) in residency, and little is known about supervisors' perceptions of their roles in residents' PIF. In this study, we sought to understand how supervisors perceive their roles in the PIF of General Practice (GP) residents. Guided by principles of qualitative description, we conducted eight focus groups with 55 supervisors at four General Practice training institutes across the Netherlands. Informed by a conceptual framework of PIF, we performed a thematic analysis of focus group transcripts. Three themes related to how GP supervisors described their roles in supporting residents' PIF: supervising with the desired goal of GP training in mind; role modeling and mentoring as key strategies to achieve that goal; and the value of developing bonds of trust to support the process. To our knowledge, this study is the first to explore PIF in GP training from the perspective of clinical supervisors. The identified themes mirror the components of the therapeutic alliance between doctors and patients from a supervisor's perspective and highlight the pivotal roles of the supervisor in a resident's PIF. [ABSTRACT FROM AUTHOR]

Introduction: Identifying costs and values in healthcare interventions as well as the ability to measure and consider costs relative to value for patients are pivotal in clinical decision-making and medical education. This study explores residents' preferences in educating value-based healthcare (VBHC) during postgraduate medical education. Exploring residents' preferences in VBHC education, in order to understand what shapes their choices, might contribute to improved medical residency education and healthcare as a whole.Methods: A discrete choice experiment (DCE) examined which conditions for educating VBHC are preferred by residents. DCE gives more insight into the trade-off's residents make when choosing alternatives, and which conditions for educating VBHC have the most influence on residents' preference.Results: This DCE shows that residents prefer knowledge on both medical practice as well as the process of care-to be educated by an expert on VBHC together with a clinician. They prefer limited protected time to conduct VBHC initiatives (thus while at work) and desire the inclusion of VBHC in formal educational plans.Conclusion: When optimising graduate and postgraduate medical education curricula, these preferences should be considered to create necessary conditions for the facilitation and participation of residents in VBHC education and the set-up of VBHC initiatives. [ABSTRACT FROM AUTHOR]

Although male Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) patients have higher Intensive Care Unit (ICU) admission rates and a worse disease course, a comprehensive analysis of female and male ICU survival and underlying factors such as comorbidities, risk factors, and/or anti-infection/inflammatory therapy administration is currently lacking. Therefore, we investigated the association between sex and ICU survival, adjusting for these and other variables. In this multicenter observational cohort study, all patients with SARS-CoV-2 pneumonia admitted to seven ICUs in one region across Belgium, The Netherlands, and Germany, and requiring vital organ support during the first pandemic wave were included. With a random intercept for a center, mixed-effects logistic regression was used to investigate the association between sex and ICU survival. Models were adjusted for age, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, comorbidities, and anti-infection/inflammatory therapy. Interaction terms were added to investigate effect modifications by sex with country and sex with obesity. A total of 551 patients (29% were females) were included. Mean age was 65.4 ± 11.2 years. Females were more often obese and smoked less frequently than males (p-value 0.001 and 0.042, respectively). APACHE II scores of females and males were comparable. Overall, ICU mortality was 12% lower in females than males (27% vs 39% respectively, p-value < 0.01) with an odds ratio (OR) of 0.62 (95%CI 0.39–0.96, p-value 0.032) after adjustment for age and APACHE II score, 0.63 (95%CI 0.40–0.99, p-value 0.044) after additional adjustment for comorbidities, and 0.63 (95%CI 0.39–0.99, p-value 0.047) after adjustment for anti-infection/inflammatory therapy. No effect modifications by sex with country and sex with obesity were found (p-values for interaction > 0.23 and 0.84, respectively). ICU survival in female SARS-CoV-2 patients was higher than in male patients, independent of age, disease severity, smoking, obesity, comorbidities, anti-infection/inflammatory therapy, and country. Sex-specific biological mechanisms may play a role, emphasizing the need to address diversity, such as more sex-specific prediction, prognostic, and therapeutic approach strategies. [ABSTRACT FROM AUTHOR]

Background: A patient who fulfils the due diligence requirements for euthanasia, and is medically suitable, is able to donate his organs after euthanasia in Belgium, the Netherlands and Canada. Since 2012, more than 70 patients have undergone this combined procedure in the Netherlands. Even though all patients who undergo euthanasia are suffering hopelessly and unbearably, some of these patients are nevertheless willing to help others in need of an organ. Organ donation after euthanasia is a so-called donation after circulatory death (DCD), Maastricht category III procedure, which takes place following cardiac arrest, comparable to donation after withdrawal of life sustaining therapy in critically ill patients. To minimize the period of organ ischemia, the patient is transported to the operating room immediately after the legally mandated no-touch period of 5 min following circulatory arrest. This means that the organ donation procedure following euthanasia must take place in the hospital, which appears to be insurmountable to many patients who are willing to donate, since they already spent a lot of time in the hospital.Case Presentation: This article describes the procedure of organ donation after euthanasia starting at home (ODAEH) following anesthesia in a former health care professional suffering from multiple system atrophy. This case is unique for at least two reasons. He spent his last conscious hours surrounded by his family at home, after which he underwent general anaesthesia and was intubated, before being transported to the hospital for euthanasia and organ donation. In addition, the patient explicitly requested the euthanasia to be performed in the preparation room, next to the operating room, in order to limit the period of organ ischemia due to transport time from the intensive care unit to the operating room. The medical, legal and ethical considerations related to this illustrative case are subsequently discussed.Conclusions: Organ donation after euthanasia is a pure act of altruism. This combined procedure can also be performed after the patient has been anesthetized at home and during transportation to the hospital. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Clear definitions for septic shock assist clinicians regarding recognition, treatment and standardized reporting of characteristics and outcome of this entity. Sepsis-3 definition of septic shock incorporates a new criterion, a lactate level >2mmol/L. Differences in epidemiology and outcome of septic shock based upon both definitions were studied in an intensive care (ICU) population of septic patients. Methods: We analyzed a prospectively collected cohort of data in the ICU of the Maastricht University Medical Centre. 632 septic patients were included. ICU mortality was compared between the patient group fulfilling Sepsis-3 definition for septic shock and those that met Sepsis-2 definition. Furthermore, association between lactate levels and ICU mortality was studied. Results: Of 632 septic patients, 482 (76.3%) had septic shock according to Sepsis-2 and 300 patients (48.4%) according to Sepsis-3 definition, respectively. Patients meeting Sepsis-3 definition had a higher mortality than patients meeting Sepsis-2 definition (38.9 vs. 34.0%). Serum lactate levels between 2 and 4mmol/L (25.0 vs. 26.2%, OR 0.94 (0.5-1.5)) and between 4 and 6mmol/L (23.8 vs. 26.2%, OR 0.88 (0.4-1.7)) compared to levels ≤2mmol/L were not associated with significantly higher ICU mortality. Serum lactate values ≥6mmol/L, were significantly associated with increased ICU mortality. Conclusion: Patients classified according to Sepsis-3 criteria had a higher ICU mortality compared with Sepsis-2 criteria. Lactate levels <6mmol/L were not able to identify patients with increased ICU mortality. Lactate threshold of 2mmol/L may be too low to point out patients with actual increased ICU mortality. [ABSTRACT FROM AUTHOR]

The use of mitochondrial DNA (mtDNA) for maternal lineage identification often marks the last resort when investigating forensic and missing-person cases involving highly degraded biological materials. As with all comparative DNA testing, a match between evidence and reference sample requires a statistical interpretation, for which high-quality mtDNA population frequency data are crucial. Here, we determined, under high quality standards, the complete mtDNA control-region sequences of 680 individuals from across the Netherlands sampled at 54 sites, covering the entire country with 10 geographic sub-regions. The complete mtDNA control region (nucleotide positions 16,024–16,569 and 1–576) was amplified with two PCR primers and sequenced with ten different sequencing primers using the EMPOP protocol. Haplotype diversity of the entire sample set was very high at 99.63% and, accordingly, the random-match probability was 0.37%. No population substructure within the Netherlands was detected with our dataset. Phylogenetic analyses were performed to determine mtDNA haplogroups. Inclusion of these high-quality data in the EMPOP database (accession number: EMP00666 ) will improve its overall data content and geographic coverage in the interest of all EMPOP users worldwide. Moreover, this dataset will serve as (the start of) a national reference database for mtDNA applications in forensic and missing person casework in the Netherlands. [ABSTRACT FROM AUTHOR]

The aims of this study were to analyze reproductive outcomes of women and men born very preterm (gestational age <32 weeks) or with a very low birth weight (<1500 g) in 1983 in the Netherlands and to compare their reproductive outcomes with the total population at a similar age of 28 years. Young adults who were born after a pregnancy complicated by very preterm (VP) delivery or with a very low birth weight (VLBW) in the Netherlands in 1983 (Project on Preterm and Small for Gestational Age Infants (POPS) cohort) were invited to complete an online questionnaire at the age of 28. In total, 293 POPS-28 participants (31.6 %) completed the questionnaire including 185 female and 108 male participants. Female and male participants who were born VP or with a VLBW had significant reduced reproductive rates compared to the total Dutch population at 28 years of age (female 23.2 vs 31.9 % and male 7.4 vs 22.2 %). Pregnancies of the female participants were in 14 % complicated by preterm delivery in at least one pregnancy. Conclusion: This study indicates that women and men born VP or with a VLBW have reduced reproductive rates at the age of 28 compared to the total Dutch population at a similar age. [ABSTRACT FROM AUTHOR]

Background: although proactive primary care, including early detection and treatment of community-dwelling frail older people, is a part of the national healthcare policy in several countries, little is known about its cost-effectiveness. Objective: to evaluate the cost-effectiveness of a proactive primary care approach in community-dwelling frail older people. Design and setting: embedded in a cluster randomised trial among 12 Dutch general practitioner practices, an economic evaluation was performed from a societal perspective with a time horizon of 24 months. Method: frail older people in the intervention group received an in-home assessment and interdisciplinary care based on a tailor-made treatment plan and regular evaluation and follow-up. Practices in the control group delivered usual care. The primary outcome for the cost-effectiveness and cost-utility analysis was disability and health-related quality of life, respectively. Results: multilevel analyses among 346 frail older people showed no significant differences between the groups regarding disability and health-related quality of life at 24 months. People in the intervention group used, as expected, more primary care services, but there was no decline in more expensive hospital and long-term care. Total costs over 24 months tended to be higher in the intervention group than in the control group (€26,503 versus €20,550, P = 0.08). Conclusions: the intervention under study led to an increase in healthcare utilisation and related costs without providing any beneficial effects. This study adds to the scarce amount of evidence of the cost-effectiveness of proactive primary care in community-dwelling frail older people. Trial registration: Current Controlled Trials, ISRCTN 31954692. [ABSTRACT FROM AUTHOR]

Background Chronic postsurgical pain ( CPSP) is a common complication of surgery with high impact on quality of life. Peripheral and central sensitization caused by enhanced and prolonged afferent nociceptive input are considered important mechanisms for the development of CPSP. This case-control study investigated whether epidural analgesia is associated with a reduced incidence of CPSP after open abdominal surgery. Methods Six months after surgery, Short- Form-36 Health Survey ( SF-36) pain scores, possible predictors of chronic pain, and quality of life were assessed. Patients treated with epidural analgesia in combination with general anesthesia (epidural group, N = 51) were compared to patients undergoing matched surgical procedures receiving general anesthesia alone ( GA-group, N = 50). Multivariate analysis was performed by logistic regression analysis. Results Twenty-six (25.7%) patients experienced chronic pain, 9 in the epidural group (17.6%), 17 in the GA-group (34%), crude odds ratio ( OR) 0.42 (95% confidence interval ( CI) 0.16 to 1.05). After adjustment for the most prominent predictors of CPSP, such as age, sex, pre-operative pain, and acute postoperative pain, the OR for chronic pain in the epidural group was 0.19 (95% CI 0.05 to 0.76). Patients with CPSP reported a significantly lower quality of life compared to patients without CPSP ( SF-36 total score median ( IQR) 39.2 (27.2 to 56.7) vs. 84.3 (69.9 to 92.5, P < 0.001) and a lower level of long-term global perceived recovery (70.0% (50.0 to 80.0) vs. 90.0% (80.0 to 100.0), P < 0.001). Conclusion Chronic postsurgical pain occurs in a significant number of patients 6 months after open abdominal surgery. Postoperative epidural analgesia is associated with a reduced incidence of CPSP after abdominal surgery. [ABSTRACT FROM AUTHOR]

Aim The aim of this study was to examine the incidence, placental characteristics and outcome in acute peripartum twin-twin transfusion syndrome ( TTTS). Material and Methods All consecutive cases of monochorionic ( MC) twins admitted to our center were included in the study. We excluded cases with chronic TTTS or twin anemia polycythemia sequence. Acute peripartum TTTS was defined when the inter-twin hemoglobin difference at birth was >8 g/dL. Results A total of 241 MC twin pregnancies were included in the study. Acute peripartum TTTS was detected in six cases (2.5%, 6/241). Vaginal delivery occurred more often in the acute peripartum TTTS group compared to the control group of uncomplicated MC pregnancies, 100% (6/6) versus 57% (135/235) ( P = 0.002), respectively. Acute anemia was detected only in firstborn twins. Placental angioarchitecture in acute peripartum TTTS was similar to the placentas in the control group. Conclusions The incidence of acute peripartum TTTS is low (2.5%). Birth order and mode of delivery appear to be associated with increased risk of acute peripartum TTTS. [ABSTRACT FROM AUTHOR]

Background Refusal to consent to organ donation is an important cause of the persisting gap between the number of potential organ donors and effectuated donors. In the Netherlands, organ donors include both uncontrolled donors: donors who die unexpectedly after cardiac death (DCD), after failed resuscitation and donors in whom death can be expected and donors after brain death, and controlled DCD donors: those who die after the withdrawal of treatment. Different donor type implies a different setting in which relatives are requested to consent to organ donation. It is unknown whether the setting influences the eventual decision for donation or not. Therefore, we compared the consent rate in potential donors who died unexpectedly (UD group) and in whom death was expected. Methods A total of 523 potential organ donors between 2003 and 2011 in the 715-bed Maastricht University Medical Centre, the Netherlands were included. Both the patients' registration in the national donor register (DR) and the relatives' refusal rate in the two groups were retrospectively assessed using data from the donation application database. Results There were 109 unexpected and 414 expected potential donors The potential donors in the UD group were younger (mean age 52 versus55 years, P = 0.032) and more often male (68 versus 52%, P = 0.003). There were no significant differences in registration in the DR between the groups. The relatives' consent rate in non-registered potential donors, or those who mandated the relatives for that decision, was higher in the UD group (53 versus 29%, P < 0.001). Conclusions Less than 50% of the potential donors were registered in the national DR. Therefore, the relatives have an important role in the choice for organ donation. The relatives of potential donors who died unexpectedly consented more often to donation than those in whom death was expected. [ABSTRACT FROM AUTHOR]

Background: Extremely preterm infants are at high risk of neonatal mortality and adverse outcome. Survival rates are slowly improving, but increased survival may come at the expense of more handicaps. Methodology/Principal Findings: Prospective population-based cohort study of all infants born at 23 to 27 weeks of gestation in the Netherlands in 2007. 276 of 345 (80%) infants were born alive. Early neonatal death occurred in 96 (34.8%) live born infants, including 61 cases of delivery room death. 29 (10.5%) infants died during the late neonatal period. Survival rates for live born infants at 23, 24, 25 and 26 weeks of gestation were 0%, 6.7%, 57.9% and 71% respectively. 43.1% of 144 surviving infants developed severe neonatal morbidity (retinopathy of prematurity grade ≥3, bronchopulmonary dysplasia and/or severe brain injury). At two years of age 70.6% of the children had no disability, 17.6% was mild disabled and 11.8% had a moderate-to-severe disability. Severe brain injury (p = 0.028), retinopathy of prematurity grade ≥3 (p = 0.024), low gestational age (p = 0.019) and non-Dutch nationality of the mother (p = 0.004) increased the risk of disability. Conclusions/Significance: 52% of extremely preterm infants born in the Netherlands in 2007 survived. Surviving infants had less severe neonatal morbidity compared to previous studies. At two years of age less than 30% of the infants were disabled. Disability was associated with gestational age and neonatal morbidity. [ABSTRACT FROM AUTHOR]

Background: Ventilator-induced lung injury has been recognized as a major contributing factor for bronchopulmonary dysplasia (BPD) in preterm infants. In the last decade, focus has shifted towards a more gentle respiratory approach. Aim: To evaluate whether guideline changes in respiratory management in the delivery room and the unit improved the incidence of BPD in very preterm infants. Methods: Three cohorts of infants <30 weeks of gestation, born at the Leiden University Medical Center in the Netherlands in 1996-1997 (cohort '96), 2003-2004 (cohort '03) and 2008-2009 (cohort '08), were compared retrospectively. The major change was increasing use of continuous positive airway pressure in time, and monitoring the tidal volume during mechanical ventilation in cohort '08. The primary outcome was BPD at 36 weeks. Results: The incidence of BPD did not change from 47% in cohort '96 to 55% in cohort '03 (n.s.), but decreased significantly to 37% in cohort '08 (cohort '96 vs. '08 and cohort '03 vs. '08: p < 0.01). We observed the same effect when only moderate and severe BPD were counted with 27% in cohort '96, 31% in cohort '03 and 14% in '08 (cohort '96 vs. '03: p = n.s., cohort '96 vs. '08: p < 0.01, cohort '03 vs. '08: p < 0.05). The mortality rate was not significantly different between the three cohorts. Conclusion: The incidence of BPD in our cohort of preterm infants has decreased during the last decade and could be due to the changes in respiratory management. Copyright © 2012 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

BACKGROUND: Despite limited data, international guidelines recommend the use of intravenous immunoglobulin (IVIg) in neonates with rhesus hemolytic disease. OBJECTIVE: We tested whether prophylactic use of IVIg reduces the need for exchange transfusions in neonates with rhesus hemolytic disease. DESIGN AND SETTING: We performed a randomized, double-blind, placebo-controlled trial in neonates with rhesus hemolytic disease. After stratification for treatment with intrauterine transfusion, neonates were randomly assigned for IVIg (0.75 g/kg) or placebo (5% glucose). The primary outcome was the rate of exchange transfusions. Secondary outcomes were duration of phototherapy, maximum biliru- bin levels, and the need of top-up red-cell transfusions. RESULTS: Eighty infants were included in the study, 53 of whom (66%) were treated with intrauterine transfusion (s). There was no difference in the rate of exchange transfusions between the IVIg and placebo groups (7 of 41 [17%] vs6of39 [15%]; P = .99) and in the number of exchange transfusions per patient (median [range]: 0 [0-2] vs 0 [0-2]; P = .90) or in duration of phototherapy (4.7 [1.8] vs 5.1 [2.1] days; P = .34), maximum bilirubin levels (14.8 [4.7] vs 14.1 [4.9] mg/dL; P= .52), and proportion of neonates who required top-up red-cell transfusions (34 of 41 [83%] vs 34 of 39 [87%]; P = .76). CONCLUSIONS: Prophylactic IVIg does not reduce the need for exchange transfusion or the rates of other adverse neonatal outcomes. Our findings do not support the use of IVIg in neonates with rhesus hemolytic disease. [ABSTRACT FROM AUTHOR]

Background: From 2002 onwards, a nationwide working group of representatives from all medical (8), dental (3) and veterinary medicine (1) schools collaborated in order to develop and implement recommendations for teaching and assessing professional behaviour. Aim: The aim of this article is to describe the outcomes of this process, including hurdles encountered and challenges to be met. Method: By a qualitative survey, information was requested on teaching professional behaviour, assessment, instruments used, consequences of unprofessional behaviour and faculty training. Results: All schools have adopted at least parts of the 2002 recommendations. Differences exist mainly in the organisational structure of teaching and assessment as well as in the assessment instruments used. In all schools a longitudinal assessment of professional behaviour was accomplished. Conclusion: All schools involved have made progress since 2002 with regard to teaching and assessment of professional behaviour, resulting in a shift from an instrumental to a cultural change for some schools. A stimulating factor was society's call to focus on patient safety and therefore on assessment of unprofessional behaviour. Hurdles yet to be taken are the involvement of students in the assessment process, teacher confidence in personal assessment capacities, remediation programmes and logistic and administrative support. [ABSTRACT FROM AUTHOR]

Background: New national guidelines recommend more restricted fluid intake and early initiation of total parenteral nutrition (TPN) in very preterm infants. The aim was study the effect of these guidelines on serum sodium and potassium levels and fluid balance in the first three days after birth. Methods: Two cohorts of infants <28 weeks gestational age, born at the Leiden University Medical Center in the Netherlands, were compared retrospectively before (2002-2004, late-TPN) and after (2006-2007, early-TPN) introduction of the new Dutch guideline. Outcome measures were serum sodium and potassium levels, diuresis, and changes in body weight in the first three postnatal days. Results: In the first three postnatal days no differences between late-TPN (N = 70) and early-TPN cohort (N = 73) in mean (SD) serum sodium (141.1 (3.8) vs 141.0 (3.7) mmol/l) or potassium (4.3 (0.5) vs 4.3 (0.5) mmol/l) were found, but in the early-TPN cohort diuresis (4.5 (1.6) vs 3.2 (1.4) ml/kg/h) and loss of body weight were decreased (-6.0% (7.7) vs -0.8% (8.0)). Conclusions: Initiation of TPN immediately after birth and restricted fluid intake in very preterm infants do not seem to influence serum sodium and potassium levels in first three postnatal days. Further research is needed to see if a decreased diuresis and loss of body weight in the first days is the result of a delayed postnatal adaptation or better energy balance. [ABSTRACT FROM AUTHOR]

Aim: To determine if selective intubation, use of early nasal continuous positive airway pressure (NCPAP) at birth with a low threshold for early surfactant treatment, reduces the need for intubation in very preterm infants in the first days after birth. Methods: Two cohorts of very preterm infants ≤ 32 weeks, born at the Leiden University Medical Center in the Netherlands, were compared retrospectively before (1996–1997) and after (2003–2004) introducing selective intubation and use of early NCPAP. A FiO2≥ 0.40 was used as criterion for intubation. Primary outcome measure was intubation < 72 h of age. Bronchopulmonary dysplasia (BPD) was a secondary outcome. Results: The rate of intubation in the delivery room (69% vs. 46%, p < 0.001) and within 72 h of age (73% vs. 57%, p < 0.001) was lower following the change in policy. Early NCPAP was, in 2003–2004, increasingly used as primary treatment (10% vs. 33%, p < 0.001) with higher maximum NCPAP levels (4.0 (0.9) vs. 5.8 (1.5), p < 0.001). There was no change in BPD (14.3% vs. 15.2%, p = 0.82). Conclusion: Avoiding intubation by using early NCPAP while maintaining a low-threshold for surfactant treatment decreased the need for intubation. [ABSTRACT FROM AUTHOR]

We evaluated the effects of platelet transfusions and intravenous immunoglobulin (IVIG) in neonates with fetal and neonatal alloimmune thrombocytopenia (FNAIT) with and without antenatal treatment with IVIG. Records of neonates with FNAIT admitted between January 2000 and November 2005 were reviewed. The patients were divided into group I, treated antenatally with IVIG for known FNAIT, and group II, postnatally diagnosed with FNAIT. The primary outcome was the time interval to reach a platelet level above 100 x 10(9)/L in relation to the type of treatment. Nineteen neonates with FNAIT were identified, 13 in group I and 6 in group II. In group I, four children were born with a platelet count above 100 x 10(9)/L and never needed treatment, and four received a single matched platelet transfusion at birth with a maintained response. Five neonates received IVIG and one matched transfusion, with all but one rapidly responding. In antenatally treated cases, postnatal IVIG had no apparent effect on the platelet count. In group II, two neonates died on day 1 with severe intracranial hemorrhage. Two of the four other patients responded to a number of unmatched platelet transfusions, with one neonate rapidly responding after one matched transfusion, while another needed nine matched transfusions before a persistent adequate platelet count was reached after 9 weeks. Postnatal IVIG had no apparent effect on the platelet count in any of our cases. In neonates with FNAIT treated antenatally with IVIG, neonatal management using a single matched platelet transfusion was adequate in all cases. In neonatally diagnosed cases not treated before birth, multiple matched platelet transfusions may be required. We found no evidence to support the use of IVIG in neonates with FNAIT. [ABSTRACT FROM AUTHOR]

AbstractApproximately 40 years ago, Dr. Peter Dunn introduced a simple method to determine the insertion length of umbilical catheters in neonates, by using the ‘shoulder-umbilical’ (S-U) length. Since then, various studies have reported a high rate of malposition of umbilical catheters. One of the possible reasons is that the method used to determine the S-U length varies among paediatric professionals. We performed a questionnaire study among 101 paediatric professionals in the Netherlands and found that the method used by the participants to measure the S-U length was highly inconsistent. Placement of an umbilical venous catheter in a too deep position may lead to potentially life-threatening complications. Therefore, uniformity in measurement is paramount for clinical and teaching purposes. Paediatric professionals using Dunn’s definition to place umbilical catheters should adhere more strictly to the original description of the measurement of the S-U length.Copyright © 2008 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

The article presents a study which investigates the presence of human metapneumovirus (hMPV) in critically ill patients. The study conducted bronchoalveolar lavage (BAL) cytological analysis and culture in the 18-bed general intensive care unit (ICU) of the Maastricht University Medical Centre in the Netherlands. Results show that hMPV may have caused the respiratory deterioration in critically ill patients with suspected pneumonia and subsequent mechanical ventilation is needed.

Describes a walking aid for people with walking disabilities, developed in the Netherlands. Features of the walking aid; Materials used in the development of the device; Problem with using saddle for a long period.

The article discusses research investigating effectiveness of interdisciplinary primary care strategies in reducing disability and functional decline in frail elderly people. It reports use of a computer-generated list in the cluster randomised controlled trial. It describes participant selection process conducted, measurement of primary outcomes, and patient follow-up rates recorded. It also outlines disability scores gathered using the Groningen Activity Restriction Sale.

Background: Teaching and assessment of professional behaviour (PB) has been receiving increasing attention in the educational literature and educational practice. Although the focus tends to be summative aspects, it seems perfectly feasible to combine formative and summative approaches in one procedural approach. Aims and method: Although, many examples of frameworks of professionalism and PB can be found in the literature, most originate from North America, and only few are designed in other continents. This article presents the framework for PB that is used at Maastricht medical school, the Netherlands. Results: The approach to PB used in the Dutch medical schools is described with special attention to 4 years (2005-2009) of experience with PB education in the first 3 years of the 6-year undergraduate curriculum of Maastricht medical school. Future challenges are identified. Conclusions: The adages 'Assessment drives learning' and 'They do not respect what you do not inspect' [Cohen JJ. 2006. Professionalism in medical education, an American perspective: From evidence to accountability. Med Educ 40, 607-617] suggest that formative and summative aspects of PB assessment can be combined within an assessment framework. Formative and summative assessments do not represent contrasting but rather complementary approaches. The Maastricht medical school framework combines the two approaches, as two sides of the same coin. [ABSTRACT FROM AUTHOR]

Objectives: Spinal muscular atrophy (SMA) is a rare genetic disorder that causes progressive muscle weakness and paralysis. In its most common and severe form, the majority of untreated infants die before 2 years of age. Early detection and treatment, ideally before symptom onset, maximize survival and achievement of age-appropriate motor milestones, with potentially substantial impact on health-related quality of life. Therefore, SMA is an ideal candidate for inclusion in newborn screening (NBS) programs. We evaluated the cost-effectiveness of including SMA in the NBS program in The Netherlands.Methods: We developed a cost-utility model to estimate lifetime health effects and costs of NBS for SMA and subsequent treatment versus a treatment pathway without NBS (ie, diagnosis and treatment after presentation with overt symptoms). Model inputs were based on literature, local data, and expert opinion. Sensitivity and scenario analyses were conducted to assess model robustness and validity of results.Results: After detection of SMA by NBS in 17 patients, the number of quality-adjusted life-years gained per annual birth cohort was estimated at 320 with NBS followed by treatment compared with treatment after clinical SMA diagnosis. Total healthcare costs, including screening, diagnostics, treatment, and other healthcare resource use, were estimated to be €12 014 949 lower for patients identified by NBS.Conclusions: NBS for early identification and treatment of SMA versus later symptomatic treatment after clinical diagnosis improves health outcomes and is less costly and, therefore, is a cost-effective use of resources. Results were robust in sensitivity and scenario analyses. [ABSTRACT FROM AUTHOR]

Euthanasia is categorically prohibited in almost all countries throughout the world. In Belgium and the Netherlands, combining euthanasia and subsequent organ donation in a so-called donation after circulatory-death (DCD) procedure is feasible on legal and medical grounds, and is increasingly gaining social and ethical acceptance. However, heart transplantation after DCD is currently not performed in Belgium and the Netherlands after euthanasia due to concerns surrounding the prolonged warm ischemia time associated with DCD and its effect on subsequent heart function. A number of patients who undergo euthanasia explicitly express their wish to donate their organs in a "living organ donation" procedure, which then causes death. Assuming that euthanasia is permitted, as expressed in Dutch and Belgian legislation, this exploratory article addresses whether it is legally and ethically sound to donate organs, especially the heart, as a living donor and to perform euthanasia in the same procedure in a patient who fulfills the due diligence requirements for euthanasia. Organ donation euthanasia (ODE) would then cause death by the associated surgical procedure, and in addition would improve the quality of the other donated organs, a procedure that would fully respect the patient's autonomy. [ABSTRACT FROM AUTHOR]

The article provides information on a study which identified patient and treatment characteristics that may accurately predict which potential donation after cardiac death (DCD) donors die within 60 or 12 minutes, in whom a donation procedure should be started. The prospective multicenter study identified all potential donation after cardiac death donors on the Netherlands from May 2007 to June 2009. It also identified risk factors for early death.