Publications by authors named "Walther N K A van Mook"

81 Publications

Positive Health dialogue tool and value-based healthcare: a qualitative exploratory study during residents' outpatient consultations.

BMJ Open 2021 Nov 24;11(11):e052688. Epub 2021 Nov 24.

School of Health Professions Education, Maastricht University, Maastricht, The Netherlands.

Objective: To explore how residents experienced the application of the Positive Health dialogue tool (PH-tool) during outpatient consultations and its influence on the delivery of value-based healthcare (VBHC).

Design: Qualitative study using non-participant observations of outpatient consultations during which residents used the PH-tool, followed by longitudinal individual, semistructured interviews. To analyse the data from observations and interviews, observational form notes' summarisation and categorisation, and an iterative-inductive thematic approach was used.

Participants: Eight residents-five from the ear, nose, and throat-department and three from the gastroenterology-hepatology-department-were selected through convenience sampling, accounting for 79 observations and 79 interviews.

Results: Residents had bivalent experiences with using the PH-tool. Residents discussed three main benefits: a gained insight into the individual patient's context and functioning, a changed dynamics in resident-patient communication, and an increased awareness regarding value in terms of patient-related outcomes and healthcare costs. Three barriers became apparent: doubts regarding the PH-tool's relevance and scope, boundaries of superspecialised medical professionals, and a lack of demarcation in clinical practice.

Conclusion: The PH-tool use can be beneficial for residents during outpatient consultations with new patients and follow-up in cases of multidimensional problems, particularly in cases of chronic conditions and generalist care. In these situations, the tool yielded valuable patient information beyond physical health, helped foster patient engagement, and enabled tailoring the treatment plan to individual patients' needs. On the other hand, the PH-tool was not a good fit for simple problems, clearly demarcated help requests, periodic follow-up consultations, or verbose patients. In addition, it was not suitable for superspecialised care, because it yielded an abundance of general information. For particular patients and problems, using the PH-tool seems a promising strategy to increase VBHC delivery. Nevertheless, further research and detailing is needed to better align the PH-tool's broad intent and clinical practice.
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http://dx.doi.org/10.1136/bmjopen-2021-052688DOI Listing
November 2021

The QUality of Interhospital Transportation in the Euregion Meuse-Rhine (QUIT-EMR) score: a cross-validation study.

BMJ Open 2021 Nov 19;11(11):e051100. Epub 2021 Nov 19.

Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.

Objectives: Interhospital transports of critically ill patients are high-risk medical interventions. Well-established parameters to quantify the quality of transports are currently lacking. We aimed to develop and cross-validate a score for interhospital transports.

Setting: An expert panel developed a score for interhospital transport by a Mobile Intensive Care Unit (MICU), the QUality of Interhospital Transportation in the Euregion Meuse-Rhine (QUIT-EMR) score. The QUIT-EMR score is an overall sum score that includes component scores of monitoring and intervention variables of the neurological (proxy for airway patency), respiratory and circulatory organ systems, ranging from -12 to +12. A score of 0 or higher defines an adequate transport. The QUIT-EMR score was tested to help to quantify the quality of transport.

Participants: One hundred adult patients were randomly included and the transport charts were independently reviewed and classified as adequate or inadequate by four transport experts (ie, anaesthetists/intensivists).

Outcome Measures: Subsequently, the level of agreement between the QUIT-EMR score and expert classification was calculated using Gwet's AC.

Results: From April 2012 to May 2014, a total of 100 MICU transports were studied. The median (IQR) QUIT-EMR score was 1 (0-2). Experts classified six transports as inadequate. The percentage agreement between the QUIT-EMR score and experts' classification for adequate/inadequate transport ranged from 84% to 92% (Gwet's AC0.81-0.91). The interobserver agreement between experts was 87% to 94% (Gwet's AC0.89-0.98).

Conclusion: The QUIT-EMR score is a novel validated tool to score MICU transportation adequacy in future studies contributing to quality control and improvement.

Trial Registration Number: NTR 4937.
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http://dx.doi.org/10.1136/bmjopen-2021-051100DOI Listing
November 2021

Moral distress and ethical climate in intensive care medicine during COVID-19: a nationwide study.

BMC Med Ethics 2021 06 17;22(1):73. Epub 2021 Jun 17.

Department of Intensive Care, Maastricht University Medical Center+, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.

Background: The COVID-19 pandemic has created ethical challenges for intensive care unit (ICU) professionals, potentially causing moral distress. This study explored the levels and causes of moral distress and the ethical climate in Dutch ICUs during COVID-19.

Methods: An extended version of the Measurement of Moral Distress for Healthcare Professionals (MMD-HP) and Ethical Decision Making Climate Questionnaire (EDMCQ) were online distributed among all 84 ICUs. Moral distress scores in nurses and intensivists were compared with the historical control group one year before COVID-19.

Results: Three hundred forty-five nurses (70.7%), 40 intensivists (8.2%), and 103 supporting staff (21.1%) completed the survey. Moral distress levels were higher for nurses than supporting staff. Moral distress levels in intensivists did not differ significantly from those of nurses and supporting staff. "Inadequate emotional support for patients and their families" was the highest-ranked cause of moral distress for all groups of professionals. Of all factors, all professions rated the ethical climate most positively regarding the culture of mutual respect,  ethical awareness and support. "Culture of not avoiding end-of-life-decisions" and "Self-reflective and empowering leadership" received the lowest mean scores. Moral distress scores during COVID-19 were significantly lower for ICU nurses (p < 0.001) and intensivists (p < 0.05) compared to one year prior.

Conclusion: Levels and causes of moral distress vary between ICU professionals and differ from the historical control group. Targeted interventions that address moral distress during a crisis are desirable to improve the mental health and retention of ICU professionals and the quality of patient care.
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http://dx.doi.org/10.1186/s12910-021-00641-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8211309PMC
June 2021

Perception of social media behaviour among medical students, residents and medical specialists.

Perspect Med Educ 2021 08 7;10(4):215-221. Epub 2021 Apr 7.

Academy for Postgraduate Medical Training, Maastricht University Medical Centre, Maastricht, The Netherlands.

Introduction: Behaviour is visible in real-life events, but also on social media. While some national medical organizations have published social media guidelines, the number of studies on professional social media use in medical education is limited. This study aims to explore social media use among medical students, residents and medical specialists.

Methods: An anonymous, online survey was sent to 3844 medical students at two Dutch medical schools, 828 residents and 426 medical specialists. Quantitative, descriptive data analysis regarding demographic data, yes/no questions and Likert scale questions were performed using SPSS. Qualitative data analysis was performed iteratively, independently by two researchers applying the principles of constant comparison, open and axial coding until consensus was reached.

Results: Overall response rate was 24.8%. Facebook was most popular among medical students and residents; LinkedIn was most popular among medical specialists. Personal pictures and/or information about themselves on social media that were perceived as unprofessional were reported by 31.3% of students, 19.7% of residents and 4.1% of medical specialists. Information and pictures related to alcohol abuse, partying, clinical work or of a sexually suggestive character were considered inappropriate. Addressing colleagues about their unprofessional posts was perceived to be mainly dependent on the nature and hierarchy of the interprofessional relation.

Discussion: There is a widespread perception that the presence of unprofessional information on social media among the participants and their colleagues is a common occurrence. Medical educators should create awareness of the risks of unprofessional (online) behaviour among healthcare professionals, as well as the necessity and ways of addressing colleagues in case of such lapses.
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http://dx.doi.org/10.1007/s40037-021-00660-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8368941PMC
August 2021

Resumption of Cardiac Activity after Withdrawal of Life-Sustaining Measures.

N Engl J Med 2021 01;384(4):345-352

From the Children's Hospital of Eastern Ontario (S.D.), Children's Hospital of Eastern Ontario Research Institute (S.D., L.H., A. van Beinum, M.H., H.T.), Faculty of Medicine (S.D.) and Centre for Health Law, Policy, and Ethics (J.A.C.), University of Ottawa, Canadian Blood Services (L.H., S.D.S.), Carleton University (A. van Beinum), the Dynamical Analysis Lab (N.B.S., C.H., A.S.), Clinical Epidemiology Program (N.B.S., C.H., A.S.), and Clinical Epidemiology Program Methods Centre (T.R.), Ottawa Hospital Research Institute, the Departments of Critical Care and General Surgery (G.P.) and Surgery (A.S.) and Division of Thoracic Surgery (A.S.), Ottawa Hospital, and Interventional Cardiology Program, University of Ottawa Heart Institute (D. So), Ottawa, the Department of Critical Care, Trauma and Neurosurgery Program, St. Michael's Hospital (A. Baker), Li Ka Shing Knowledge Institute, Unity Health-St. Michael's Hospital (J.O.F., D. Scales), University of Toronto (J.O.F.), Mount Sinai Hospital (S.M., L.M.) and Interdepartmental Division of Critical Care Medicine (S.M., L.M., D. Scales), University of Toronto, Department of Critical Care Medicine, Sunnybrook Health Sciences Centre (D. Scales), and the Canadian Donation and Transplantation Research Program (H.T.), Toronto, the Departments of Critical Care and Anesthesia, Dalhousie University, Halifax, NS (S.B.), the Departments of Medicine and Critical Care Medicine, Queen's University, Kingston, ON (J.G.B., D.M.M.), the Department of Medicine (Critical Care), Research Centre of the University of Montreal Hospital (M.C.), the Department of Critical Care, Division of Pulmonary Medicine, McGill University (J.S.), McGill University Health Centre and Research Institute (J.S., S.D.S.), Transplant Québec (M.W.), and the Division of Critical Care, Montreal Children's Hospital (S.D.S.), Montreal, the Department of Anesthesiology, Université de Sherbrooke and Centre de Recherche du Centre Hospitalier Universitaire (CHU) de Sherbrooke, Sherbrooke, QC (F. D'Aragon), the Departments of Critical Care Medicine, Community Health Sciences, and Medicine, Cumming School of Medicine (C.J.D.), and the Departments of Critical Care Medicine and Clinical Neurosciences (A.H.K.), University of Calgary, and Calgary Zone, Alberta Health Services (C.J.D.), Calgary, the Department of Clinical Neurological Sciences, London Health Sciences Centre (T.G.), Schulich School of Medicine and Dentistry (T.G.), the Department of Psychology, King's University College (L.N.), and the Department of Medicine and the Brain and Mind Institute (M. Slessarev), Western University, London, ON, the Division of Critical Care, Departments of Medicine and Anesthesia, University of British Columbia, Vancouver (G.I.), the Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton (D.J.K.), the Department of Medicine, McMaster University, and Hamilton Health Sciences Centre, Hamilton, ON (M.M.), and the Division of Pediatric Intensive Care, CHU de Québec, Centre Mère-Enfant Soleil, and the Department of Pediatrics, Faculté de Médecine, Université Laval, Quebec City, QC (M.W.) - all in Canada; Safar Center for Resuscitation Research, Critical Care Medicine Department, University of Pittsburgh School of Medicine, Pittsburgh (C.D.); Charles University, Third Faculty of Medicine and FNKV University Hospital (F. Duska, M. Schmidt, P.W.), and the Department of Palliative Medicine, First Faculty of Medicine, Charles University and General University Hospital (K.R.), Prague, Czech Republic; NHS Blood and Transplant, Bristol (D.G., D.H.), and Adult Critical Care, Nottingham University Hospitals NHS Trust, Nottingham (D.G., D.H.) - both in the United Kingdom; and the Department of Intensive Care Medicine, Maastricht University Medical Center, and the School of Health Professions Education, Maastricht University (W.N.K.A.M.), and the Heart and Vascular Center, Maastricht University Medical Center (J.T.W.), Maastricht, the Netherlands.

Background: The minimum duration of pulselessness required before organ donation after circulatory determination of death has not been well studied.

Methods: We conducted a prospective observational study of the incidence and timing of resumption of cardiac electrical and pulsatile activity in adults who died after planned withdrawal of life-sustaining measures in 20 intensive care units in three countries. Patients were intended to be monitored for 30 minutes after determination of death. Clinicians at the bedside reported resumption of cardiac activity prospectively. Continuous blood-pressure and electrocardiographic (ECG) waveforms were recorded and reviewed retrospectively to confirm bedside observations and to determine whether there were additional instances of resumption of cardiac activity.

Results: A total of 1999 patients were screened, and 631 were included in the study. Clinically reported resumption of cardiac activity, respiratory movement, or both that was confirmed by waveform analysis occurred in 5 patients (1%). Retrospective analysis of ECG and blood-pressure waveforms from 480 patients identified 67 instances (14%) with resumption of cardiac activity after a period of pulselessness, including the 5 reported by bedside clinicians. The longest duration after pulselessness before resumption of cardiac activity was 4 minutes 20 seconds. The last QRS complex coincided with the last arterial pulse in 19% of the patients.

Conclusions: After withdrawal of life-sustaining measures, transient resumption of at least one cycle of cardiac activity after pulselessness occurred in 14% of patients according to retrospective analysis of waveforms; only 1% of such resumptions were identified at the bedside. These events occurred within 4 minutes 20 seconds after a period of pulselessness. (Funded by the Canadian Institutes for Health Research and others.).
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http://dx.doi.org/10.1056/NEJMoa2022713DOI Listing
January 2021

Bail-out extracorporeal membrane oxygenation for hydroxychloroquine intoxication: a warning for COVID-19 health-care givers.

Acta Cardiol 2021 Apr 14;76(2):200-203. Epub 2020 Dec 14.

Department of Intensive Care and Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands.

This case report describes an intentional intoxication with 18 g of hydroxychloroquine (HCQ) presenting with unconsciousness, ventricular dysrhythmias, cardiogenic shock and pulmonary oedema. Initial treatment consisted of sodium bicarbonate, lipid emulsion, diazepam and norepinephrine. Because of persistent cardiogenic shock veno-arterial extracorporeal membrane oxygenation (V-A ECMO) was successfully used as a bridge to recovery. This case underscores the possible side effects of HCQ and the importance of considering ECMO in cardiogenic shock caused by HCQ intoxication which may occur also in patients with coronavirus disease 2019 (COVID-19) based on the currently frequent use of such a compound.
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http://dx.doi.org/10.1080/00015385.2020.1802903DOI Listing
April 2021

The "sex gap" in COVID-19 trials: a scoping review.

EClinicalMedicine 2020 Dec 30;29:100652. Epub 2020 Nov 30.

Department of Obstetrics and Gynaecology, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands.

Background: Many studies investigate the role of pharmacological treatments on disease course in Corona Virus Disease 2019 (COVID-19). Sex disparities in genetics, immunological responses, and hormonal mechanisms may underlie the substantially higher fatality rates reported in male COVID-19 patients. To optimise care for COVID-19 patients, prophylactic and therapeutic studies should include sex-specific design and analyses. Therefore, in this scoping review, we investigated whether studies on pharmacological treatment in COVID-19 were performed based on a priori sex-specific design or post-hoc sex-specific analyses.

Methods: We systematically searched PubMed, EMBASE, UpToDate, clinical trial.org, and MedRxiv for studies on pharmacological treatment for COVID-19 until June 6th, 2020. We included case series, randomized controlled trials, and observational studies in humans (≥18 years) investigating antiviral, antimalarial, and immune system modulating drugs. Data were collected on 1) the proportion of included females, 2) whether sex stratification was performed (a priori by design or post-hoc), and 3) whether effect modification by sex was investigated.

Findings: 30 studies were eligible for inclusion, investigating remdesivir ( = 2), lopinavir/ritonavir ( = 5), favipiravir ( = 1), umifenovir ( = 1), hydroxychloroquine/chloroquine ( = 8), convalescent plasma ( = 6), interleukin-6 (IL-6) pathway inhibitors ( = 5), interleukin-1 (IL-1) pathway inhibitors ( = 1) and corticosteroids ( = 3). Only one study stratified its data based on sex in a post-hoc analysis, whereas none did a priori by design. None of the studies investigated effect modification by sex. A quarter of the studies included twice as many males as females.

Interpretation: Analyses assessing potential interference of sex with (side-)effects of pharmacological therapy for COVID-19 are rarely reported. Considering sex differences in case-fatality rates and genetic, immunological, and hormonal mechanisms, studies should include sex-specific analyses in their design to optimise COVID-19 care.

Funding: None.
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http://dx.doi.org/10.1016/j.eclinm.2020.100652DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7701906PMC
December 2020

Preferred teaching styles of medical faculty: an international multi-center study.

BMC Med Educ 2020 Nov 30;20(1):480. Epub 2020 Nov 30.

Faculty of Medicine, University of Gezira, Gezira, Sudan.

Background: In the current wave of educational reforms, understanding teaching styles of medical faculty can help modify instructional strategies for effective teaching. Few studies have probed distinctive teaching styles of medical faculty. We compared preferred teaching styles of faculty from seven medical schools in United Arab Emirates, the Netherlands, Saudi Arabia, Malaysia, Pakistan, and Sudan.

Methods: The validated Grasha-Riechmann teaching style inventory was administered online for data collection and used SPSS version 20.0 for statistical analysis.

Results: Of the 460 invitees, 248 responded (response rate; 54%). Delegator teaching style was most common with a highest median and mean of 2.38 and 2.45, respectively. There was a significant correlation between expert and authority teaching styles, correlation coefficient 0.62. Similarly, we found a significant correlation between authority teaching style and nature of curriculum, correlation coefficient 0.30. Multiple regression analysis showed that only authority teaching style and male gender had significant correlation. Interestingly, 117 (47%) teachers disagreed with the teaching philosophy of delivering course contents by strictly following learning outcomes. Female teachers (114/248) were more willing to negotiate with their students regarding how and what to teach in their course, while male teachers tended to allow more autonomy by allowing students to set their learning agenda.

Conclusions: This study showed that the medical teachers preferred delegator teacher style that promotes students' collaboration and peer-to-peer learning. Most teachers are conscious of their teaching styles to motivate students for scientific curiosity. These findings can help medical educators to modify their teaching styles for effective learning.
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http://dx.doi.org/10.1186/s12909-020-02358-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7708200PMC
November 2020

Decreased serial scores of severe organ failure assessments are associated with survival in mechanically ventilated patients; the prospective Maastricht Intensive Care COVID cohort.

J Crit Care 2021 04 17;62:38-45. Epub 2020 Nov 17.

Department of Intensive Care, Maastricht University Medical Centre+, P. Debyelaan 25, 6202 AZ Maastricht, the Netherlands; Care and Public Health Research Institute (CAPHRI), Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, the Netherlands. Electronic address:

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 factors, 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 during mechanical ventilation in patients with SARS-CoV-2. Surviving women appeared to improve faster than surviving men. Serial SOFA scores may unravel an unfavourable trajectory and guide decisions in mechanically ventilated patients with SARS-CoV-2.
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http://dx.doi.org/10.1016/j.jcrc.2020.11.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7669472PMC
April 2021

Nitric Oxide Ventilation Improves Recirculation and Right Ventricular Function During Veno-Venous Extracorporeal Membrane Oxygenation in a COVID-19 Patient.

J Cardiothorac Vasc Anesth 2021 09 5;35(9):2763-2767. Epub 2020 Oct 5.

Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands; Department of Cardiology, Maastricht University Medical Center+, Maastricht, the Netherlands.

Patients with coronavirus disease 2019 (COVID-19) are prone to pulmonary artery hypertension (PAH) and right ventricular pressure overload due to severe bilateral infiltrates, high ventilation pressures, persistent hypoxemia, pulmonary fibrosis, and/or pulmonary embolism. In patients on extracorporeal membrane oxygenation (ECMO), this potentially leads to increased recirculation. In the current report, the authors present a case in which continuous inhaled nitric oxide (iNO)-enriched ventilation was effective in terms of PAH and recirculation reduction in a COVID-19 patient on veno-venous ECMO.
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http://dx.doi.org/10.1053/j.jvca.2020.09.137DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7534592PMC
September 2021

Serial measurements in COVID-19-induced acute respiratory disease to unravel heterogeneity of the disease course: design of the Maastricht Intensive Care COVID cohort (MaastrICCht).

BMJ Open 2020 09 29;10(9):e040175. Epub 2020 Sep 29.

Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands.

Introduction: The course of the disease in SARS-CoV-2 infection in mechanically ventilated patients is unknown. To unravel the clinical heterogeneity of the SARS-CoV-2 infection in these patients, we designed the prospective observational Maastricht Intensive Care COVID cohort (MaastrICCht). We incorporated serial measurements that harbour aetiological, diagnostic and predictive information. The study aims to investigate the heterogeneity of the natural course of critically ill patients with a SARS-CoV-2 infection.

Methods And Analysis: Mechanically ventilated patients admitted to the intensive care with a SARS-CoV-2 infection will be included. We will collect clinical variables, vital parameters, laboratory variables, mechanical ventilator settings, chest electrical impedance tomography, ECGs, echocardiography as well as other imaging modalities to assess heterogeneity of the course of a SARS-CoV-2 infection in critically ill patients. The MaastrICCht is also designed to foster various other studies and registries and intends to create an open-source database for investigators. Therefore, a major part of the data collection is aligned with an existing national intensive care data registry and two international COVID-19 data collection initiatives. Additionally, we create a flexible design, so that additional measures can be added during the ongoing study based on new knowledge obtained from the rapidly growing body of evidence. The spread of the COVID-19 pandemic requires the swift implementation of observational research to unravel heterogeneity of the natural course of the disease of SARS-CoV-2 infection in mechanically ventilated patients. Our study design is expected to enhance aetiological, diagnostic and prognostic understanding of the disease. This paper describes the design of the MaastrICCht.

Ethics And Dissemination: Ethical approval has been obtained from the medical ethics committee (Medisch Ethische Toetsingscommissie 2020-1565/3 00 523) of the Maastricht University Medical Centre+ (Maastricht UMC+), which will be performed based on the Declaration of Helsinki. During the pandemic, the board of directors of Maastricht UMC+ adopted a policy to inform patients and ask their consent to use the collected data and to store serum samples for COVID-19 research purposes. All study documentation will be stored securely for fifteen years after recruitment of the last patient. The results will be published in peer-reviewed academic journals, with a preference for open access journals, while particularly considering deposition of the manuscripts on a preprint server early.

Trial Registration Number: The Netherlands Trial Register (NL8613).
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http://dx.doi.org/10.1136/bmjopen-2020-040175DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7526030PMC
September 2020

Lessons learned: Contribution to healthcare by medical students during COVID-19.

J Crit Care 2021 06 19;63:113-116. Epub 2020 Sep 19.

Department of Intensive Care, Maastricht University Medical Centre+ and Maastricht University, Maastricht, the Netherlands; Academy for Postgraduate Medical Training, Maastricht University Medical Centre+ and Maastricht University, Maastricht, the Netherlands; School of Health Professions Education, Maastricht University Medical Centre+ and Maastricht University, Maastricht, the Netherlands. Electronic address:

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.
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http://dx.doi.org/10.1016/j.jcrc.2020.09.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7501515PMC
June 2021

Long-Term Mortality Among ICU Patients With Stroke Compared With Other Critically Ill Patients.

Crit Care Med 2020 10;48(10):e876-e883

National Intensive Care Evaluation Foundation, Amsterdam University Medical Center, Amsterdam, The Netherlands.

Objectives: Assessment of all-cause mortality of intracerebral hemorrhage and ischemic stroke patients admitted to the ICU and comparison to the mortality of other critically ill ICU patients classified into six other diagnostic subgroups and the general Dutch population.

Design: Observational cohort study.

Setting: All ICUs participating in the Dutch National Intensive Care Evaluation database.

Patients: All adult patients admitted to these ICUs between 2010 and 2015; patients were followed until February 2017.

Interventions: None.

Measurements And Main Results: Of all 370,386 included ICU patients, 7,046 (1.9%) were stroke patients, 4,072 with ischemic stroke, and 2,974 with intracerebral hemorrhage. Short-term mortality in ICU-admitted stroke patients was high with 30 days mortality of 31% in ischemic stroke and 42% in intracerebral hemorrhage. In the longer term, the survival curve gradient among ischemic stroke and intracerebral hemorrhage patients stabilized. The gradual alteration of mortality risk after ICU admission was assessed using left-truncation with increasing minimum survival period. ICU-admitted stroke patients who survive the first 30 days after suffering from a stroke had a favorable subsequent survival compared with other diseases necessitating ICU admission such as patients admitted due to sepsis or severe community-acquired pneumonia. After having survived the first 3 months after ICU admission, multivariable Cox regression analyses showed that case-mix adjusted hazard ratios during the follow-up period of up to 3 years were lower in ischemic stroke compared with sepsis (adjusted hazard ratio, 1.21; 95% CI, 1.06-1.36) and severe community-acquired pneumonia (adjusted hazard ratio, 1.57; 95% CI, 1.39-1.77) and in intracerebral hemorrhage patients compared with these groups (adjusted hazard ratio, 1.14; 95% CI, 0.98-1.33 and adjusted hazard ratio, 1.49; 95% CI, 1.28-1.73).

Conclusions: Stroke patients who need intensive care treatment have a high short-term mortality risk, but this alters favorably with increasing duration of survival time after ICU admission in patients with both ischemic stroke and intracerebral hemorrhage, especially compared with other populations of critically ill patients such as sepsis or severe community-acquired pneumonia patients.
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http://dx.doi.org/10.1097/CCM.0000000000004492DOI Listing
October 2020

Neurophysiological and paraspinal oximetry monitoring to detect spinal cord ischemia in patients during and after descending aortic repair: An international multicenter explorative study.

Contemp Clin Trials Commun 2020 Mar 19;17:100545. Epub 2020 Feb 19.

Maastricht University Medical Center, P. Debyelaan 25, 6229, HX, Maastricht, the Netherlands.

Background: During descending aortic repair, critically decreased blood flow to the myelum can result in ischemic spinal cord injury and transient or permanent paraplegia. Assessment of motor evoked potentials (MEPs) has been shown to be a valuable tool which allows to detect spinal cord ischemia (SCI) intraoperatively within a therapeutic window suitable to prevent progression to paraparesis or paraplegia. MEP monitoring is not feasible during postoperative care in the awakening patient. Therefore, ancillary techniques to monitor integrity of spinal cord function are needed to detect delayed spinal cord ischemia.

Objective: The purpose of this study is to evaluate whether assessment of long loop reflexes (LLR; F-waves) and paraspinal muscle oximetry using Near-Infrared Spectroscopy (NIRS) are feasible and valid in detecting delayed SCI.

Methods: We aim to include patients from three tertiary referral centers undergoing aortic repair with MEP monitoring in this study.F-wave measurements and paraspinal NIRS oximetry will be operated intra- and postoperatively. Measurement characteristics and feasibility will be assessed in the first 25 patients. Subsequently, a second cohort of 75 patients will be investigated to determine the sensitivity and specificity of F-waves and NIRS in detecting perioperative SCI. In this context for the MEP group SCI is defined intraoperatively as significant MEP changes and postoperatively as newly developed paraplegia.

Conclusions: A clinical study design and protocol is proposed to assess if F-waves and/or NIRS-based paraspinal oximetry are feasible and valid in detecting and monitoring for occurrences of delayed SCI.
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http://dx.doi.org/10.1016/j.conctc.2020.100545DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7063092PMC
March 2020

Exploring burnout and depression of Thai medical students: the psychometric properties of the Maslach Burnout Inventory.

Int J Med Educ 2019 Nov 29;10:223-229. Epub 2019 Nov 29.

Department of Pathology, Faculty of Health, Medicine & Life Sciences (FHML), School of Health Profession Education, Maastricht University (UM), The Netherlands.

Objectives: To examine the psychometric properties of the Maslach Burnout Inventory-Student Survey (MBI-SS) Thai version and to determine the frequency of burnout and correlation between burnout and associated factors.

Methods: A cross-sectional study was conducted among undergraduate medical students using convenience sampling (n=545, 76.1% response rate, female 52.1%). Data were collected by a self-report survey. The MBI-SS was translated in Thai and tested for internal consistency using Cronbach's coefficient alpha. A confirmatory factor analysis was performed using as fit indices of the chi-square and degree of freedom ratio (χ/df), Comparative Fit Index (CFI), the Goodness of Fit Index (GFI), the Non-normed Fit Index (NNFI), Akaike information criterion (AIC) and the Root Mean Square Error of Approximation (RMSEA). Spearman and Kendall's tau-b were used to identify correlations between burnout, depression and other factors.

Results: Interrater reliability was acceptable with Kappa of 0.83. Confirmatory factor analysis demonstrated good fit indices (χ/df=197.62/83, CFI=0.97, GFI=0.95, NNFI=0.96, AIC=271.62 and RMSEA=0.06). Burnout had a weak, positive association with the PHQ-9 (r=0.294, df=2, p< 0.001). The screening depression score had a significant, modest positive association with emotional exhaustion (r=0.469, df=4, p<0.001) and cynicism (r=0.411, df=4, p< 0.001), and a weak inverse association with professional efficacy (r=-0.273, df=4, p< 0.001).

Conclusions: The Thai version of the MBI-SS had adequate psychometric properties among Thai medical students and can be used to assess burnout among undergraduate medical students in Thailand. Burnout was associated with risk for depression. Further studies on other associated factors contributing to depression are suggested.
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http://dx.doi.org/10.5116/ijme.5dc6.8228DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7252444PMC
November 2019

Entrustable professional activities (EPAs) for postgraduate competency based intensive care medicine training in the Netherlands: The next step towards excellence in intensive care medicine training.

J Crit Care 2019 12 14;54:261-267. Epub 2019 Sep 14.

Department of Critical Care, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700, RB, Groningen, the Netherlands.

Introduction: The Competency Based Training in Intensive Care Education (CoBaTrICE) programme developed common standards of ICM training by describing competencies of an intensivist. Entrustable Professional Activities (EPAs) of Intensive Care Medicine (ICM) (EPAsICM) are presented as a new workplace-based assessment tool in competency-based training of intensivists. EPAs are activities to be entrusted to a trainee once he (or she) has attained competence. EPAs emphasise the role of trust between trainees and supervisors. EPAs bridge the gap between competencies and competence.

Methods: An expert panel of ICM (vice)programme directors and intensivists in The Netherlands integrated the CoBaTrICE and CanMEDS competencies into EPAsICM. Comment and feedback was sought from other ICM programme directors and educational experts and processed in the final version of EPAsICM before implementation in the Dutch ICM training programme.

Results: A list of 15 EPAsICM are considered to reflect the spectrum of clinical practice while incorporating the competencies of CoBaTrICE and CanMEDS. The grading system is designed as a 5-point entrustment scale based on the amount of supervision a trainee needs, aligning with daily judgement of trainees by intensivists.

Conclusion: EPAsICM is an assessment tool that formalises entrustment decisions and can be a valuable addition in international ICM training.
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http://dx.doi.org/10.1016/j.jcrc.2019.09.012DOI Listing
December 2019

[How does a doctor declare death?]

Ned Tijdschr Geneeskd 2019 10 1;163. Epub 2019 Oct 1.

Maastricht UMC+, Afd. Intensive Care, Maastricht.

Ward doctors in regular medical departments have to be competent in declaring the death of a patient. The majority of literature on confirmation of death focuses on special circumstances, including intensive care patients and cases involving organ donation. There is no consensus regarding the procedure and criteria for declaration of death in a 'normal' patient on a medical ward. In this article we describe the death criteria, changes that occur in the body following death, and how death can be declared in in a 'normal' patient on a medical ward and in special circumstances.
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October 2019

Trainees' preferences regarding choice of place of work after completing medical training in traditional or problem-based learning/community-based education and service curricula: a study in Ghanaian medical schools.

Rural Remote Health 2019 09 3;19(3):5087. Epub 2019 Sep 3.

Faculty of Health, Medicine and Life Sciences (FHML), School of Health Professions Education (SHE), Maastricht University (MU), PO Box 5800, 6202 AZ Maastricht, The Netherlands

Introduction: Career choices, recruitment and subsequent retention of healthcare professionals in the rural areas are a major worldwide concern and challenge to the health sector, leading to human resource shortages, resulting in poor quality health care for rural communities. Medical education has integrated community-oriented medical education strategies in undergraduate medical training to help address the challenges of health care in rural communities. These strategies are likely to impact the strategies of delivering the content of undergraduate medical curricula. This study explored medical trainees' preferences regarding place of work and choice of specialty after completing training using either the traditional or mixed problem-based learning/community-based education and service (PBL/COBES) curriculum in Ghanaian medical schools.

Method: This study was a cross-sectional descriptive design using a questionnaire consisting of 25 open- and close-ended questions. The questionnaire was administered to first-, third- and sixth-year students of two medical schools in Ghana: University of Ghana School of Medicine and Dentistry (UG-SMD) and University for Development Studies, School of Medicine and Health Sciences (UDS-SMHS). UG-SMD uses the traditional method of teaching and learning, whilst UDS-SMHS uses PBL/COBES curriculum in the training of their students. Associations between gender, type of curriculum, choice of specialty and practice location were assessed using the χ2 test. Logistic regression analysis was performed to determine the association between medical school and curriculum type and students' preparation for rural practice while controlling all other factors. Qualitative data analysis of answers to open-ended questions was performed, applying the principles of thematic analysis.

Results: Of the students from PBL/COBES track, 64.2% were male, and from the traditional track 52.0%. The majority (74.1%) of students from PBL/COBES track indicated that their medical school curriculum adequately prepared them for rural practice as compared to those from the traditional track (35.1%). The willingness of third-year students at UDS-SMHS to choose to practise in rural areas after graduation decreases as compared to their colleagues in first and sixth years. Students from the traditional track were 80% less likely to state that their medical school curriculum adequately prepared them for rural practice compared to students from the PBL/COBES track (odds ratio=0.19, confidence interval=0.13-0.28, p=0.001). Students following the PBL/COBES curriculum stated that the program was very useful and could influence their choice of future practice location. Students following the traditional curriculum called for the introduction of innovative teaching methodology incorporating rural outreach programs as part of the medical curriculum.

Conclusion: Students using the PBL/COBES curriculum indicated that their curriculum adequately prepared them for future rural practice. Students following the traditional curriculum called for the introduction of an innovative teaching methodology incorporating rural outreach programs. This, they believed, would help them cultivate an interest for rural practice and also increase their willingness to choose rural practice after graduation from medical school.
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http://dx.doi.org/10.22605/RRH5087DOI Listing
September 2019

Failure of faculty to fail failing medical students: Fiction or an actual erosion of professional standards?

J Taibah Univ Med Sci 2019 Apr 1;14(2):103-109. Epub 2019 Feb 1.

Department of Orthopedics, College of Medicine Taibah University, Almadinah Almunawwarah, KSA.

Objectives: Literature has shown that some assessors assign passing grades to medical students who, in fact, should not have passed. This inability of the faculty to fail underperforming students can jeopardise the reputation of professional programs, be it in the medical field or beyond. Simultaneously, weak students become incompetent physicians and, thus, endanger the community they serve. The impetus for conducting this systematic review was to identify barriers to faculty in failing struggling medical students.

Methods: The databases of MEDLINE, Scopus, Wiley online library, Cochrane library, OVID, Taylor and Francis, CINAHL, Springer link, ProQuest, and ISI Web of knowledge were searched using Medical Subject Headings (MeSH) terms Faculty failure' AND 'Failing students' AND 'Failure to fail' OR 'Assessment'. The data were synthesised, and the results were analysed.

Results: This search showed a wealth of barriers to faculty contributing to a 'failure to fail' such as their concerns about legal action and an appeals process; the stress of failing students; a lack of knowledge about proper documentation; unavailability of support, resources, and offices for faculty; absence of administrative guidelines; and complex dismissal procedures discouraging the faculty from failing students.

Conclusion: Institutional faculty development programs and training workshops should facilitate the education of supervisors and assessors for timely evaluation and regular documentation of trainee assessment. The provision of legal advice in cases of appeal and professional support by the resource and support office is emphasised.
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http://dx.doi.org/10.1016/j.jtumed.2019.01.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6694968PMC
April 2019

Correction to: Exploring burnout and the association with the educational climate in pediatric residents in Thailand.

BMC Med Educ 2019 08 1;19(1):296. Epub 2019 Aug 1.

Department of Educational Development & Research, Faculty of Health, Medicine & Life Sciences (FHML), Maastricht University (UM), Maastricht, The Netherlands.

Following publication of the original article.
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http://dx.doi.org/10.1186/s12909-019-1723-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6676602PMC
August 2019

Exploring burnout and the association with the educational climate in pediatric residents in Thailand.

BMC Med Educ 2019 Jul 5;19(1):245. Epub 2019 Jul 5.

Department of Educational Development & Research, Faculty of Health, Medicine & Life Sciences (FHML), Maastricht University (UM), Maastricht, The Netherlands.

Background: This study, undertaken in Bangkok, Thailand, explored the extent to which paediatric residents in a non-Western setting experienced burnout and the potential association with factors in the medical educational climate and work-related quality of life.

Methods: An exploratory sequential mixed methods design was employed in a cross-sectional study. The initial, quantitative phase used the validated Maslach Burnout Inventory, the Postgraduate Hospital Educational Environmental Measure (PHEEM) and Work-Related Quality of Life scale (WRQoL). Regression analysis was used to identify the correlation between burnout and educational climate. Thereafter, residents in all years with high levels of burnout on subscales were interviewed individually.

Results: Forty-one paediatric residents completed the three questionnaires. None had high levels related to burnout in all three domains (emotional exhaustion, high level of depersonalization and perceived low personal accomplishment), seven (17%) showed high levels in two out of three domains. Emotional exhaustion and educational climate (perceptions of role autonomy, perceptions of teaching, perceptions of social support) were correlated with work-related quality of life. In the interviews, the main themes related to burnout were inappropriate tasks, teachers and teaching styles, the perception of knowledge insecurity relating to task performance, time dimensions, life crisis during training, role expectations and work allocation clarity, and facilities such as accommodation.

Conclusions: The study, in a non-Western setting, demonstrated a positive relation between educational climate and work-related quality of life. To help reduce the risk of burnout, the following factors were identified: minimize unnecessary or duplicated workload, schedule time arrangements to avoid extension of regular duty hours, and clearly define role expectations. The impact of inappropriate tasks, teachers and teaching styles (including unsafe environment) on the incidence of burnout was also highlighted. Additional studies focusing on teaching styles, safe learning climate and mistreatment in a non-Western context are needed.
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http://dx.doi.org/10.1186/s12909-019-1687-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6612205PMC
July 2019

Exploring medical residents' perceived need for negotiation skills training.

Int J Med Educ 2019 Feb 28;10:45-53. Epub 2019 Feb 28.

Department of Pediatrics, Zuyderland Medical Centre, Heerlen, the Netherlands.

Objectives: This study explores the optimal focus for negotiation skills development training by investigating how often medical residents negotiate in practice, and how they perceive the effectiveness of their negotiation capabilities.

Methods: An exploratory study was performed using a questionnaire regarding the medical residents' working environment, negotiation frequency, knowledge and skills using a 5-point Likert scale, multiple choice questions and open questions. Exploratory factor analysis with principal component analysis, varimax rotation, reliability analysis, and content analysis were used to reduce the number of variables. Descriptive and interferential statistics and multiple regression analysis were used to analyze the data.

Results: We analyzed the responses of 60 medical residents. The findings showed that the perceived development of their negotiation knowledge (M=3.06, SD=0.83) was less than their negotiation skills (M=3.69, SD=0.47). Their attitude during negotiations, especially females, differed substantially in the interactions with nurses than with their supervisors. Medical residents with more working experience, better negotiation skills or who worked in hierarchical environments negotiated more frequently with their supervisors. Medical residents with better collaboration skills and negotiation knowledge demonstrated better negotiation skills.

Conclusions: This study underlines medical residents' need for negotiation training. In addition to the basic negotiation knowledge and skills, training programs in negotiation should focus on the medical residents' awareness of their attitudes during negotiations, combining the assertiveness shown in interactions with supervisors with the empathy and emotional engagement present in interactions with nurses.  Furthermore, attention should be paid to the influence of the environmental hierarchy on negotiation skill development.
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http://dx.doi.org/10.5116/ijme.5c6c.3430DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6766400PMC
February 2019

Iatrogenic cardiac tamponade after laparoscopic hiatal hernia repair requiring emergency sternotomy.

Eur J Cardiothorac Surg 2019 Jul;56(1):215

Department of Cardiothoracic Surgery, Maastricht University Medical Center+, Maastricht, Netherlands.

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http://dx.doi.org/10.1093/ejcts/ezy433DOI Listing
July 2019

A Road Map for Attending to Medical Students' Professionalism Lapses.

Acad Med 2019 04;94(4):570-578

M.C. Mak-van der Vossen is general physician, coordinator of professional behavior, and PhD student, Department of Research in Education, VUmc School of Medical Sciences, Amsterdam University Medical Centers, Amsterdam, The Netherlands; ORCID: https://orcid.org/0000-0001-7810-6575. A. de la Croix is assistant professor, LEARN! Academy, Vrije Universiteit, and researcher, Department of Research in Education, VUmc School of Medical Sciences, Amsterdam University Medical Centers, Amsterdam, The Netherlands. A. Teherani is professor of medicine and education researcher, Center for Faculty Educators, School of Medicine, University of California, San Francisco, San Francisco, California. W.N.K.A. van Mook is internist/intensivist, Department of Intensive Care Medicine, postgraduate dean, Maastricht University Medical Center, and professor of medical education, Maastricht University, Maastricht, The Netherlands. G. Croiset is professor of education and training, Health and Life Sciences, and dean of education and training, University Medical Center Groningen, Groningen, The Netherlands. R.A. Kusurkar is associate professor of medical education and head, Department of Research in Education, VUmc School of Medical Sciences, Amsterdam University Medical Centers, Amsterdam, The Netherlands; ORCID: https://orcid.org/0000-0002-9382-0379.

Purpose: To develop a road map for educators attending to medical students' professionalism lapses, aiming to offer an empirical base for approaching students who display such lapses.

Method: Between October 2016 and January 2018, 23 in-depth interviews with 19 expert faculty responsible for remediation from 13 U.S. medical schools were conducted about the way they handle students' professionalism lapses. Three researchers independently completed three rounds of coding. Data collection, coding, and analysis were performed in a constant comparative process. A constructivist grounded theory approach was used to develop an explanatory model for attending to students' professionalism lapses.

Results: Based on participants' descriptions, the authors developed a three-phase approach for attending to professionalism lapses. In phase 1, experts enacted the role of concerned teacher, exploring the lapse from the student's perspective. In phase 2, they functioned as supportive coach, providing feedback on professionalism values, improving skills, creating reflectiveness, and offering support. In phase 3, if the student did not demonstrate reflectiveness and improvement, and especially if (future) patient care was potentially compromised, participants assumed an opposite role: gatekeeper of the profession.

Conclusions: An explanatory model for attending to professionalism lapses that fits in the overarching "communities of practice" framework was created. Whereas phase 1 and 2 aim at keeping students in the medical community, phase 3 aims at guiding students out. These findings provide empirical support to earlier descriptive, opinion-based models and may offer medical educators an empirical base for attending to students who display professionalism lapses.
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http://dx.doi.org/10.1097/ACM.0000000000002537DOI Listing
April 2019

Developing a two-dimensional model of unprofessional behaviour profiles in medical students.

Adv Health Sci Educ Theory Pract 2019 05 1;24(2):215-232. Epub 2018 Nov 1.

Department of Research in Education, VUmc School of Medical Sciences, Amsterdam UMC, PO Box 7057, 1007 MB, Amsterdam, The Netherlands.

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 behaviour and disavowing behaviour) 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.
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http://dx.doi.org/10.1007/s10459-018-9861-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6484089PMC
May 2019

Euthanasia through living organ donation: Ethical, legal, and medical challenges.

J Heart Lung Transplant 2019 02 27;38(2):111-113. Epub 2018 Jul 27.

Department of Intensive Care, Maastricht University Medical Center, Maastricht, The Netherlands.

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.
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http://dx.doi.org/10.1016/j.healun.2018.07.014DOI Listing
February 2019

Organ donation after euthanasia in children: Belgian and Dutch perspectives.

Arch Dis Child 2019 09 28;104(9):827-830. Epub 2018 Aug 28.

Department of Intensive Care, Maastricht University Medical Center, Maastricht, The Netherlands.

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http://dx.doi.org/10.1136/archdischild-2018-315560DOI Listing
September 2019

Investigating US medical students' motivation to respond to lapses in professionalism.

Med Educ 2018 08 25;52(8):838-850. Epub 2018 Jun 25.

Department of Research in Education, VUmc School of Medical Sciences, Amsterdam University Medical Centers, Amsterdam, the Netherlands.

Context: As unprofessional behaviour in physicians can compromise patient safety, all physicians should be willing and able to respond to lapses in professionalism. Although students endorse an obligation to respond to lapses, they experience difficulties in doing so. If medical educators knew how students respond and why they choose certain responses, they could support students in responding appropriately.

Objectives: The aim of this study was to describe medical students' responses to professionalism lapses in peers and faculty staff, and to understand students' motivation for responding or not responding.

Methods: We conducted an explorative, qualitative study using template analysis, in which three researchers independently coded transcripts of semi-structured, face-to-face interviews. We purposefully sampled 18 student representatives convening at a medical education conference. Preliminary open coding of a data subset yielded an initial template, which was applied to further data and modified as necessary. All transcripts were coded using the final template. Finally, three sensitising concepts from the Expectancy-Value-Cost model were used to map participants' responses.

Results: Students mentioned having observed lapses in professionalism in both faculty staff and peers. Students' responses to these lapses were avoiding, addressing, reporting or initiating policy change. Generally, students were not motivated to respond if they did not know how to respond, if they believed responding was futile and if they feared retaliation. Students were motivated to respond if they were personally affected, if they perceived the individual as approachable and if they thought that the whole group of students could benefit from their actions. Expectancy of success, value and costs each appeared to be influenced by (inter)personal and system factors.

Conclusions: The Expectancy-Value-Cost model effectively explains students' motivation for responding to lapses. The (inter)personal and system factors influencing students' motivation to respond are modifiable and can be used by medical educators to enhance students' motivation to respond to lapses in professionalism observed in medical school.
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http://dx.doi.org/10.1111/medu.13617DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6055660PMC
August 2018

The Use of Continuous EEG Monitoring in Intensive Care Units in The Netherlands: A National Survey.

Neurocrit Care 2018 10;29(2):195-202

Department of Clinical Neurophysiology, Maastricht University Medical Center + (MUMC +), PO-box 5800, 6202, Maastricht, The Netherlands.

Background: Currently, continuous electroencephalographic monitoring (cEEG) is the only available diagnostic tool for continuous monitoring of brain function in intensive care unit (ICU) patients. Yet, the exact relevance of routinely applied ICU cEEG remains unclear, and information on the implementation of cEEG, especially in Europe, is scarce. This study explores current practices of cEEG in adult Dutch ICU departments focusing on organizational and operational factors, development over time and factors perceived relevant for abstaining its use.

Methods: A national survey on cEEG in adults among the neurology and adult intensive care departments of all Dutch hospitals (n = 82) was performed.

Results: The overall institutional response rate was 78%. ICU cEEG is increasingly used in the Netherlands (in 37% of all hospitals in 2016 versus in 21% in 2008). Currently in 88% of university, 55% of teaching and 14% of general hospitals use ICU cEEG. Reasons for not performing cEEG are diverse, including perceived non-feasibility and lack of data on the effect of cEEG use on patient outcome. Mostly, ICU cEEG is used for non-convulsive seizures or status epilepticus and prognostication. However, cEEG is never or rarely used for monitoring cerebral ischemia and raised intracranial pressure in traumatic brain injury. Review and reporting practices differ considerably between hospitals. Nearly all hospitals perform non-continuous review of cEEG traces. Methods for moving toward continuous review of cEEG traces are available but infrequently used in practice.

Conclusions: cEEG is increasingly used in Dutch ICUs. However, cEEG practices vastly differ between hospitals. Future research should focus on uniform cEEG practices including unambiguous EEG interpretation to facilitate collaborative research on cEEG, aiming to provide improved standard patient care and robust data on the impact of cEEG use on patient outcome.
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http://dx.doi.org/10.1007/s12028-018-0525-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6208830PMC
October 2018

The influence of a change in septic shock definitions on intensive care epidemiology and outcome: comparison of sepsis-2 and sepsis-3 definitions.

Infect Dis (Lond) 2018 03 26;50(3):207-213. Epub 2017 Sep 26.

a Department of Intensive Care Medicine , Maastricht University Medical Centre , Maastricht , The Netherlands.

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 >2 mmol/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 4 mmol/L (25.0 vs. 26.2%, OR 0.94 (0.5-1.5)) and between 4 and 6 mmol/L (23.8 vs. 26.2%, OR 0.88 (0.4-1.7)) compared to levels ≤2 mmol/L were not associated with significantly higher ICU mortality. Serum lactate values ≥6 mmol/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 <6 mmol/L were not able to identify patients with increased ICU mortality. Lactate threshold of 2 mmol/L may be too low to point out patients with actual increased ICU mortality.
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http://dx.doi.org/10.1080/23744235.2017.1383630DOI Listing
March 2018
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