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Contains fulltext : 251797.pdf (Publisher’s version ) (Open Access) AIMS: Management of kaposiform haemangioendotheliomas (KHE) with Kasabach-Merritt phenomenon is challenging in young infants who are subjected to developmental pharmacokinetic changes. Sirolimus, sometimes combined with corticosteroids, can be used as an effective treatment of KHE. Simultaneously, toxicities such as interstitial pneumonitis related to the use of sirolimus may be fatal. As infants have a very low CYP3-enzyme expression at birth, which rises during ageing, we hypothesize that a reduced metabolization of sirolimus might lead to high sirolimus serum levels and low dose may be sufficient without the side effects. METHODS: A case series of 5 infants with kaposiform haemangioendothelioma with Kasabach-Merritt phenomenon was analysed retrospectively. All infants were treated with sirolimus 0.2 mg/m(2) every 24 or 48 hours according to their age. Prednisone was added to the therapy for additional effect in 4 patients. RESULTS: In all patients, low dose of sirolimus led to therapeutic sirolimus levels (4-6 ng/mL). All infants (aged 4 days-7 months) had a complete haematological response, without serious adverse events. In all patients, the Kasabach-Merritt phenomenon resolved, the coagulation profile normalized and tumour size reduction was seen. CONCLUSION: Low-dose sirolimus treatment is safe for infants with kaposiform haemangioendothelioma and Kasabach-Merritt phenomenon. It is essential to realize that during the first months of life, metabolism is still developing and enzymes necessary to metabolise drugs like sirolimus still have to mature. To avoid toxic levels, the sirolimus dosage should be based on age and the associated pharmacological developments.

Item does not contain fulltext Introduction: Acquiring and retaining minimally invasive surgery (MIS) skills may be aided by using MIS take-home box simulators. This study aims to evaluate the use of a take-home MIS box trainer for training sessions at-home. Methods: Trainees who previously bought the LaparoscopyBoxx (between 2016 and 2020) were asked to complete an online questionnaire. The first part was on their demographic data, and the second part was on their use and opinion on the box trainer (on a 5-point Likert scale). Results: A total of 39 participants (9 surgeons and 30 trainees) completed the questionnaire (response rate 40%). Overall, participants had a positive opinion on the use of the box trainer and would recommend it to others for training (mean 4.2). Basic tasks, such as needle trail and ring transfer, were practiced most often and were regarded most relevant (mean 4.1-4.3). They regarded practicing on the stimulator of added value to practicing in the clinic (mean 4.2), were more confident during clinical procedures (mean 3.9), and felt that their skills had improved (mean 4.1). Of quarter of the participants who bought the MIS box trainer during the COVID-19 pandemic reported an increased use during times of less clinical exposure. Conclusion: Surgeons and trainees have a positive opinion on using a take-home MIS box trainer for at-home training for general as well as for pediatric MIS skills. Especially during periods of less exposure in the clinical setting and less hands-on courses, such as during the COVID-19 pandemic, at-home training may be a valuable addition. 01 januari 2023

Contains fulltext : 290616.pdf (Publisher’s version ) (Open Access) Introduction: Minimally invasive surgery (MIS) suturing demands advanced surgical skills. Therefore, it is important these skills are adequately trained and assessed. Assessment and feedback can consist of judgments and scores of expert observers or objective parameters using instrument tracking. The aim of this study was to determine to what extent objective parameters correspond to expert assessment. Methods: Participants performed an intracorporeal suturing task on the EoSim simulator repeatedly (maximum 20 repetitions) during training. The best discriminating parameters, which previously shown construct validation, were combined into a composite score, using regression analysis. All videos were blinded and assessed by 2 independent reviewers using the validated laparoscopic suturing competency assessment tool (LS-CAT). These scores were compared with the composite score. Results: A 100 videos of 16 trainees, during separate points on their learning curve, and 8 experts were used. The parameters "time" and "distance" were statistically significantly correlated with all LS-CAT domains. The composite score (calculated from "time" and "distance") showed improvement between the first and the last knot (57% versus 94%, P

This retrospective study examines the outcomes of sclerotherapy in children with (veno)lymphatic malformations who received sclerotherapy between 2011 and 2016 (116 children, 234 procedures). Complication severity was classified using the Society of Interventional Radiology classification. Clinical response was rated on a scale of 0 (no change) to 3 (good improvement). The sclerosants used were bleomycin (n = 132; 56%), lauromacrogol (n = 42; 18%), doxycycline (n = 15; 6%), ethanol (n = 12; 5%), or a combination (n = 33; 14%). Four major and 25 minor complications occurred without significant differences between the agents. The median response rate per procedure was 2—some improvement—for all sclerosants. However, in pure LMs (67%), bleomycin and a combination of agents resulted in the best clinical response. On patient level, all had some or good clinical response. Mixed macrocystic and microcystic lesions showed a significantly lower clinical response (median 2 versus 3; p = 0.023 and p = 0.036, respectively) and required significantly more procedures (median 2 versus 1; p = 0.043 and p = 0.044, respectively) compared with lesions with one component.Conclusion: Sclerotherapy for (V)LMs in children is safe and effective. Bleomycin is the most frequently used agent in this clinic and seemed most effective for pure LMs. Mixed macrocystic and microcystic lesions are most difficult to treat effectively. What is Known:• A variety of agents can be used for sclerotherapy of lymphatic malformations in children.• Macrocystic lesions have favorable outcomes compared with microcystic and mixed lesions. What is New:• Bleomycin and a combination of agents seem to be most effective to treat lymphatic malformations in children.• Mixed macrocystic and microcystic lesions are more difficult to treat effectively compared with lesions with either one of these components.

Contains fulltext : 238665.pdf (Publisher’s version ) (Open Access) PURPOSE: To evaluate imaging, treatment, and outcomes in neonates with a lymphatic malformation (LM) adjacent to the airway and to evaluate risk factors that can predict outcome. METHODS: A retrospective case series was conducted of ten patients treated between January 2011 and July 2019. The main outcome measures included airway compromise and clinical response to sclerotherapy +/- surgery. Categorical data were compared using the Fisher's exact test. RESULTS: Ex-utero intrapartum therapy was performed in four cases, among whom one died due to sepsis. All patients underwent schlerotherapy, with surgical debulking in two. Four patients showed a good clinical response, and five started experimental systemic treatment. Patients with bilateral disease and patients with an LM with >180 degrees tracheal surrounding were significantly at risk for airway compromise (bilateral: n = 6/6 versus n = 0/4, p = 0.005; >180 degrees : n = 5/5 versus n = 1/5, p = 0.048). The need for LM treatment in the neonatal period was indicative of a poor clinical response ('non-responders' 5/6, 'responders' 0/4; p = 0.048). CONCLUSIONS: This study indicates that bilateral disease and >180 degrees tracheal surrounding are risk factors for airway compromise in neonates with an LM adjacent to the airway. In addition, the need for early treatment seems to be indicative of a poor clinical response.

Introduction Self-assessment aids “reflection-before-practice,” which is expected to result in a better understanding of one's strengths and weaknesses and consequently a better overall performance. This is, however, rarely used in surgical training. This study aims to evaluate the correlation between self-, peer-, and expert assessment on surgical skills of pediatric surgical trainees. Materials and Methods A competency assessment tool for the posterior sagittal anorectoplasty (CAT-PSARP) was previously developed and validated. During international hands-on pediatric colorectal workshops in 2019 and 2020, participants practiced the PSARP on an inanimate anorectal malformation model. They were assisted by a peer and assessed by two independent expert observers, using the CAT-PSARP. After the training session, both self- and peer assessment were completed, using the same CAT-PSARP. Results A total of 79 participants were included. No correlation was found between the overall CAT-PSARP scores of the expert observers and the self-assessment (r = 0.179, p = 0.116), while a weak correlation was found between experts and peer assessment (r = 0.317, p = 0.006). When comparing the self-assessment scores with peer assessment, a moderate correlation was found for the overall performance score (r = 0.495, p Conclusion Participants, peers, and experts seemed to have a unique view on the performance during training because there was little correlation between outcomes of the trainees and the experts. Self-assessment may be useful for reflection during training; however, expert assessment seems to be essential for assessment of surgical skills.

Background Simulation-based training may be used to acquire MIS skills. While mostly done in a simulation center, it is proposed that this training can be undertaken at-home as well. The aim of this study is to evaluate whether unsupervised at-home training and assessment of MIS skills is feasible and results in increased MIS skills. Methods Medical doctors and senior medical students were tested on their innate abilities by performing a pre-test on a take-home simulator. Henceforth, they followed a two-week interval training practicing two advanced MIS skills (an interrupted suture with knot tying task and a precise peg transfer task) and subsequently performed a post-test. Both tests and all training moments were performed at home. Performance was measured using motion analysis software (SurgTrac) and by expert-assessment and self-assessment using a competency assessment tool for MIS suturing (LS-CAT). Results A total of 38 participants enrolled in the study. Participants improved significantly between the pre-test and the post-test for both tasks. They were faster (632 s vs. 213 s, p p = 0.001) in the suturing task. Total LS-CAT scores, rated by an expert, improved significantly with a decrease from 36 at the pre-test to 20 at the post-test (p R 0.771, p The precise peg transfer task was completed faster (300 s vs. 163 s, p p = 0.005). Additionally, they placed more rings correctly (7 vs. 12, p = 0.010). Conclusion Unsupervised at-home training and assessment of MIS skills is feasible and resulted in an evident increase in skills. Especially in times of less exposure in the clinical setting and less education on training locations this can aid in improving MIS skills.

Contains fulltext : 229345.pdf (Publisher’s version ) (Closed access) PURPOSE: To evaluate treatment outcomes of embolization for peripheral arteriovenous malformations (AVMs) in a tertiary referral center where ethanol is the primary agent of choice. METHODS: A retrospective study was performed of 93 patients (median age, 31 years; range, 2-66 years) with peripheral AVMs treated with embolization (n = 442; median, 2 per patient; range, 1-82) between January 2010 and July 2016. Ethanol was used in most cases (n = 428; 97%). AVMs were classified as type I (n = 3), type II (n = 57), type IIIa (n = 5), type IIIb (n = 15), and type IV (n = 13) according to the Yakes classification system. Effectiveness of embolization was based on AVM devascularization on angiography: 100% (total), 90%-99% (near-total), 70%-90% (substantial), 30%-70% (partial), and 0%-30% (failure). Complications were graded according to the Society of Interventional Radiology classification. RESULTS: In 69% of patients, 70%-100% devascularization was achieved. Total and near-total occlusion of the nidus were more often achieved in AVMs of types I and IIIa (both 100%) than in AVMs of types II, IIIb, and IV (56%, 67%, and 39%, respectively; P = .019). A total of 109 complications were identified: 101 minor (22.9%) and 8 major (1.8%). Major complications included wounds (n = 5), false aneurysm (n = 1), finger contracture (n = 1), and severe pain (n = 1) requiring therapy. The patient complication risk was significantly affected by the number of procedures (relative risk = 2.0; P < .001). Age, AVM location, and angioarchitecture type did not significantly affect complication risk. CONCLUSIONS: AVM embolization resulted in 70%-100% devascularization in 69% of patients, with few major complications. This study indicates that the type of AVM angioarchitecture affects the number of procedures needed and the achievability of AVM devascularization.

Background Skill deterioration of minimally invasive surgical (MIS) skills may be prevented by continuous training. The aim of this study is to evaluate whether unsupervised continuous at-home training of MIS skills results in better skill retention compared to no training. Methods Medical doctors followed a two-week interval training for two MIS tasks (precise peg transfer and interrupted suture with knot tying), ending with a baseline test. They were randomly assigned to the no-practice group or continuous-practice group. The latter practiced unsupervised at home every two weeks during the study period. Skill retention was measured after three and six months on both tasks by the total time needed, distance traveled by instruments and LS-CAT score (8 best possible score and > 40 worst score). Results A total of 38 participants were included. No significant differences in performance were found at pre-test or baseline. At six months the no-practice group needed more time for the suturing task (309 s vs. 196 s at baseline, p = 0.010) and the LS-CAT score was significantly worse (30 vs. 20 at baseline, p p p p = 0.034 and p = 0.001). Conclusion This study shows a skill decay after only a few months of non-use and shows better skill retention after continuous unsupervised at-home practice of MIS skills. This indicates an added value of regular at-home practice of surgical skills.

Background: The eoSim® laparoscopic augmented reality (AR) simulator has instrument tracking capabilities that may be suitable for implementation in laparoscopic training. The objective is...

BACKGROUND: The coronavirus disease 2019 pandemic led to major changes in health care and education options for all health care employees. The aim of this study is to achieve insight into coronavirus disease-care participation of surgical residents in the Netherlands, the impact of coronavirus disease 2019 on the experienced quality of surgical training, and the influence on Burn-out and Work Engagement compared with the non-coronavirus disease 2019 period in January 2020.METHODS: In this study, we have conducted 2 digital surveys immediately before and 2 months after the start of the coronavirus disease 2019 pandemic. We surveyed a validated Dutch questionnaire 'Utrecht Burn-out Scale,' derived from the Maslach Burn-out Inventory, and also collected the 'Utrecht Work Engagement Scale' measuring work engagement. Additionally, we describe the coronavirus disease-care participation of surgical residents, the impact on how they experienced the quality of their surgical training, and the influence on 'Burn-out and Work Engagement' compared with the pre-coronavirus disease 2019 period for surgical residents in the Netherlands.RESULTS: In January 2020, a total of 317 residents completed the online survey, and in April 2020, a total of 313 residents completed the online survey. Of the responders, 48.6%, in April, participated in coronavirus disease-care in both the coronavirus disease ward as well as the coronavirus disease intensive care unit. Residents experienced that the coronavirus disease 2019 influenced their surgical training in 85.2% of responders. In only 5% of the residents did the pandemic not affect the exposure to surgical training in the operating theater. More burn-out symptoms were noted amongst coronavirus disease ward deployed residents versus no coronavirus disease ward deployment, (16.0% vs 7.6%, P = .06). The Work-Engagement questionnaire showed a significantly lower work engagement score of 4.2 for residents who were deployed in a coronavirus disease-care intensive care unit versus a score of 4.6 for residents scheduled in a coronavirus disease ward (P = .02).CONCLUSION: This study shows a significant impact of the first months of the coronavirus disease 2019 pandemic on the Dutch surgical trainee program, with a major redistribution of residents with a decrease of surgical exposure and education. We emphasize the need for adequate guidance of all surgical residents and potentially lengthening the surgical training program.

Introduction Patients with congenital vascular malformations often suffer from an impaired quality of life (QoL) because of pain and functional disabilities. Previous studies have shown that the mTOR inhibitor sirolimus can reduce complaints and improve QoL in some patients. High target levels of sirolimus of 10–15 ng/ml were well tolerated; however, in a relative high percentage of patients sirolimus caused serious adverse events (AEs). Methods A case series of 12 patients with therapy-resistant low-flow vascular malformations was treated with sirolimus, using low target levels of 4–10 ng/ml. Efficacy of sirolimus was evaluated in regard to pain symptoms using the visual analogue scale/numeric rating scale and patients reported QoL. To rule out a placebo effect of sirolimus, sirolimus was stopped after a certain time point and reintroduced as soon as complaints returned. Adverse events were closely monitored and graded using the Common Terminology Criteria for Adverse Events (CTCAE) grading. Results An improvement in symptoms was seen in 92% (n = 11/12) of patients. In nine patients pain complaints returned. Seven out of nine of them (78%) again experienced a reduction of symptoms after restarting sirolimus treatment. Despite low target levels, these response rates are comparable to those found in the literature using higher target levels of sirolimus. However, significantly less serious AEs were observed with low dose sirolimus, suggesting low dose sirolimus might be safer. Unfortunately, young adolescent female patients developed serious menstrual disturbances during treatment with low dose sirolimus. We describe this adverse event for the first time in patients with congenital vascular malformations and this might be specifically related to low dose sirolimus. Conclusions Low dose sirolimus showed a high efficacy in patients with therapy-resistant and low-flow malformation, with a lower incidence of serious adverse events. At the same time a new adverse event, namely menstrual cycle disturbance, was observed in young adolescents, indicating the need for caution when sirolimus is given. This is extremely relevant to patients with low-flow vascular malformation, who are likely to require lifelong treatment for their condition. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-021-01758-y.

Contains fulltext : 235247.pdf (Publisher’s version ) (Closed access)

Background Patients with congenital low-flow vascular malformations (capillary (CM), lymphatic (LM), venous (VM) or combined) may have an impaired quality of life (QoL), due to their symptoms, which include pain, swelling, bleeding, thrombosis, and functional impairment. Unfortunately, current treatment methods are challenging and not always successful. Previous studies have shown that the mTOR-inhibitor sirolimus is an effective treatment for these patients. Target levels of 10–15 ng/ml were well tolerated; however, grade three adverse events were observed (ranged 20–40%). Methods A pilot study was performed using a Challenge–Dechallenge–Rechallenge (CDR) design to determine the pharmacodynamics of low target levels of sirolimus (target levels 4–10 ng/ml) in respect of efficacy and adverse events in patients with disabling low-flow vascular malformations without treatment alternatives. The patients received sirolimus over a three-to-six-month period (Challenge), followed by the withdrawal of sirolimus (Dechallenge). If the complaints returned, sirolimus was reintroduced during a twelve month period (Rechallenge). Efficacy was determined on pain (end point of the pilot study) and other symptoms related to the vascular malformation; and adverse events were determined in all phases of the study. Results An improvement in symptoms was seen in 92% (n = 11/12) of patients during the Challenge phase. In the Rechallenge phase, a positive response rate of 78% was found (n = 7/9). These response rates are comparable to those found in the literature despite low target levels of sirolimus. However, less serious adverse events were observed with low dose sirolimus, especially bone marrow toxicity and grade III liver toxicity. Conclusions This pilot using low dose sirolimus showed high efficacy in patients with therapy resistant and disabling low-flow malformation, with a lower incidence of serious adverse events (especially bone marrow toxicity and grade III liver toxicity). This is extremely relevant to patients with low-flow vascular malformation, as current clinical protocols tend to advise lifelong treatment. Trial registration The pilot study was part of a phase III study. Trial registration: EudraCT number: 2016-002157-38 and ClinicalTrials.gov Identifier: NCT03987152, registered 06/14/2019 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03987152?term=sirolimus&cond=Vascular+Malformations&cntry=NL&draw=2&rank=1

Contains fulltext : 239077.pdf (Publisher’s version ) (Closed access) Background: To increase complex minimally invasive skills (MIS), frequent training outside the clinical setting is of uttermost importance. This study compares two low-cost pediatric MIS simulators, which can easily be used preclinically. Materials and Methods: The LaparoscopyBoxx is a portable simulator without a tracking system, with costs ranging from €90 to €315. The EoSim simulator has a built-in camera and tracking system and costs range from €780 to €1800. During several pediatric surgical conferences and workshops (January 2017-December 2018), participants were asked to use both simulators. Afterward, they completed a questionnaire regarding their opinion on realism and didactic value, scored on a five-point Likert scale. Results: A total of 50 participants (24 experts and 25 target group, one unknown) evaluated one or both simulators. Both simulators scored well on the questionnaire. The LaparoscopyBoxx scored significantly better regarding the "on screen representation of the instrument actions" (mean 4.2 versus 3.5, P = .001), "training tool for pediatric surgery" (mean 4.4 versus 3.9, P = .005), and "appealing take-home simulator" (mean 4.6 versus 4.0, P = .002). Conclusion: The simulators tested in this study were both regarded an appealing take-home simulator. The LaparoscopyBoxx scored significantly better than the EoSim, even though this is a low budget simulator without tracking capabilities.

Item does not contain fulltext BACKGROUND: In shared decision-making, clinicians and patients arrive at a joint treatment decision, by incorporating best available evidence and the patients' personal values and preferences. Little is known about the role of shared decision-making in managing patients with congenital vascular malformations, for which preference-sensitive decision-making seems obvious. The authors investigated preferences regarding decision-making and current shared decision-making behavior during physician-patient encounters. METHODS: In two Dutch university hospitals, adults and children with congenital vascular malformations facing a treatment-related decision were enrolled. Before the consultation, patients (or parents of children) expressed their preference regarding decision-making (Control Preferences Scale). Afterward, participants completed shared decision-making-specific questionnaires (nine-item Shared Decision-Making Questionnaire, CollaboRATE, and satisfaction), and physicians completed the Shared Decision-Making Questionnaire-Physician questionnaire. Consultations were audiotaped and patient involvement was scored by two independent researchers using the five-item Observing Patient Involvement instrument. All questionnaire results were expressed on a scale of 0 to 100 (optimum shared decision-making). RESULTS: Fifty-five participants (24 parents and 31 adult patients) were included. Two-thirds preferred the shared decision-making approach (Control Preferences Scale). Objective five-item Observing Patient Involvement scores were low (mean SD, 31 15), whereas patient and physician Shared Decision-Making Questionnaire scores were high, with means of 68 18 and 68 19, respectively. The median CollaboRATE score was 93. There was no clear relationship between shared decision-making and satisfaction scores. CONCLUSIONS: Although adults and parents of children with vascular malformations express a strong desire for shared decision-making, objective shared decision-making behavior is still lacking, most likely because of poor awareness of the shared decision-making concept among patients, parents, and physicians. To improve shared decision-making practice, targeted interventions (e.g., decision aids, staff training) are essential.

Contains fulltext : 204299.pdf (Publisher’s version ) (Open Access) Vascular malformations are part of overgrowth syndromes characterized by somatic mosaic mutations or rarely by germline mutations. Due to their similarities and diversity, clinicopathological classification can be challenging. A comprehensive targeted Next Generation Sequencing screen using Unique Molecular Identifiers with a technical sensitivity of 1% mutant alleles was performed for frequently mutated positions in >/=21 genes on 319 formalin-fixed paraffin-embedded samples. In 132 out of 319 cases pathogenic mosaic mutations were detected affecting genes previously linked to vascular malformations e.g. PIK3CA (n=80), TEK (TIE2) (n=11), AKT1 (n=1), GNAQ (n=7), GNA11 (n=4), IDH1 (n=3), KRAS (n=9), and NRAS (n=1). Six cases harbored a combination of mutations in PIK3CA and in GNA11 (n=2), GNAQ (n=2), or IDH1 (n=2). Aberrations in PTEN and RASA1 with a variant allele frequency approaching 50% suggestive of germline origin were identified in six out of 102 cases tested; four contained a potential second hit at a lower allele frequency. Ninety-one of the total 142 pathogenic mutations were present at a variant allele frequency

Objective To establish whether a systematized approach to self-assessment in a laparoscopic surgical skills course improves accordance between expert- and self-assessment. Design A systematic training course in self-assessment using Competency Assessment Tool was introduced into the normal course of evaluation within a Laparoscopic Surgical Skills training course for the test group ( n = 30). Differences between these and a control group ( n = 30) who did not receive the additional training were assessed. Setting Catharina Hospital, Eindhoven, The Netherlands ( n = 27), and GSL Medical College, Rajahmundry, India ( n = 33). Participants Sixty postgraduate year 2 and 3 surgical residents who attended the 2-day Laparoscopic Surgical Skills grade 1 level 1 curriculum were invited to participate. Results The test group ( n = 30) showed better accordance between expert- and self-assessment (difference of 1.5, standard deviation [SD] = 0.2 versus 3.83, SD = 0.6, p = 0.009) as well as half the number (7 versus 14) of cases of overreporting. Furthermore, the test group also showed higher overall mean performance (mean = 38.1, SD = 0.7 versus mean = 31.8, SD = 1.0, p n = 30). The systematic approach to self-assessment can be viewed as responsible for this and can be seen as “reflection- before -practice” within the framework of reflective practice as defined by Donald Schon. Conclusion Our results suggest that “reflection- before -practice” in implementing self-assessment is an important step in the development of surgical skills, yielding both better understanding of one’s strengths and weaknesses and also improving overall performance.

Contains fulltext : 173021.pdf (Publisher’s version ) (Open Access) Placement of catheters, drains, shunts, and tubes in children can lead to serious or even fatal complications at the moment of placement, such as hemorrhage at insertion, or in the longterm, such as infections and migration into adjacent organs. The clinician should always be aware of these potential complications, especially if the child is unwell. For postmortem diagnostic evaluation, either with a computed tomography scan or an invasive autopsy, all tubes, drains, shunts, and/or catheters should be left in situ. We present three cases with fatal complications after the placement of a chest drain, ventriculoperitoneal shunt, and gastrostomy tube.

AIM: This paper reviews changes that are underway in postgraduate medical education in various European countries. Training in the workplace is a very effective way of learning, but it has many imperfections. Changes in in-training assessment are proposed to remedy some of these. ASSESSMENT TOOLS: The focus is on a set of assessment tools for performance in authentic work-based contexts. These tools include direct performance measures of single clinical events (mini-Clinical Evaluation Exercise, Direct Observation of Practical Skills, Objective Structured Assessment of Technical Skills, Case-based Discussion, Mini-Peer Assessment Tool) and performance measures over a period of time (Multi-Source Feedback), based on judgement by one or more knowledgeable assessors (supervisor, other healthcare professional, patient, trainee himself/herself). Quantitative and qualitative information from single assessments is first and foremost used to promote learning, but also aggregated across a large sample of contexts and assessors in order to obtain an overall picture of a trainee's progress. Aggregating instruments, such as the portfolio, can be used to collect, support and assess outcomes in terms of competencies achieved. We will describe this set of instruments and provide theoretical background as well as our own practical experiences. DISCUSSION: A central message is that the utility of assessment methods lies very much in the (understanding of) the users. Therefore, our concern is more with the actual implementation of change than with the assessment technology per se. If we fail in our efforts to implement real change, postgraduate education may be at risk for bureaucratization and trivialization. We nevertheless are excited to see change happening in the right direction, but remain patient, not expecting very quick wins.

Item does not contain fulltext PURPOSE: Nissen fundoplication is an effective treatment for gastro-esophageal reflux disease (GERD). Mobilization of the gastric fundus during fundoplication requires division of short gastric vessels of the spleen, which may cause splenic ischemia. The aim of this study was to determine if Nissen fundoplication results in hypotrophy of the spleen. METHODS: We performed pre-operative and post-operative ultrasound measurements of the spleen in children undergoing Nissen fundoplication. During operation, the surgeon estimated the compromised blood flow by assessment of the percentage of discoloration of the spleen. RESULTS: Twenty-four consecutive children were analyzed. Discoloration of the upper pole of the spleen was observed in 11 patients (48%) of a median estimated splenic surface of 20% (range 5-50%). The median ratio for pre-operative and post-operative length, width, and area of the spleen was 0.97, 1.03, and 0.96, respectively. The percentage of the estimated perfusion defect during surgery was not correlated with the ratios. In three patients, the area ratio was smaller than 0.8 (0.67-0.75), meaning that the area decreased with at least 20% after surgery. In none of these patients a discoloration was observed. CONCLUSION: Discoloration of the spleen after Nissen fundoplication is not associated with post-operative splenic atrophy. 01 maart 2012

Item does not contain fulltext PURPOSE: Residency programs around the world use multisource feedback (MSF) to evaluate learners' performance. Studies of the reliability of MSF show mixed results. This study aimed to identify the reliability of MSF as practiced across occasions with varying numbers of assessors from different professional groups (physicians and nonphysicians) and the effect on the reliability of the assessment for different competencies when completed by both groups. METHOD: The authors collected data from 2008 to 2012 from electronically completed MSF questionnaires. In total, 428 residents completed 586 MSF occasions, and 5,020 assessors provided feedback. The authors used generalizability theory to analyze the reliability of MSF for multiple occasions, different competencies, and varying numbers of assessors and assessor groups across multiple occasions. RESULTS: A reliability coefficient of 0.800 can be achieved with two MSF occasions completed by at least 10 assessors per group or with three MSF occasions completed by 5 assessors per group. Nonphysicians' scores for the "Scholar" and "Health advocate" competencies and physicians' scores for the "Health advocate" competency had a negative effect on the composite reliability. CONCLUSIONS: A feasible number of assessors per MSF occasion can reliably assess residents' performance. Scores from a single occasion should be interpreted cautiously. However, every occasion can provide valuable feedback for learning. This research confirms that the (unique) characteristics of different assessor groups should be considered when interpreting MSF results. Reliability seems to be influenced by the included assessor groups and competencies. These findings will enhance the utility of MSF during residency training.

Sharing and collaboration relating to progress testing already takes place on a national level and allows for quality control and comparisons of the participating institutions. This study explores the possibilities of international sharing of the progress test after correction for cultural bias and translation problems. Three progress tests were reviewed and administered to 3043 Pretoria and 3001 Maastricht medical students. In total, 16% of the items were potentially biased and removed from the test items administered to the Pretoria students (9% due to translation problems; 7% due to cultural differences). Of the three clusters (basic, clinical and social sciences) the social sciences contained most bias (32%), basic sciences least (11%). The differences that were found, comparing the student results of both schools, seem a reflection of the deliberate accentuations that both curricula pursue. The results suggest that the progress test methodology provides a versatile instrument that can be used to assess medical schools across the world. Sharing of test material is a viable strategy and test outcomes are interesting and can be used in international quality control.

Introduction An earlier study showed that an Angoff procedure with greater than or equal to 10 recently graduated students as judges can be used to estimate the passing score of a progress test. As the acceptability and feasibility of this approach are questionable, we conducted an Angoff procedure with test item writers as judges. This paper reports on thereliability and credibility of this procedure and compares the standards set by the two different panels. Methods Fourteen item writers judged 146 test items. Recently graduated students had assessed these items in a previous study. Generalizability was investigated as a function of the number of items and judges. Credibility was judged by comparing the pass/fail rates associated with the Angoff standard, a relative standard and a fixed standard. The Angoff standards obtained by item writers and graduates were compared. Results The variance associated with consistent variability of item writers across items was 1.5% and for graduate students it was 0.4%. An acceptable error score required 39 judges. Item-Angoff estimates of the two panels and item P -values correlated highly. Failure rates of 57%, 55% and 7% were associated with the item writers' standard, the fixed standard and the graduates' standard, respectively. Conclusion The graduates' and the item writers' standards differed substantially, as did the associated failure rates. A panel of 39 item writers is not feasible. The item writers' passing score appears to be less credible. The credibility of the graduates' standard needs further evaluation. The acceptability and feasibility of a panel consisting of both students and item writers may be worth investigating.

Objective: In myocardial perfusion single-photon emission computed tomography (SPECT), abdominal activity often interferes with the evaluation of perfusion in the inferior wall, especially after pharmacological stress. In this randomized study, we examined the effect of carbonated water intake versus still water intake on the quality of images obtained during myocardial perfusion images (MPI) studies. Methods: A total of 467 MIBI studies were randomized into a carbonated water group and a water group. The presence of intestinal activity adjacent to the inferior wall was evaluated by two observers. Furthermore, a semiquantitative analysis was performed in the adenosine subgroup,using a count ratio of the inferior myocardial wall and adjacent abdominal activity. Results: The need for repeated SPECT in the adenosine studies was 5.3 % in the carbonated water group versus 19.4 % in the still water group (p = 0.019). The inferior wall-to-abdomen count ratio was significantly higher in the carbonated water group compared to the still water group (2.11 ± 1.00 vs. 1.72 ± 0.73, p\0.001). The effect of carbonated water during rest and after exercise was not significant. Conclusions: This randomized study showed that carbonated water significantly reduced the interference of extra-cardiac activity in adenosine SPECT MPI. Keywords: Extra-cardiac radioactivity, Myocardial SPECT, Image quality enhancement, Carbonated water

Purpose To determine the effect on test reliability when a separate written assessment component is added to an objective structured clinical examination (OSCE). Method Volunteers (n=38) from Maastricht Medical School were recruited to take a skills-related knowledge test in addition to their regular end-of-year OSCE. The OSCE scores of these volunteers did not differ from those of the other students of their class. Multivariate generalizability theory was used to investigate the combined reliability of the two test formats as well as their respective contributions to overall reliability. Results Combining the two formats has an added value. The loss of reliability due to the use of fewer stations in the OSCE can be fully compensated by lengthening the written test component. Conclusion From the perspective of test reliability, it is possible to economize on the resources needed for performance-based assessment by adding a separate written test component.

Comparisons between PBL and non-PBL medical schools on problem-solving ability often show no differences. This could be either due to the fact that no difference in problem-solving skills exists or that the instruments used are inadequate. In this study a key-feature approach case-based examination was used to compare two medical schools in the Netherlands, one of which has a PBL curriculum (Maastricht) and one which has a program half way a transition from a non-PBL towards a PBL curriculum (Groningen). Differences were found both in proficiency scores and in the pattern of response times, both supporting the assumption that a PBL approach would lead to a higher level of problem solving ability. The effect size, however, is not as large as originally assumed by the PBL proponents. Conclusions must be drawn with caution, but it seems likely that a test based on large numbers of short cases is the most sensitive in detecting differences in problem solving ability between students of different curricula.

Contains fulltext : 89807.pdf (Publisher’s version ) (Closed access) OBJECTIVES: To improve diagnosis of necrotizing enterocolitis (NEC) by noninvasive markers representing gut wall integrity loss (I-FABP and claudin-3) and gut wall inflammation (calprotectin). Furthermore, the usefulness of I-FABP to predict NEC severity and to screen for NEC was evaluated. METHODS: Urinary I-FABP and claudin-3 concentrations and fecal calprotectin concentrations were measured in 35 consecutive neonates suspected of NEC at the moment of NEC suspicion. To investigate I-FABP as screening tool for NEC, daily urinary levels were determined in 6 neonates who developed NEC out of 226 neonates included before clinical suspicion of NEC. RESULTS: Of 35 neonates suspected of NEC, 14 developed NEC. Median I-FABP, claudin-3, and calprotectin levels were significantly higher in neonates with NEC than in neonates with other diagnoses. Cutoff values for I-FABP (2.20 pg/nmol creatinine), claudin-3 (800.8 INT), and calprotectin (286.2 microg/g feces) showed clinically relevant positive likelihood ratios (LRs) of 9.30, 3.74, 12.29, and negative LRs of 0.08, 0.36, 0.15, respectively. At suspicion of NEC, median urinary I-FABP levels of neonates with intestinal necrosis necessitating surgery or causing death were significantly higher than urinary I-FABP levels in conservatively treated neonates. Of the 226 neonates included before clinical suspicion of NEC, 6 developed NEC. In 4 of these 6 neonates I-FABP levels were not above the cutoff level to diagnose NEC before clinical suspicion. CONCLUSIONS: Urinary I-FABP levels are not suitable as screening tool for NEC before clinical suspicion. However, urinary I-FABP and claudin-3 and fecal calprotectin are promising diagnostic markers for NEC. Furthermore, urinary I-FABP might also be used to predict disease severity. 01 juni 2010

Item does not contain fulltext OBJECTIVE: To assess whether laparoscopic surgery lowers the threshold for surgical intervention, we examined whether the introduction of the laparoscopic technique at our institution in 1997 has resulted in an increase in antireflux surgery in children at our clinic. PATIENTS AND METHODS: The number of annual fundoplications between 1997 and 2008 at a single institution was assessed in children younger than 18 years. The number of fundoplications was compared with the number of pyloromyotomies and appendicectomies per year in the same period of time to prove or exclude a general increase in the referral of children. RESULTS: Since 1997, the proportion of laparoscopic fundoplications increased from 60% in 1997 to 100% in 2008. During this period, 109 laparoscopic fundoplications were performed: 31 in the period from 1997 to 2002 and 78 from 2003 to 2008. Regression analysis shows a significant increase in the number of performed fundoplications (slope: 1.03 +/- 0.28, P = 0.0043), whereas both the number of pyloromyotomies and appendicectomies remained stable (slopes: -0.14 +/- 0.40, P = 0.73, and -0.75 +/- 0.47, P = 0.14, respectively). CONCLUSIONS: Since the introduction of minimally invasive surgery at our tertiary referral center in 1997, the number of patients referred for an antireflux operation has increased. This cannot be explained by an increase of referrals from outside the region or a change in the indication for surgery. We conclude that laparoscopy lowers the threshold for the surgical treatment of gastroesophageal reflux disease in children. 01 november 2010

A 10 year old boy presented to the emergency department with a 24 hour history of abdominal pain in a colicky pattern; nausea; and bilious and faecal vomiting. His history included well controlled cystic fibrosis with pancreatic insufficiency and a meconium ileus in the neonatal period, which was treated surgically. He passed his last stools the night before presentation. In the previous days he had passed stools once daily. His drug regimen included pancreatin (pancreatic enzymes), omeprazole, vitamin A, D, E, and K supplements, and hypertonic saline inhalations. On physical examination the boy was uncomfortable and had a distended abdomen with minimal peristalsis. There was tenderness across the whole abdomen and a positive rebound response without guarding or other signs of peritonitis. His body temperature was normal. Laboratory results showed a white blood cell count of 8.8 × 109/L (normal range 4.5-13.0) with normal differential count, platelet count 278 × 109/L (normal range 120-350), C reactive protein 10 mg/L (normal range

Radiofrequency ablation of liver tumours is a useful therapy for otherwise unresectable tumours. The complication rate is said to be low. In this case report we describe hyperkalaemia after radiofrequency ablation of a hepatocellular carcinoma in a patient with end-stage renal insufficiency.

Het gynaecologisch en andrologisch onderzoek is voor studenten een beladen onderzoek. Het is een goede ontwikkeling dat in een aantal faculteiten studenten de mogelijkheid hebben om deze onderzoeken te oefenen bij speciaal daarvoor getrainde medewerkers, die zowel de rol van patient als van docent vervullen. Dergelijke trainingen worden in Maastricht sinds 1985 aangeboden in het Skillslab. Net als de andere vaardigheidstrainingen in het Skillslab zijn de trainingen gynaecologisch en andrologisch onderzoek niet verplicht. Aan de hand van de inschrijf- en aanwezigheidsregistratie van het Skillslab is nagegaan hoeveel studenten deze trainingen volgen en of er studentkenmerken zijn die verband houden met het al of niet meedoen aan deze trainingen. Het blijkt dat vrouwelijke studenten, studenten die op schema studeren en studenten die meer andere vaardigheidstrainingen volgen, zich voor deze trainingen vaker inschrijven. In vervolgonderzoek zal uitgezocht moeten worden wat de drempels zijn voor de studenten die zich niet inschrijven.