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van der Wal LI, Grim CCA, Del Prado MR, van Westerloo DJ, Schultz MJ, Helmerhorst HJF, de Vries MC, de Jonge E. Perspectives of ICU Patients on Deferred Consent in the Context of Post-ICU Quality of Life: A Substudy of a Randomized Clinical Trial. Crit Care Med 2024; 52:694-703. [PMID: 38180043 PMCID: PMC11008447 DOI: 10.1097/ccm.0000000000006184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
OBJECTIVES Deferred consent enables research to be conducted in the ICU when patients are unable to provide consent themselves, and there is insufficient time to obtain consent from surrogates before commencing (trial) treatment. The aim of this study was to evaluate how former ICU patients reflect on their participation in a study with deferred consent and examine whether their opinions are influenced by the quality of life (QoL) following hospital discharge. DESIGN Survey study by questionnaire. SETTING Eight ICUs in The Netherlands. PATIENTS Former ICU patients who participated in the ICONIC trial, a multicenter randomized clinical trial that evaluated oxygenation targets in mechanically ventilated ICU patients. INTERVENTIONS Participants enrolled in the ICONIC trial in one of the eight participating centers in The Netherlands received a questionnaire 6 months after randomization. The questionnaire included 12 close-ended questions on their opinion about the deferred consent procedure. QoL was measured using the EQ-5D-5L questionnaire. By calculating the EQ-5D index, patients were divided into four QoL quartiles, where Q1 reflects the lowest and Q4 is the highest. MEASUREMENTS AND MAIN RESULTS Of 362 participants who were contacted, 197 responded (54%). More than half of the respondents (59%) were unaware of their participation in the ICONIC study. In total 61% were content with the deferred consent procedure, 1% were not content, 25% neutral, 9% did not know, and 9% answered "other." Those with a higher QoL were more likely to be content ( p = 0.02). In all QoL groups, the legal representative was the most often preferred individual to provide consent. CONCLUSIONS Former ICU patients who participated in the ICONIC study often did not remember their participation but were predominantly positive regarding the use of deferred consent. Those with a higher QoL were most likely to be content.
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Affiliation(s)
- L Imeen van der Wal
- Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Anaesthesiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Chloe C A Grim
- Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Anaesthesiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Michael R Del Prado
- Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - David J van Westerloo
- Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Anaesthesiology, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Intensive Care, Amsterdam University Medical Centre, Location AMC, Amsterdam, The Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Department of Medical Ethics and Health Law, Leiden University Medical Centre, Leiden, The Netherlands
| | - Hendrik J F Helmerhorst
- Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Anaesthesiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Martine C de Vries
- Department of Medical Ethics and Health Law, Leiden University Medical Centre, Leiden, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
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Vrouenraets LJJJ, de Vries ALC, Arnoldussen M, Hannema SE, Lindauer RJL, de Vries MC, Hein IM. Medical decision-making competence regarding puberty suppression: perceptions of transgender adolescents, their parents and clinicians. Eur Child Adolesc Psychiatry 2023; 32:2343-2361. [PMID: 36115898 PMCID: PMC10576681 DOI: 10.1007/s00787-022-02076-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 08/31/2022] [Indexed: 11/30/2022]
Abstract
According to international transgender care guidelines, transgender adolescents should have medical decision-making competence (MDC) to start puberty suppression (PS) and halt endogenous pubertal development. However, MDC is a debated concept in adolescent transgender care and little is known about the transgender adolescents', their parents', and clinicians' perspectives on this. Increasing our understanding of these perspectives can improve transgender adolescent care. A qualitative interview study with adolescents attending two Dutch gender identity clinics (eight transgender adolescents who proceeded to gender-affirming hormones after PS, and six adolescents who discontinued PS) and 12 of their parents, and focus groups with ten clinicians was conducted. From thematic analysis, three themes emerged regarding transgender adolescents' MDC to start PS: (1) challenges when assessing MDC, (2) aspects that are considered when assessing MDC, and (3) MDC's relevance. The four criteria one needs to fulfill to have MDC-understanding, appreciating, reasoning, communicating a choice-were all, to a greater or lesser extent, mentioned by most participants, just as MDC being relative to a specific decision and context. Interestingly, most adolescents, parents and clinicians find understanding and appreciating PS and its consequences important for MDC. Nevertheless, most state that the adolescents did not fully understand and appreciate PS and its consequences, but were nonetheless able to decide about PS. Parents' support of their child was considered essential in the decision-making process. Clinicians find MDC difficult to assess and put into practice in a uniform way. Dissemination of knowledge about MDC to start PS would help to adequately support adolescents, parents and clinicians in the decision-making process.
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Affiliation(s)
- Lieke Josephina Jeanne Johanna Vrouenraets
- Department of Medical Psychology, Willem Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands.
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
| | - Annelou L C de Vries
- Department of Child and Adolescent Psychiatry, Emma Children's Hospital, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Marijn Arnoldussen
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Sabine E Hannema
- Department of Paediatric Endocrinology, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
- Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Ramón J L Lindauer
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Centers, Location AMC, University of Amsterdam and Levvel, Amsterdam, The Netherlands
| | - Martine C de Vries
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Irma M Hein
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Centers, Location AMC, University of Amsterdam and Levvel, Amsterdam, The Netherlands
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van Dijk WB, Leeuwenberg AM, Grobbee DE, Siregar S, Houterman S, Daeter EJ, de Vries MC, Groenwold RHH, Schuit E. Dynamics in cardiac surgery: trends in population characteristics and the performance of the EuroSCORE II over time. Eur J Cardiothorac Surg 2023; 64:ezad301. [PMID: 37672025 PMCID: PMC10504469 DOI: 10.1093/ejcts/ezad301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 06/21/2023] [Accepted: 09/05/2023] [Indexed: 09/07/2023] Open
Abstract
OBJECTIVES The aim of this study was to investigate the performance of the EuroSCORE II over time and dynamics in values of predictors included in the model. METHODS A cohort study was performed using data from the Netherlands Heart Registration. All cardiothoracic surgical procedures performed between 1 January 2013 and 31 December 2019 were included for analysis. Performance of the EuroSCORE II was assessed across 3-month intervals in terms of calibration and discrimination. For subgroups of major surgical procedures, performance of the EuroSCORE II was assessed across 12-month time intervals. Changes in values of individual EuroSCORE II predictors over time were assessed graphically. RESULTS A total of 103 404 cardiothoracic surgical procedures were included. Observed mortality risk ranged between 1.9% [95% confidence interval (CI) 1.6-2.4] and 3.6% (95% CI 2.6-4.4) across 3-month intervals, while the mean predicted mortality risk ranged between 3.4% (95% CI 3.3-3.6) and 4.2% (95% CI 3.9-4.6). The corresponding observed:expected ratios ranged from 0.50 (95% CI 0.46-0.61) to 0.95 (95% CI 0.74-1.16). Discriminative performance in terms of the c-statistic ranged between 0.82 (95% CI 0.78-0.89) and 0.89 (95% CI 0.87-0.93). The EuroSCORE II consistently overestimated mortality compared to observed mortality. This finding was consistent across all major cardiothoracic surgical procedures. Distributions of values of individual predictors varied broadly across predictors over time. Most notable trends were a decrease in elective surgery from 75% to 54% and a rise in patients with no or New York Heart Association I class heart failure from 27% to 33%. CONCLUSIONS The EuroSCORE II shows good discriminative performance, but consistently overestimates mortality risks of all types of major cardiothoracic surgical procedures in the Netherlands.
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Affiliation(s)
- Wouter B van Dijk
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Artuur M Leeuwenberg
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Diederick E Grobbee
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Sabrina Siregar
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Erasmus University, Rotterdam, Netherlands
| | | | - Edgar J Daeter
- Netherlands Heart Registration, Utrecht, Netherlands
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Martine C de Vries
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden University, Leiden, Netherlands
| | - Rolf H H Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden University, Leiden, Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden University, Leiden, Netherlands
| | - Ewoud Schuit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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Gallant CD, Toelen J, Sluiter-Post J, De Coninck D, Hendriks AC, Sombroek-van Doorm MP, van der Veek S, de Vries MC, de Winter JP. [What do parents know of patient rights of minors in the Netherlands?]. Ned Tijdschr Geneeskd 2023; 167. [PMID: 37257126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
INTRODUCTION In the Netherlands, medical decision-making without parental permission is allowed from the age of 16. The aim of this study was to examine parents' knowledge of this age-based framework to discover potential knowledge gaps that hinder the communication between doctors, parents, and their children. METHODS Survey-based research was conducted to examine parents' knowledge of the age-based framework that applies to minors in Dutch healthcare. The survey was based on 5 topics: medical diagnosis and treatment, medical advice, reproductive and sexual health services, abortion, and euthanasia. The survey was sent to 1,010 Dutch parents, aged 35-55 years, with at least one child. The data were analysed using SPSS. Percentages and means were calculated. RESULTS Parental knowledge of the age-based framework varied depending on the topic. CONCLUSION This study provides insights into parents' current level of knowledge of the age-based framework that applies to minors in Dutch healthcare. This information is useful in the conversation between health care professional, parents, and their children.
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Affiliation(s)
| | - Jaan Toelen
- KU Leuven, Leuven Instituut voor Kind en Jeugd, Leuven, België
| | | | | | - Aart C Hendriks
- Universiteit Leiden, Faculteit der Rechtsgeleerdheid, Leiden
| | | | | | | | - J Peter de Winter
- Spaarne Gasthuis, afd. Kindergeneeskunde, Haarlem en Hoofddorp
- Contact: J. Peter de Winter
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Krom A, de Boer A, Geurtzen R, de Vries MC. Capabilities and Stakeholders - Two Ways of Enriching the Ethical Debate on Artificial Womb Technology. Am J Bioeth 2023; 23:110-113. [PMID: 37130420 DOI: 10.1080/15265161.2023.2191028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Affiliation(s)
| | - Angret de Boer
- Leiden University Medical Center
- Radboudumc Amalia Children's Hospital
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van Dijk WB, Schuit E, van der Graaf R, Groenwold RHH, Laurijssen S, Casadei B, Roffi M, Abimbola S, de Vries MC, Grobbee DE. Applicability of European Society of Cardiology guidelines according to gross national income. Eur Heart J 2022; 44:598-607. [PMID: 36396400 PMCID: PMC9925274 DOI: 10.1093/eurheartj/ehac606] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 08/24/2022] [Accepted: 10/11/2022] [Indexed: 11/19/2022] Open
Abstract
AIMS To assess the feasibility to comply with the recommended actions of ESC guidelines on general cardiology areas in 102 countries and assess how compliance relates to the country's income level. METHODS AND RESULTS All recommendations from seven ESC guidelines on general cardiology areas were extracted and labelled on recommended actions. A survey was sent to all 102 ESC national and affiliated cardiac societies (NCSs). Respondents were asked to score recommended actions on their availability in clinical practice on a four-point Likert scale (fully available, mostly/often available, mostly/often unavailable, fully unavailable), and select the top three barriers perceived as being responsible for limiting their national availability. Applicability was assessed overall, per World Bank gross national income (GNI) level, and per guideline.A total of 875 guideline recommendations on general cardiology was extracted. Responses were received from 64 of 102 (62.7%) NCSs. On average, 71·6% [95% confidence interval (CI): 68.6-74.6] of the actions were fully available, 9.9% (95% CI: 8.7-11.1) mostly/often available, 6.7% (95% CI: 5.4-8.0) mostly/often unavailable, and 11·8% (95% CI: 9.5-14.1) fully unavailable. In low-income countries (LICs), substantially more actions were fully unavailable [29·4% (95% CI: 22.6-36.3)] compared with high-income countries [HICs, countries 2.4% (95% CI: 1.2-3.7); P < 0.05]. Nevertheless, a proportion of actions with the lowest availability scores were often fully or mostly unavailable independent of GNIs. Actions were most often not available due to lack of reimbursement and other financial barriers. CONCLUSION Local implementation of ESC guidelines on general cardiology is high in HICs and low in LICs , being inversely correlated with country gross national incomes.
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Affiliation(s)
- Wouter B van Dijk
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands
| | - Ewoud Schuit
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands
| | - Rieke van der Graaf
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands
| | - Rolf H H Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden University, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Sara Laurijssen
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden University, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Barbara Casadei
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, Headington Oxford OX3 9DU, United Kingdom
| | - Marco Roffi
- Division of Cardiology, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205 Genève, Switzerland
| | - Seye Abimbola
- School of Public Health, Sydney Medical School, University of Sydney, Edward Ford Building (A27) Fisher Road, Sydney, NSW 2006, Australia
| | - Martine C de Vries
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden University, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
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Laurijssen SJ, van der Graaf R, van Dijk WB, Schuit E, Groenwold RH, Grobbee DE, de Vries MC. When is it impractical to ask informed consent? A systematic review. Clin Trials 2022; 19:545-560. [PMID: 35775421 PMCID: PMC9523816 DOI: 10.1177/17407745221103567] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Informed consent is one of the cornerstones of biomedical research with human subjects. Research ethics committees may allow for a modification or a waiver of consent when the research has social value, involves minimal risk, and if consent is impractical to obtain. While the conditions of social value and minimal risk have received ample attention in research ethics literature, the impractical condition remains unclear. There seem to be different interpretations of the meaning of impractical within academic literature. To address this lack of clarity, we performed a systematic review on the interpretation of impractical. METHODS First, we examined international research ethics guidelines on their usage and interpretation of impractical. Next, we used international ethical guidelines to identify synonyms of the term "impractical." Accordingly, PubMed, Embase, and Web of Science were searched for articles that included "informed consent" and "impractical" or one of its synonyms. RESULTS We found that there were only a few international ethics guidelines that described what could be considered impractical. Out of 2329 identified academic articles, 42 were included. Impractical was used to describe four different conditions: (1) obtaining informed consent becomes too demanding for researchers, (2) obtaining informed consent leads to invalid study outcomes, (3) obtaining informed consent harms the participant, and (4) obtaining informed consent is meaningless for the participant. CONCLUSION There are conditions that render conventional informed consent truly impractical, such as untraceable participants or harm for participants. At the same time, researchers have a moral responsibility to design an infrastructure in which consent can be obtained, even if they face hardship in obtaining consent. In addition, researchers should seek to minimize harm inflicted upon participants when harm may occur as a result of the consent procedure. Invalidity of research due to consent issues should not be regarded as impractical but as a condition that limits the social value of research. Further research is essential for when a waiver of informed consent based on impractical is also reasonable.
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Affiliation(s)
- Sara Jm Laurijssen
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden University, Leiden, The Netherlands
| | - Rieke van der Graaf
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Wouter B van Dijk
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Ewoud Schuit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Rolf Hh Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden University, Leiden, The Netherlands
| | - Diederick E Grobbee
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Martine C de Vries
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden University, Leiden, The Netherlands
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Hendriks AC, Sombroek-van Doorm MJP, de Vries MC. [The Dutch Mandatory Mental Health Care Act allows more care for pregnant women under coercion]. Ned Tijdschr Geneeskd 2022; 166:D6790. [PMID: 35899730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Women with mental health issues may wish to get pregnant. In some situations a pregnancy is contra-indicated or not be in the best interests of the future child. This article analyses the way treating physicians may assist these women and, if needed, treat these women by using somatic of psychiatric care. This on the basis of the Dutch Patients' Rights Act and mental health legislation. The recent Dutch Mandatory Health Care Act provides physicians more opportunities to act in comparison with the previous situation.
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Affiliation(s)
- Aart C Hendriks
- Universiteit Leiden, Faculteit der Rechtsgeleerdheid, afd. Publiekrecht,Leiden
- Contact: Aart C. Hendriks
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Groenhof TKJ, Mostert M, Lea NC, Haitjema S, de Vries MC, van Dijk WB, Grobbee DE, Asselbergs FW, Bots ML, van der Graaf R. How Traditional Informed Consent Impairs Inclusivity in a Learning Healthcare System: Lessons Learned from the Utrecht Cardiovascular Cohort. J Clin Epidemiol 2022; 149:190-194. [DOI: 10.1016/j.jclinepi.2022.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 04/23/2022] [Accepted: 04/26/2022] [Indexed: 11/25/2022]
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den Boer MC, Houtlosser M, Witlox RSGM, van Zanten HA, de Vries MC, Te Pas AB. Consent for Delivery Room Studies: What Can Be Learned from Perceptions of Parents. Neonatology 2022; 119:214-221. [PMID: 35184062 DOI: 10.1159/000521587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 12/08/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Obtaining ethically valid consent to participate in delivery room (DR) studies from parents facing an imminent premature birth can be challenging. This study aims to provide insight into parental experiences with and perceptions of consent for DR studies. METHODS Semistructured interviews were conducted with parents of very and extreme preterm infants. Interviews were audio-recorded, transcribed, and analyzed using the qualitative data analysis software Atlas. ti V.8.4. RESULTS Twenty-five parents were interviewed. Despite being in an emotional and stressful situation, most parents considered being approached for DR studies as valuable. According to parents, this was mostly due to appropriate timing and communication, compassion, and investigators not being obtrusive. Interviewed parents generally decided to accept or decline study participation based on perceived risk. Parents differed widely in how risk of specific study interventions was perceived, but agreed on the fact that parental consent is needed for DR studies that involve risk. There was no consensus among parents on deferred consent for DR studies running at our NICU. However, parents considered deferred consent appropriate for observational studies. Furthermore, it became clear that parental misunderstanding of various aspects of DR studies, including aims, the concept of randomization, and risk associated with specific interventions, was common. CONCLUSIONS Insight into parental perceptions of consent for DR studies allowed us to determine areas where the validity of parental consent can be improved. Further research on parental perspectives for consent for DR studies will allow us to establish consent procedures that are considered both valid and valuable.
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Affiliation(s)
- Maria C den Boer
- Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, The Netherlands
| | - Mirjam Houtlosser
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, The Netherlands
| | - Ruben S G M Witlox
- Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Martine C de Vries
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, The Netherlands.,Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Arjan B Te Pas
- Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
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Vrouenraets LJJJ, de Vries ALC, de Vries MC, van der Miesen AIR, Hein IM. Assessing Medical Decision-Making Competence in Transgender Youth. Pediatrics 2021; 148:183482. [PMID: 34850191 DOI: 10.1542/peds.2020-049643] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/15/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND According to international transgender care guidelines, an important prerequisite for puberty suppression (PS) is transgender adolescents' competence to give informed consent (IC). In society, there is doubt whether transgender adolescents are capable of this, which in some countries has even led to limited access to this intervention. Therefore, this study examined transgender adolescents' medical decision-making competence (MDC) to give IC for starting PS in a structured, replicable way. Additionally, potential associated variables on MDC, such as age, intelligence, sex, psychological functioning, were investigated. METHODS A cross-sectional semistructured interview study with 74 transgender adolescents (aged 10-18 years; 16 birth-assigned boys, 58 birth-assigned girls) within two Dutch specialized gender-identity clinics was performed. To assess MDC, judgements based on the reference standard (clinical assessment) and the MacArthur Competence Assessment Tool for Treatment (MacCAT-T), a validated semistructured interview, were used. RESULTS Of the transgender adolescents, 93.2% (reference standard judgements; 69 of 74) and 89.2% (MacCAT-T judgements; 66 of 74) were assessed competent to consent. Intermethod agreement was 87.8% (65 of 74). Interrater agreements of the reference standard and MacCAT-T-based judgements were 89.2% (198 of 222) and 86.5% (192 of 222), respectively. IQ and sex were both significantly related to MacCAT-T total score, whereas age, level of emotional and behavioral challenges, and diagnostic trajectories duration were not. CONCLUSIONS By using the MacCAT-T and clinicians' assessments, 93.2% and 89.2%, respectively, of the transgender adolescents in this study were assessed competent to consent for starting PS.
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Affiliation(s)
- Lieke J J J Vrouenraets
- Department of Child and Adolescent Psychiatry, Leiden University Medical Center Curium, Leiden University Medical Center, Oegstgeest, the Netherlands.,Department of Child and Adolescent Psychiatry, Amsterdam University Medical Center, Location VUmc, VU University, Amsterdam, the Netherlands.,Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, the Netherlands
| | - Annelou L C de Vries
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Center, Location VUmc, VU University, Amsterdam, the Netherlands
| | - Martine C de Vries
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, the Netherlands
| | - Anna I R van der Miesen
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Center, Location VUmc, VU University, Amsterdam, the Netherlands
| | - Irma M Hein
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Center and University of Amsterdam, Amsterdam, the Netherlands
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Vrouenraets LJ, de Vries MC, Hein IM, Arnoldussen M, Hannema SE, de Vries AL. Perceptions on the function of puberty suppression of transgender adolescents who continued or discontinued treatment, their parents, and clinicians. Int J Transgend Health 2021; 23:428-441. [PMID: 36324881 PMCID: PMC9621271 DOI: 10.1080/26895269.2021.1974324] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Purpose: Treatment of transgender adolescents with puberty suppression (PS) was developed to provide time for exploration before pursuing gender affirming medical treatment (GAMT) with irreversible effects. It may also result in a more satisfactory physical outcome for those who continue with GAMT. Despite being the current first choice treatment, little research has examined the function of PS from the perspectives of transgender adolescents, their parents, and clinicians. Insight into the perceived functions of PS will help to adequately support adolescents in their decision-making process and give them the care they need. Methods: Qualitative study using interviews with eight transgender adolescents who proceeded with GAMT after PS ("continuers"), six adolescents who discontinued PS ("discontinuers") and 12 parents, and focus groups with ten clinicians. Results: All informants considered inhibition of development of secondary sex characteristics an important function of PS. Most continuers saw PS as the first step of GAMT. Nevertheless, some were glad that the effects were reversible even if they didn't expect to change their minds. Some discontinuers did experience PS as an expanded diagnostic phase. One continuer used the time on PS to get used to living in the affirmed gender role, and several parents found the time helpful to adapt to their child's new gender role. PS provided clinicians more time for diagnostic assessment. Conclusions: Adolescents, parents and clinicians do not all report the same functions of PS. Although international guidelines emphasize providing time for exploration of gender identity as an important reason for PS, many adolescents nowadays seem to have clear ideas about their gender identity and treatment wishes, and experience PS as the first step of GAMT. For some discontinuers however, PS offered a valued period of exploration. Guidelines could be modified to provide more customized care, taking adolescents' and parents' ideas about the functions of PS into account.
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Affiliation(s)
- Lieke J.J.J. Vrouenraets
- LUMC Curium-Department of Child and Adolescent Psychiatry, Leiden University Medical Center, Oegstgeest, The Netherlands
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, The Netherlands
| | - Martine C. de Vries
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, The Netherlands
| | - Irma M. Hein
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Centers, Location AMC, University of Amsterdam and Levvel, Amsterdam, The Netherlands
| | - Marijn Arnoldussen
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Centers, Location VUmc, VU Universiteit, Amsterdam, The Netherlands
| | - Sabine E. Hannema
- Department of Paediatric Endocrinology, Amsterdam University Medical Centers, Location VUmc, VU Universiteit, Amsterdam, the Netherlands
- Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Annelou L.C. de Vries
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Centers, Location VUmc, VU Universiteit, Amsterdam, The Netherlands
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den Boer MC, Houtlosser M, Witlox RSGM, van der Stap R, de Vries MC, Lopriore E, Te Pas AB. Reviewing recordings of neonatal resuscitation with parents. Arch Dis Child Fetal Neonatal Ed 2021; 106:346-351. [PMID: 33514631 DOI: 10.1136/archdischild-2020-320059] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 01/08/2021] [Accepted: 01/11/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Recording of neonatal resuscitation, including video and respiratory parameters, was implemented for research and quality purposes at the neonatal intensive care unit (NICU) of the Leiden University Medical Center, and parents were offered to review the recording of their infant together with a neonatal care provider. We aimed to provide insight in parental experiences with reviewing the recording of the neonatal resuscitation of their premature infant. METHODS This study combined participant observations during parental review of recordings with retrospective qualitative interviews with parents. RESULTS Parental review of recordings of neonatal resuscitation was observed on 20 occasions, reviewing recordings of 31 children (12 singletons, 8 twins and 1 triplet), of whom 4 died during admission. Median (range) gestational age at birth was 27+5 (24+5-30+3) weeks. Subsequently, 25 parents (13 mothers and 12 fathers) were interviewed.Parents reported many positive experiences, with special emphasis on the value for getting hold of the start of their infant's life and coping with the trauma of neonatal resuscitation. Reviewing recordings of neonatal resuscitation frequently resulted in appreciation for the child, the father and the medical team. Timing and set-up of the review contributed to positive experiences. Parents considered screenshots/copies of the recording of the resuscitation of their infant as valuable keepsakes of their NICU story and reported that having the screenshots/video comforted them, especially when their child died during admission. CONCLUSION Parents consider reviewing recordings of neonatal resuscitation as valuable. These positive parental experiences could allay concerns about sharing recordings of neonatal resuscitation with parents.
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Affiliation(s)
- Maria C den Boer
- Department of Neonatology, Leiden University Medical Center, Leiden, The Netherlands .,Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, The Netherlands
| | - Mirjam Houtlosser
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, The Netherlands
| | - Ruben S G M Witlox
- Department of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Martine C de Vries
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Enrico Lopriore
- Department of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Arjan B Te Pas
- Department of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
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14
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Verweij EJ, de Vries MC, Oldekamp EJ, Eggink AJ, Oepkes D, Slaghekke F, Spoor JKH, Deprest JA, Miller JL, Baschat AA, DeKoninck PLJ. Fetoscopic myelomeningocoele closure: Is the scientific evidence enough to challenge the gold standard for prenatal surgery? Prenat Diagn 2021; 41:949-956. [PMID: 33778976 PMCID: PMC8360048 DOI: 10.1002/pd.5940] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 03/18/2021] [Accepted: 03/22/2021] [Indexed: 12/18/2022]
Abstract
Since the completion of the Management of Myelomeningocoele Study, maternal-fetal surgery for spina bifida has become a valid option for expecting parents. More recently, multiple groups are exploring a minimally invasive approach and recent outcomes have addressed many of the initial concerns with this approach. Based on a previously published framework, we attempt to delineate the developmental stage of the surgical techniques. Furthermore, we discuss the barriers of performing randomized controlled trials comparing two surgical interventions and suggest that data collection through registries is an alternative method to gather high-grade evidence.
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Affiliation(s)
- E Joanne Verweij
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Martine C de Vries
- Department of Medical Ethics & Health Law, Leiden University Medical Center, Leiden, The Netherlands
| | - Esther J Oldekamp
- Department of Medical Ethics & Health Law, Leiden University Medical Center, Leiden, The Netherlands
| | - Alex J Eggink
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dick Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Femke Slaghekke
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Jochem K H Spoor
- Department of Neurosurgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jan A Deprest
- Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Department of Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Jena L Miller
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ahmet A Baschat
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Philip L J DeKoninck
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
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15
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Vreugdenhil M, Akkermans MD, van Swelm RPL, Laarakkers CM, Houdijk ECAM, Bakker B, Clement-de Boers A, van der Kaay DCM, de Vries MC, Woltering MC, Mul D, van Goudoever JB, Brus F. Serum hepcidin concentrations in relation to iron status in children with type 1 diabetes. Pediatr Hematol Oncol 2021; 38:108-123. [PMID: 33026897 DOI: 10.1080/08880018.2020.1820650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Chronic low-grade inflammation in type 1 diabetes (T1D) might increase hepcidin synthesis, possibly resulting in functional iron deficiency (FID). We hypothesized that in T1D children with FID, hepcidin concentrations are increased compared to those with normal iron status and those with absolute iron deficiency (AID). We evaluated hepcidin concentrations in T1D children in relation to iron status, and investigated whether hepcidin is useful in assessing FID. A cross-sectional study was conducted. FID was defined as elevated zinc protoporphyrin/heme ratio and/or red blood cell distribution width, and AID as low serum ferritin concentration. Post-hoc analyses with different definitions of FID were performed, using transferrin saturation and reticulocyte hemoglobin content. Serum hepcidin concentrations were measured using mass-spectrometry. The IRODIAB-study is registered at www.trialregister.nl (NTR4642). This study included 215 T1D children with a median age of 13.7 years (Q1-Q3: 10.1-16.3). The median (Q1-Q3) hepcidin concentration in patients with normal iron status was 1.8 nmol/l (0.9-3.3), in AID-patients, 0.4 nmol/l (0.4-0.4) and in FID-patients, 1.6 nmol/l (0.7-3.5). Hepcidin concentrations in FID-patients were significantly higher than in AID-patients (p < 0.001). Irrespective of FID-definition used, hepcidin concentrations did not differ between FID-patients and patients with normal iron status. This might be explained by the influence of various factors on hepcidin concentrations, and/or by differences in response of iron parameters over time. Single hepcidin measurements do not seem useful in assessing FID in T1D children. Multiple hepcidin measurements over time in future studies, however, might prove to be more useful in assessing FID in children with T1D.
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Affiliation(s)
- Mirjam Vreugdenhil
- Department of Pediatrics, Juliana Children's Hospital/Haga Teaching Hospital, The Hague, The Netherlands
| | - Marjolijn D Akkermans
- Department of Pediatrics, Juliana Children's Hospital/Haga Teaching Hospital, The Hague, The Netherlands
| | - Rachel P L van Swelm
- Department of Laboratory Medicine, Translational Metabolic Laboratory (TML 830), Hepcidinanalysis.com, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Coby M Laarakkers
- Department of Laboratory Medicine, Translational Metabolic Laboratory (TML 830), Hepcidinanalysis.com, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Euphemia C A M Houdijk
- Department of Pediatrics, Juliana Children's Hospital/Haga Teaching Hospital, The Hague, The Netherlands
| | - Boudewijn Bakker
- Department of Pediatrics, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Agnes Clement-de Boers
- Department of Pediatrics, Juliana Children's Hospital/Haga Teaching Hospital, The Hague, The Netherlands
| | - Daniëlle C M van der Kaay
- Department of Pediatrics, Juliana Children's Hospital/Haga Teaching Hospital, The Hague, The Netherlands
| | - Martine C de Vries
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - M Claire Woltering
- Department of Pediatrics, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Dick Mul
- Diabeter, Center for Pediatric and Adolescent Diabetes Care and Research, Rotterdam, The Netherlands
| | - Johannes B van Goudoever
- Department of Pediatrics, Amsterdam University Medical Center, University of Amsterdam, Vrije Universiteit, Emma Children's Hospital, Amsterdam, The Netherlands
| | - Frank Brus
- Department of Pediatrics, Juliana Children's Hospital/Haga Teaching Hospital, The Hague, The Netherlands
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16
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van der Graaf R, van Dijk W, Laurijssen SJM, Schuit E, Grobbe DE, de Vries MC. The Duty to Support Learning Health Systems: A Broad Rather than a Narrow Interpretation. Am J Bioeth 2021; 21:14-16. [PMID: 33373568 DOI: 10.1080/15265161.2020.1845870] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
| | | | | | - Ewoud Schuit
- University Medical Center Utrecht, Utrecht University
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17
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van Dijk WB, Fiolet ATL, Schuit E, Sammani A, Groenhof TKJ, van der Graaf R, de Vries MC, Alings M, Schaap J, Asselbergs FW, Grobbee DE, Groenwold RHH, Mosterd A. Text-mining in electronic healthcare records can be used as efficient tool for screening and data collection in cardiovascular trials: a multicenter validation study. J Clin Epidemiol 2020; 132:97-105. [PMID: 33248277 DOI: 10.1016/j.jclinepi.2020.11.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 10/24/2020] [Accepted: 11/18/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVE This study aimed to validate trial patient eligibility screening and baseline data collection using text-mining in electronic healthcare records (EHRs), comparing the results to those of an international trial. STUDY DESIGN AND SETTING In three medical centers with different EHR vendors, EHR-based text-mining was used to automatically screen patients for trial eligibility and extract baseline data on nineteen characteristics. First, the yield of screening with automated EHR text-mining search was compared with manual screening by research personnel. Second, the accuracy of extracted baseline data by EHR text mining was compared to manual data entry by research personnel. RESULTS Of the 92,466 patients visiting the out-patient cardiology departments, 568 (0.6%) were enrolled in the trial during its recruitment period using manual screening methods. Automated EHR data screening of all patients showed that the number of patients needed to screen could be reduced by 73,863 (79.9%). The remaining 18,603 (20.1%) contained 458 of the actual participants (82.4% of participants). In trial participants, automated EHR text-mining missed a median of 2.8% (Interquartile range [IQR] across all variables 0.4-8.5%) of all data points compared to manually collected data. The overall accuracy of automatically extracted data was 88.0% (IQR 84.7-92.8%). CONCLUSION Automatically extracting data from EHRs using text-mining can be used to identify trial participants and to collect baseline information.
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Affiliation(s)
- Wouter B van Dijk
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| | - Aernoud T L Fiolet
- Department of Cardiology, Meander Medical Center, Amersfoort, the Netherlands; Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Ewoud Schuit
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Arjan Sammani
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - T Katrien J Groenhof
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Rieke van der Graaf
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Martine C de Vries
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden University, Leiden, the Netherlands
| | - Marco Alings
- Department of Cardiology, Amphia Hospital, Breda, the Netherlands; Dutch Network for Cardiovascular Research (WCN), Utrecht, the Netherlands
| | - Jeroen Schaap
- Department of Cardiology, Amphia Hospital, Breda, the Netherlands; Dutch Network for Cardiovascular Research (WCN), Utrecht, the Netherlands
| | - Folkert W Asselbergs
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Institute of Cardiovascular Science, Faculty of Population Health Sciences, University College London, London, United Kingdom; Health Data Research UK and Institute of Health Informatics, University College London, London, United Kingdom
| | - Diederick E Grobbee
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Rolf H H Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden University, Leiden, the Netherlands
| | - Arend Mosterd
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Cardiology, Meander Medical Center, Amersfoort, the Netherlands; Dutch Network for Cardiovascular Research (WCN), Utrecht, the Netherlands
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18
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Brik T, Vrouenraets LJJJ, de Vries MC, Hannema SE. Trajectories of Adolescents Treated with Gonadotropin-Releasing Hormone Analogues for Gender Dysphoria. Arch Sex Behav 2020; 49:2611-2618. [PMID: 32152785 PMCID: PMC7497424 DOI: 10.1007/s10508-020-01660-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 02/09/2020] [Accepted: 02/10/2020] [Indexed: 05/12/2023]
Abstract
Gonadotropin-releasing hormone analogues (GnRHa) are recommended as initial treatment for adolescents diagnosed with gender dysphoria, providing time to follow gender identity development and consider further treatment wishes without distress caused by unwanted pubertal changes. This has been described as an extended diagnostic phase. However, there are also concerns about the physical, neurocognitive, and psychosocial effects of this treatment. In this retrospective study, we document trajectories after the initiation of GnRHa and explore reasons for extended use and discontinuation of GnRHa. Treatment was considered appropriate in 143 (67%) of the 214 adolescents eligible for GnRHa treatment by virtue of their age/pubertal status, and all started GnRHa (38 transgirls, 105 transboys; median age, 15.0 years [range, 11.1-18.6] and 16.1 years [range, 10.1-17.9]). After a median duration of 0.8 years (0.3-3.8) on GnRHa, 125 (87%) started gender-affirming hormones (GAH). Nine (6%) discontinued GnRHa, five of whom no longer wished gender-affirming treatment. Thirteen had used GnRHa for longer than required by protocol for reasons other than logistics and regularly met with a mental health professional during this time, supporting the use of GnRHa treatment as an extended diagnostic phase. In conclusion, the vast majority who started GnRHa proceeded to GAH, possibly due to eligibility criteria that select those highly likely to pursue further gender-affirming treatment. Due to the observational character of the study, it is not possible to say if GnRHa treatment itself influenced the outcome. Few individuals discontinued GnRHa, and only 3.5% no longer wished gender-affirming treatment.
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Affiliation(s)
- Tessa Brik
- Department of Pediatrics, Leiden University Medical Centre, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Lieke J J J Vrouenraets
- Department of Pediatric and Adolescent Psychiatry, Curium-Leiden University Medical Centre, Leiden, The Netherlands
- Department of Medical Ethics and Health Law, Leiden University Medical Centre, Leiden, The Netherlands
| | - Martine C de Vries
- Department of Pediatrics, Leiden University Medical Centre, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
- Department of Medical Ethics and Health Law, Leiden University Medical Centre, Leiden, The Netherlands
| | - Sabine E Hannema
- Department of Pediatrics, Leiden University Medical Centre, P.O. Box 9600, 2300 RC, Leiden, The Netherlands.
- Department of Paediatric Endocrinology, Sophia Children's Hospital, Erasmus Medical Centre, Rotterdam, The Netherlands.
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19
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Vrouenraets LJJJ, Hartman LA, Hein IM, de Vries ALC, de Vries MC, Molewijk BAC. Dealing with Moral Challenges in Treatment of Transgender Children and Adolescents: Evaluating the Role of Moral Case Deliberation. Arch Sex Behav 2020; 49:2619-2634. [PMID: 32592076 PMCID: PMC7497454 DOI: 10.1007/s10508-020-01762-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 06/03/2020] [Accepted: 06/05/2020] [Indexed: 05/10/2023]
Abstract
Treatment teams providing affirmative medical transgender care to young people frequently face moral challenges arising from the care they provide. An adolescent's capacity to consent, for example, could raise several issues and challenges. To deal with these challenges more effectively, several Dutch treatment teams started using a relatively well-established form of clinical ethics support (CES) called Moral Case Deliberation (MCD). MCD is a facilitator-led, collective moral inquiry based on a real case. This study's purpose is to describe the teams' perceived value and effectiveness of MCD. We conducted a mixed methods evaluation study using MCD session reports, individual interviews, focus groups, and MCD evaluation questionnaires. Our results show that Dutch transgender care providers rated MCD as highly valuable in situations where participants were confronted with moral challenges. The health care providers reported that MCD increased mutual understanding and open communication among team members and strengthened their ability to make decisions and take action when managing ethically difficult circumstances. However, the health care providers also expressed criticisms of MCD: some felt that the amount of time spent discussing individual cases was excessive, that MCD should lead to more practical and concrete results, and that MCD needed better integration and follow-up in the regular work process. We recommend future research on three matters: studying how MCD contributes to the quality of care, involvement of transgender people themselves in MCD, and integration of CES into daily work processes.
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Affiliation(s)
| | - Laura A Hartman
- Department of Medical Humanities, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, location VU University Medical Center, Amsterdam, The Netherlands
| | - Irma M Hein
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
| | - Annelou L C de Vries
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Centers, location VU University Medical Center, Amsterdam, The Netherlands
| | - Martine C de Vries
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Bert A C Molewijk
- Department of Medical Humanities, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, location VU University Medical Center, Amsterdam, The Netherlands
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20
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Mekelenkamp H, Lankester AC, Bierings MB, Smiers FJW, de Vries MC, Kars MC. Parental experiences in end-of-life decision-making in allogeneic pediatric stem cell transplantation: "Have I been a good parent?". Pediatr Blood Cancer 2020; 67:e28229. [PMID: 32134215 DOI: 10.1002/pbc.28229] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 01/22/2020] [Accepted: 02/05/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND In pediatric hematopoietic stem cell transplantation (HSCT), the end-of-life (EOL) phase and the loss of the child is often characterized by a sudden deterioration of the child following a period of intensive curative treatment. This demands a fast transition for parents. Therefore, an understanding of the parents' perspective on decision-making in such a complex situation is needed. This study aims to gain insight in parental experiences in EOL decision-making in allogeneic pediatric HSCT. METHODS A qualitative descriptive study was performed among parents of eight families. Data were thematically analyzed. RESULTS All parents were aware of their child's deterioration. Six families were confronted with a rapid deterioration, while two families experienced a gradual realization that their child would not survive. Parental EOL decision-making in pediatric HSCT shows a reflective perspective on the meaning of parenthood in EOL decision-making. Two central themes were identified: "survival-oriented decision-making" and "struggling with doubts in hindsight." Six subthemes within the first theme described the parents' goal of doing everything to achieve survival. DISCUSSION Parents experienced EOL decision-making mainly as a process guided by health care professionals (HCPs) based on the child's condition and treatment possibilities. The decision-making is characterized by following opportunities and focusing on hope for cure. In hindsight parents experienced doubts about treatment steps and their child's suffering. HCPs can strengthen the parental role by an early integration of palliative care, providing timely support to parents in the process of imminent loss. Advance care planning can be used to support communication processes, defining preferences for future care.
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Affiliation(s)
- Hilda Mekelenkamp
- Department of Pediatrics, Pediatric Stem Cell Transplantation, Leiden University Medical Centre, Leiden, The Netherlands.,Department of Medical Ethics and Health Law, Leiden University Medical Centre, Leiden, The Netherlands
| | - Arjan C Lankester
- Department of Pediatrics, Pediatric Stem Cell Transplantation, Leiden University Medical Centre, Leiden, The Netherlands
| | - Marc B Bierings
- Pediatric Stem Cell Transplantation Program, Princess Maxima Centre and University Medical Centre, Utrecht, The Netherlands
| | - Frans J W Smiers
- Department of Pediatrics, Pediatric Stem Cell Transplantation, Leiden University Medical Centre, Leiden, The Netherlands
| | - Martine C de Vries
- Department of Medical Ethics and Health Law, Leiden University Medical Centre, Leiden, The Netherlands
| | - Marijke C Kars
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
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21
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Blom M, Schoenaker MHD, Hulst M, de Vries MC, Weemaes CMR, Willemsen MAAP, Henneman L, van der Burg M. Dilemma of Reporting Incidental Findings in Newborn Screening Programs for SCID: Parents' Perspective on Ataxia Telangiectasia. Front Immunol 2019; 10:2438. [PMID: 31781088 PMCID: PMC6851017 DOI: 10.3389/fimmu.2019.02438] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 09/30/2019] [Indexed: 12/20/2022] Open
Abstract
Background: Ataxia Telangiectasia (A-T) is a severe DNA repair disorder that leads to a broad range of symptoms including neurodegeneration and a variable immunodeficiency. A-T is one of the incidental findings that accompanies newborn screening (NBS) for severe combined immunodeficiency (SCID), leading to an early diagnosis of A-T at birth in a pre-symptomatic stage. While some countries embrace all incidental findings, the current policy in the Netherlands on reporting untreatable incidental findings is more conservative. We present parents' perspectives and considerations on the various advantages vs. disadvantages of early and late diagnosis of A-T. Methods: A questionnaire was developed and sent to 4,000 parents of healthy newborns who participated in the Dutch SONNET-study (implementation pilot for newborn screening for SCID). The questionnaire consisted of open-ended and scale questions on advantages and disadvantages of early and late diagnosis of A-T. To address potential bias, demographic characteristics of the study sample were compared to a reference population. Results: A total of 664 of 4,000 parents sent back the questionnaire (response rate 16.6%). The vast majority of parents (81.9%) favored early diagnosis of A-T over late diagnosis. Main arguments were to avoid a long period of uncertainty prior to diagnosis and to ensure the most optimal clinical care and guidance from the onset of symptoms. Parents who favored late diagnosis of A-T stated that early diagnosis would not lead to improved quality of life and preferred to enjoy the asymptomatic "golden years" with their child. The majority of parents (81.1%) stated that they would participate in newborn screening for A-T if a test was available. Conclusions: Reporting untreatable incidental findings remains a disputed topic worldwide. Although the current policy in the Netherlands is not to report untreatable incidental findings, unless the health advantage is clear, the majority of parents of healthy newborns are in favor of an early A-T diagnosis in the pre-symptomatic phase of the disorder. Our results as well as other studies that showed support for the screening of untreatable disorders may serve as valuable tools to inform policymakers in their considerations about NBS for untreatable disorders.
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Affiliation(s)
- Maartje Blom
- Department of Pediatrics, Leiden University Medical Centre, Leiden, Netherlands
| | - Michiel H. D. Schoenaker
- Department of Pediatric Neurology, Radboudumc Amalia Children's Hospital and Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
| | - Myrthe Hulst
- Department of Biologicals, Innovation and Screening, National Institute for Public Health and the Environment, Bilthoven, Netherlands
| | - Martine C. de Vries
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, Netherlands
| | - Corry M. R. Weemaes
- Department of Pediatrics, Radboudumc Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Michèl A. A. P. Willemsen
- Department of Pediatric Neurology, Radboudumc Amalia Children's Hospital and Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
- Department of Pediatrics, Radboudumc Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Lidewij Henneman
- Department of Clinical Genetics, Amsterdam Reproduction & Development Research Institute, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, Netherlands
| | - Mirjam van der Burg
- Department of Pediatrics, Leiden University Medical Centre, Leiden, Netherlands
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22
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van Dijk WB, Grobbee DE, de Vries MC, Groenwold RHH, van der Graaf R, Schuit E. A systematic breakdown of the levels of evidence supporting the European Society of Cardiology guidelines. Eur J Prev Cardiol 2019; 26:1944-1952. [PMID: 31409110 PMCID: PMC6886117 DOI: 10.1177/2047487319868540] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIMS Reviews of clinical practice guidelines have repeatedly concluded that only a minority of guideline recommendations are supported by high-quality evidence from randomised controlled trials. The aim of this study is to evaluate whether these findings apply to the whole cardiovascular evidence base or specific recommendation types and actions. METHODS All recommendations from current European Society of Cardiology guidelines were extracted with their class (I, treatment is beneficial; II, treatment is possibly beneficial; III, treatment is harmful) and level of evidence (A, multiple randomised controlled trials/meta-analyses; B, single randomised controlled trials/large observational studies; C, expert opinion/small studies). Recommendations were categorised by type (therapeutic, diagnostic, other) and actions (e.g. pharmaceutical intervention/non-invasive imaging/test). RESULTS In total, 3531 recommendations (median 128, interquartile range 108-150) were extracted from 27 guidelines. Therapeutic recommendations comprised 2545 (72.1%) recommendations, 411 (16.1%) were supported by level of evidence A, 833 (32.7%) by B and 1301 (51.1%) by C. Class I/III (should/should not) recommendations on minimally invasive interventions were most supported by level of evidence A (55/183, 30.1%) (B [70/183, 38.3%], C [58/183, 31.7%]), while class I/III recommendations on open surgical interventions were least supported by level of evidence A (15/164, 9.1%) (B [34/164, 20.7%], C [115/164, 70.1%]). Of all (831, 23.5%) diagnostic recommendations, just 44/503 (8.7%) class I/III recommendations were supported by level of evidence A (B (125/503, 24.9%), C (334/503, 66.4%)). CONCLUSION Evidence levels supporting European Society of Cardiology guideline recommendations differ widely between recommendation types and actions. Attributing to this variability are different evidence requirements, therapeutic/diagnostic recommendations, different feasibility levels for trials (e.g. open surgical/pharmacological) and many off-topic/policy recommendations based on expert opinion.
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Affiliation(s)
- Wouter B van Dijk
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands
| | - Diederick E Grobbee
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands
| | - Martine C de Vries
- Department of Medical Ethics and Health Law, Leiden University Medical Center, The Netherlands
| | - Rolf H H Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, The Netherlands
| | - Rieke van der Graaf
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands
| | - Ewoud Schuit
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands.,Cochrane Netherlands, University Medical Center Utrecht, The Netherlands
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23
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Stoffers IE, de Vries MC, Hannema SE. Physical changes, laboratory parameters, and bone mineral density during testosterone treatment in adolescents with gender dysphoria. J Sex Med 2019; 16:1459-1468. [PMID: 31405768 DOI: 10.1016/j.jsxm.2019.06.014] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 05/25/2019] [Accepted: 06/23/2019] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Current treatment guidelines for adolescents with gender dysphoria recommend therapy with gonadotropin-releasing hormone agonists (GnRHa) and testosterone in transgender males. However, most evidence on the safety and efficacy of testosterone is based on studies in adults. AIM This study aimed to investigate the efficacy and safety of testosterone treatment in transgender adolescents. METHODS The study included 62 adolescents diagnosed with gender dysphoria who had started GnRHa treatment and had subsequently received testosterone treatment for more than 6 months. MAIN OUTCOME MEASURE Virilization, anthropometry, laboratory parameters, and bone mineral density (BMD) were analyzed. RESULTS Adolescents were treated with testosterone for a median duration of 12 months. Voice deepening began within 3 months in 85% of adolescents. Increased hair growth was first reported on the extremities, followed by an increase of facial hair. Acne was most prevalent between 6 and 12 months of testosterone therapy. Most adolescents had already completed linear growth; body mass index and systolic blood pressure increased but diastolic blood pressure did not change. High-density lipoprotein (HDL) cholesterol and sex hormone binding globulin significantly decreased, but hematocrit, hemoglobin, prolactin, androstenedione, and dehydroepiandrosterone sulfate significantly increased, although not all changes were clinically significant. Other lipids and HbA1c did not change. Vitamin D deficiency was seen in 32-54% throughout treatment. BMD z-scores after 12 to 24 months of testosterone treatment remained below z-scores before the start of GnRHa treatment. CLINICAL IMPLICATIONS Adolescents need to be counseled about side effects with potential longer term implications such as increased hematocrit and decreased HDL cholesterol and decreased BMD z-scores. They should be advised on diet, including adequate calcium and vitamin D intake; physical exercise; and the use of tobacco and alcohol to avoid additional risk factors for cardiovascular disease and osteoporosis. STRENGTHS & LIMITATIONS Strengths are the standardized treatment regimen and extensive set of safety parameters investigated. Limitations are the limited duration of follow-up and lack of a control group so some of the observed changes may be due to normal maturation rather than to treatment. CONCLUSION Testosterone effectively induced virilization beginning within 3 months in the majority of adolescents. Acne was a common side effect, but no short-term safety issues were observed. The increased hematocrit, decreased HDL cholesterol, and decreased BMD z-scores are in line with previous studies. Further follow-up studies will need to establish if the observed changes result in adverse outcomes in the long term. Stoffers IE, de Vries MC, Hannema SE. Physical Changes, Laboratory Parameters, and Bone Mineral Density During Testosterone Treatment in Adolescents with Gender Dysphoria. J Sex Med 2019;16:1459-1468.
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Affiliation(s)
- Iris E Stoffers
- Department of Pediatrics, Leiden University Medical Centre, Leiden, the Netherlands
| | - Martine C de Vries
- Department of Pediatrics, Leiden University Medical Centre, Leiden, the Netherlands; Department of Medical Ethics and Health Law, Leiden University Medical Centre, Leiden, the Netherlands
| | - Sabine E Hannema
- Department of Pediatrics, Leiden University Medical Centre, Leiden, the Netherlands.
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24
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Skordis N, Butler G, de Vries MC, Main K, Hannema SE. ESPE and PES International Survey of Centers and Clinicians Delivering Specialist Care for Children and Adolescents with Gender Dysphoria. Horm Res Paediatr 2019; 90:326-331. [PMID: 30695784 DOI: 10.1159/000496115] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 12/10/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Increasing numbers of children and adolescents seek medical care because they experience incongruence between their physical sex and their gender identity. METHODS The ESPE working group on gender dysphoria (GD) undertook a survey to investigate the structure and the type of medical care in centers that offer specialist care for transgender adolescents. RESULTS The personnel of each center varied from country to country, and a nationally organized network or plan for managing GD did not exist in all centers. The majority of young people were transitioning from female to male, and the number of new referrals increased remarkably during the past 3 years. Almost all centers follow the guidelines issued by the Endocrine Society and World Professional Association for Transgender Health. GnRH analogues were used as the initial treatment in the majority of the centers. The age from which adolescents are treated with gender-affirming hormones varied between centers. Several legal restrictions that concern or influence the treatment of children and adolescents with GD were finally addressed. CONCLUSION This first international survey examining the variations in availability and provisions of services for children and adolescents with GD serves as a starting block for further dialogue and future studies.
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Affiliation(s)
- Nicos Skordis
- Division of Pediatric Endocrinology, Paedi Center for Specialized Pediatrics, Nicosia, Cyprus, .,University of Nicosia Medical School, Nicosia, Cyprus,
| | - Gary Butler
- Department of Paediatric and Adolescent Endocrinology, University College London Hospitals, London, United Kingdom.,UCL Great Ormond Street Institute of Child Health, London, United Kingdom.,UK Gender Identity Development Service, Tavistock and Portman NHS Trust, London, United Kingdom
| | - Martine C de Vries
- Department of Medical Ethics and Health Law, Leiden University Medical Centre, Leiden, The Netherlands.,Department of Paediatrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Katharina Main
- Department of Growth and Reproduction and EDMaRC, Rigshospitalet, Faculty of Health Sciences, Copenhagen University, Copenhagen, Denmark
| | - Sabine E Hannema
- Department of Paediatrics, Leiden University Medical Centre, Leiden, The Netherlands
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25
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den Boer MC, Houtlosser M, Foglia EE, Davis PG, van Kaam AH, Kamlin COF, Schmölzer GM, de Vries MC, Te Pas AB. Deferred consent for the enrolment of neonates in delivery room studies: strengthening the approach. Arch Dis Child Fetal Neonatal Ed 2019; 104:F348-F352. [PMID: 31072968 DOI: 10.1136/archdischild-2018-316461] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 03/06/2019] [Accepted: 03/16/2019] [Indexed: 11/03/2022]
Affiliation(s)
- Maria C den Boer
- Neonatology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, The Netherlands
| | - Mirjam Houtlosser
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, The Netherlands
| | - Elizabeth E Foglia
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Peter G Davis
- Newborn Research, Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Anton H van Kaam
- Neonatology, Emma Children's Hospital AMC, Amsterdam, The Netherlands
| | - Camille O F Kamlin
- Division of Newborn Services, Royal Women's Hospital, Melbourne, Victoria, Australia
| | | | - Martine C de Vries
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, The Netherlands.,Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Arjan B Te Pas
- Neonatology, Leiden University Medical Center, Leiden, The Netherlands
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26
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Brik T, Vrouenraets LJJJ, Schagen SEE, Meissner A, de Vries MC, Hannema SE. Use of Fertility Preservation Among a Cohort of Transgirls in the Netherlands. J Adolesc Health 2019; 64:589-593. [PMID: 30691936 DOI: 10.1016/j.jadohealth.2018.11.008] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 11/01/2018] [Accepted: 11/02/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE The primary aims of the study are to examine the rate of attempted fertility preservation (FP) among a Dutch cohort of transgirls who started gonadotropin-releasing hormone analog treatment and the reasons why adolescents did or did not choose to attempt FP. METHODS The study was a single-center retrospective review of medical records of 35 transgirls who started gonadotropin-releasing hormone analog treatment between 2011 and 2017. RESULTS Ninety-one percent of adolescents were counseled on the option of FP. Thirty-eight percent of counseled adolescents attempted FP, and 75% of them were able to cryopreserve sperm suitable for intrauterine insemination or intracytoplasmic sperm injection. Younger and Caucasian transgirls were less likely to attempt FP. No specific reason for declining FP was known in 33% adolescents, 32% of adolescents were not able to produce a semen sample because of early puberty, 17% felt uncomfortable with masturbation, 17% did not want to have children, and 13% wanted to adopt. CONCLUSIONS One third of adolescents attempted FP, which is much more than the percentage reported in previous studies from the United States. One third of the transgirls could not make use of FP because they were unable to produce a semen sample because of early pubertal stage. For these adolescents, alternatives need to be explored.
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Affiliation(s)
- Tessa Brik
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Lieke J J J Vrouenraets
- Department of Pediatric Psychology, Curium-Leiden University Medical Center, Leiden, The Netherlands
| | | | - Andreas Meissner
- Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Martine C de Vries
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Sabine E Hannema
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.
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27
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Hissink Muller PCE, Yildiz B, Allaart CF, Brinkman DMC, van Rossum M, van Suijlekom-Smit LWA, van den Berg JM, Ten Cate R, de Vries MC. Participation in a single-blinded pediatric therapeutic strategy study for juvenile idiopathic arthritis: are parents and patient-participants in equipoise? BMC Med Ethics 2018; 19:96. [PMID: 30572875 PMCID: PMC6302476 DOI: 10.1186/s12910-018-0336-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 12/10/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Genuine uncertainty on superiority of one intervention over the other is called equipoise. Physician-investigators in randomized controlled trials (RCT) need equipoise at least in studies with more than minimal risks. Ideally, this equipoise is also present in patient-participants. In pediatrics, data on equipoise are lacking. We hypothesize that 1) lack of equipoise at enrolment among parents may reduce recruitment; 2) lack of equipoise during participation may reduce retention in patients assigned to a less favoured treatment-strategy. METHODS We compared preferences of parents/patients at enrolment, documented by a questionnaire (phase 1), with preferences developed during follow-up by an interview-study (phase 2) to investigate equipoise of child-participants and parents in the BeSt-for-Kids-study (NTR 1574). This trial in new-onset Juvenile Idiopathic Arthritis-patients consists of three strategies. One strategy comprises initial treatment with a biological disease-modifying-antirheumatic-drug (DMARD), currently not standard-of-care. Semi-structured interviews were conducted with 23 parents and 7 patients, median 11 months after enrolment. RESULTS Initially most parents and children were not in equipoise. Parents/patients who refused participation, regularly declined due to specific preferences. Many participating families preferred the biological-first-strategy. They participated to have a chance for this initial treatment, and would even consider stopping trial-participation when not randomized for it. Their conviction of superiority of the biological-first strategy was based on knowledge from internet and close relations. According to four parents, the physician-investigator preferred the biological-first-strategy, but the majority (n = 19) stated that she had no preferred strategy. In phase 2, preferences tended to change to the treatment actually received. CONCLUSIONS Lack of equipoise during enrolment did not reduce study recruitment, mainly due to the fact that preferred treatment was only available within the study. Still, when developing a trial it is important to evaluate whether the physicians' research question is in line with preferences of the patient-group. By exploring so-called 'informed patient-group'-equipoise, successful recruitment may be enhanced and bias avoided. In our study, lack of equipoise during trial-participation did not reduce retention in those assigned to a less favoured option. We observed a change for preference towards treatment actually received, possibly explained by comparable outcomes in all three arms.
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Affiliation(s)
- Petra C E Hissink Muller
- Department of Pediatric Rheumatology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, the Netherlands. .,Department of Pediatric Rheumatology, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands.
| | - Bahar Yildiz
- Department of Pediatric Rheumatology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, the Netherlands
| | - Cornelia F Allaart
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Danielle M C Brinkman
- Department of Pediatric Rheumatology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, the Netherlands.,Department of Pediatrics, Alrijne Hospital, Leiderdorp, the Netherlands
| | - Marion van Rossum
- Department of Pediatric Rheumatology, Reade Amsterdam Rheumatology Center, Amsterdam, the Netherlands
| | | | - J Merlijn van den Berg
- Department of Pediatric Hematology Immunology Infectious Diseases and Rheumatology, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Rebecca Ten Cate
- Department of Pediatric Rheumatology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, the Netherlands
| | - Martine C de Vries
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, the Netherlands
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28
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Hendriks AC, de Vries MC. [The right to sexual health and the role of doctors]. Ned Tijdschr Geneeskd 2018; 162:D2822. [PMID: 30040316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Sexual health is an internationally recognised human right, imposing obligations on States to promote the aspirations enshrined in this right. However, from a legal and ethical perspective, the right to sexual health also creates duties for doctors to protect, respect and - where possible - fulfil. By means of a number of scenarios, we discuss how doctors should react to these situations. The responsibility of doctors concerning the sexual health of patients goes further than many would assume, but also has clear restrictions.
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Affiliation(s)
- A C Hendriks
- Universiteit Leiden, Faculteit der Rechtsgeleerdheid, dep. Publiekrecht, Leiden
- Contact: A.C. Hendriks
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29
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Akkermans MD, Mieke Houdijk ECA, Bakker B, Boers ACD, van der Kaay DCM, de Vries MC, Claire Woltering M, Mul D, van Goudoever JB, Brus F. Iron status and its association with HbA1c levels in Dutch children with diabetes mellitus type 1. Eur J Pediatr 2018; 177:603-610. [PMID: 29396628 DOI: 10.1007/s00431-018-3104-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 01/17/2018] [Accepted: 01/18/2018] [Indexed: 11/30/2022]
Abstract
UNLABELLED Children with diabetes mellitus (DM) type 1 may be at risk for iron deficiency (ID) although this has been little studied. ID is either an absolute (depleted iron stores) or a functional (restricted iron stores due to chronic inflammation) deficiency each requiring a different therapeutic approach. Unfortunately, absolute ID is often not distinguished from functional ID. Furthermore, iron-deficient anemia may influence hemoglobin A1c (HbA1c) levels. We aimed to determine the prevalence and type of ID and investigate its association with HbA1c levels in pediatric DM type 1 patients. We performed a two-center prospective observational study in which the iron status of Dutch children with DM type 1 was determined during a regular check-up. Absolute ID and functional ID were found in 13/227 (5.7%) and 100/214 (47%) patients, respectively, while only 15/113 (13%) patients also had anemia. HbA1c levels in patients with and without a deprived iron status (absolute or functional) were not significantly different (65 ± 17 vs. 65 ± 16 mmol/mol, p = 0.815). CONCLUSION Functional, but not absolute, ID was common in Dutch pediatric DM type 1 patients. HbA1c levels were not associated with ID, which can be explained by the relatively mild deprived iron status in our patients. TRIAL REGISTRATION NTR4642 What is Known: • Iron deficiency is either an absolute (depleted iron stores) or a functional (restricted iron stores due to chronic inflammation) deficiency each requiring a different therapeutic approach. • Children with diabetes mellitus type 1 may be at risk for both types of iron deficiency and this can influence their hemoglobin A1c levels although this has been little studied. What is New: • In Dutch children with diabetes mellitus type 1, functional, but not absolute iron deficiency, is common and should not be treated with iron replacement therapy. • Hemoglobin A1c levels were not associated with iron deficiency, probably due to the relatively mild deprived iron status in our patients.
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Affiliation(s)
- Marjolijn D Akkermans
- Department of Pediatrics, Juliana Children's Hospital/Haga Teaching Hospital, Els Borst-Eilersplein 275, zip code, 2545, AA, The Hague, the Netherlands.
| | - E C A Mieke Houdijk
- Department of Pediatrics, Juliana Children's Hospital/Haga Teaching Hospital, Els Borst-Eilersplein 275, zip code, 2545, AA, The Hague, the Netherlands
| | - Boudewijn Bakker
- Department of Pediatrics, Reinier de Graaf Hospital, Reinier de Graafweg 5, zip code, 2625, AD, Delft, the Netherlands
| | - Agnes Clement-de Boers
- Department of Pediatrics, Juliana Children's Hospital/Haga Teaching Hospital, Els Borst-Eilersplein 275, zip code, 2545, AA, The Hague, the Netherlands
| | - Daniëlle C M van der Kaay
- Department of Pediatrics, Juliana Children's Hospital/Haga Teaching Hospital, Els Borst-Eilersplein 275, zip code, 2545, AA, The Hague, the Netherlands
| | - Martine C de Vries
- Department of Pediatrics, Leiden University Medical Center, Albinusdreef 2, zip code, 2333, ZA, Leiden, the Netherlands
| | - M Claire Woltering
- Department of Pediatrics, Reinier de Graaf Hospital, Reinier de Graafweg 5, zip code, 2625, AD, Delft, the Netherlands
| | - Dick Mul
- Department of Pediatrics, Juliana Children's Hospital/Haga Teaching Hospital, Els Borst-Eilersplein 275, zip code, 2545, AA, The Hague, the Netherlands.,Diabeter, Center for Pediatric and Adolescent Diabetes Care and Research, Blaak 6, zip code, 3011, TA, Rotterdam, the Netherlands
| | - Johannes B van Goudoever
- Department of Pediatrics, VU University Medical Center, De Boelelaan 1118, zip code, 1081, HZ, Amsterdam, the Netherlands.,Department of Pediatrics, Emma Children's Hospital - Academic Medical Center, Meibergdreef 9, zip code, 1105, AZ, Amsterdam, the Netherlands
| | - Frank Brus
- Department of Pediatrics, Juliana Children's Hospital/Haga Teaching Hospital, Els Borst-Eilersplein 275, zip code, 2545, AA, The Hague, the Netherlands
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30
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van der Graaf R, Dekking SA, de Vries MC, Zwaan CM, van Delden JJ. Pediatric oncology as a Learning Health System: Ethical implications for best available treatment protocols. Learn Health Syst 2018; 2:e10052. [PMID: 31245582 PMCID: PMC6508761 DOI: 10.1002/lrh2.10052] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 01/12/2018] [Accepted: 01/21/2018] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Pediatric oncology is often considered as a field in which research and care are highly integrated. We believe that this integration can be seen as a so-called Learning Health System, a system in which research is considered an important means to continuously improve the practice of care. In order to substantiate our assumption of pediatric oncology as an LHS, we will analyze so-called "best available treatment protocols." These protocols always contain research elements, even if themain goal of these protocols is to treat children diagnosed with cancer. METHODS We will analyze the implications for ethical review and informed consent if these protocols had to function as exponents of pediatric oncology an LHS. RESULTS An analysis of best available treatment protocols teaches us how these protocols integrate care and research and how these protocols can be seen as exponents of a system where care and research need no longer be sharply distinct practices. DISCUSSION Further intervention in the field of pediatric oncology is essential to also meet the requirements for an ethically responsible LHS. CONCLUSION Best available treatment protocols, which combine research and care, can be seen as examples of pediatric oncology as an LHS. However, in order to prevent that research elements in these protocols will be overlooked, we will have to find new ways to accommodate for the oversight of these protocols, such as multifaceted review and risk-adapted approaches. Moreover, informed consent process must be changed in order for patients to understand how care and research are integrated in these protocols.
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Affiliation(s)
- Rieke van der Graaf
- Department of Medical HumanitiesUniversity Medical Center Utrecht Julius CenterUtrechtThe Netherlands
| | - Sara A. Dekking
- Ethics Division Department of Public HealthMinistry of Health, Welfare and SportThe HagueThe Netherlands
| | - Martine C. de Vries
- Department of Medical Ethics and Health LawLeiden University Medical CenterLeidenThe Netherlands
| | - Christian Michel Zwaan
- Department of Paediatric OncologyErasmus MC‐Sophia Children's HospitalRotterdamThe Netherlands
| | - Johannes J.M. van Delden
- Department of Medical HumanitiesUniversity Medical Center Utrecht Julius CenterUtrechtThe Netherlands
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Grootens-Wiegers P, Hein IM, van den Broek JM, de Vries MC. Medical decision-making in children and adolescents: developmental and neuroscientific aspects. BMC Pediatr 2017; 17:120. [PMID: 28482854 PMCID: PMC5422908 DOI: 10.1186/s12887-017-0869-x] [Citation(s) in RCA: 134] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 04/22/2017] [Indexed: 12/16/2022] Open
Abstract
Background Various international laws and guidelines stress the importance of respecting the developing autonomy of children and involving minors in decision-making regarding treatment and research participation. However, no universal agreement exists as to at what age minors should be deemed decision-making competent. Minors of the same age may show different levels of maturity. In addition, patients deemed rational conversation-partners as a child can suddenly become noncompliant as an adolescent. Age, context and development all play a role in decision-making competence. In this article we adopt a perspective on competence that specifically focuses on the impact of brain development on the child’s decision-making process. Main body We believe that the discussion on decision-making competence of minors can greatly benefit from a multidisciplinary approach. We adopted such an approach in order to contribute to the understanding on how to deal with children in decision-making situations. Evidence emerging from neuroscience research concerning the developing brain structures in minors is combined with insights from various other fields, such as psychology, decision-making science and ethics. Four capacities have been described that are required for (medical) decision-making: (1) communicating a choice; (2) understanding; (3) reasoning; and (4) appreciation. Each capacity is related to a number of specific skills and abilities that need to be sufficiently developed to support the capacity. Based on this approach it can be concluded that at the age of 12 children can have the capacity to be decision-making competent. However, this age coincides with the onset of adolescence. Early development of the brain’s reward system combined with late development of the control system diminishes decision-making competence in adolescents in specific contexts. We conclude that even adolescents possessing capacities required for decision-making, may need support of facilitating environmental factors. Conclusion This paper intends to offer insight in neuroscientific mechanisms underlying the medical decision-making capacities in minors and to stimulate practices for optimal involvement of minors. Developing minors become increasingly capable of decision-making, but the neurobiological development in adolescence affects competence in specific contexts. Adequate support should be offered in order to create a context in which minors can make competently make decisions. Electronic supplementary material The online version of this article (doi:10.1186/s12887-017-0869-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Petronella Grootens-Wiegers
- Science Communication and Society, Leiden University, Leiden, The Netherlands. .,Athena Institute for Research on Innovation and Communication in Health and Life Sciences, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands.
| | - Irma M Hein
- Child and Adolescent Psychiatry and de Bascule, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Jos M van den Broek
- Science Communication and Society, Leiden University, Leiden, The Netherlands.,Athena Institute for Research on Innovation and Communication in Health and Life Sciences, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands
| | - Martine C de Vries
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, The Netherlands.,Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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Grootens-Wiegers P, Visser EG, van Rossum AMC, van Waardhuizen CN, de Wildt SN, Sweep B, van den Broek JM, de Vries MC. Perspectives of adolescents on decision making about participation in a biobank study: a pilot study. BMJ Paediatr Open 2017; 1:e000111. [PMID: 29637137 PMCID: PMC5862224 DOI: 10.1136/bmjpo-2017-000111] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 07/27/2017] [Accepted: 07/28/2017] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES To be able to truly involve adolescents in decision making about clinical research participation, we need more insight in the perspective of adolescents themselves. To this end, adolescents in an ongoing biobank study were consulted to test a tentative decision assessment tool. METHODS The perspectives of adolescents (n=8) concerning participation in decision making for research participation were explored in interviews with a tentative tool, which covered six topics: information material usage, understanding, disease perceptions, anxiety, decision-making process and role sharing. RESULTS All adolescents unequivocally expressed the desire to be involved in decision making, but also wanted advice from their parents. The extent of the preferred role of adolescent versus parents varied between individuals. In decision making, adolescents relied on parents for information. More than half hardly used the information material. CONCLUSIONS Adolescents in our study preferred a shared decision-making process. The extent of sharing varied between individuals. The decision assessment tool was a fruitful starting point to discuss adolescents' perspectives and may aid in tailoring the situation to the individual to achieve optimal participation practices. IMPLICATIONS Consulting adolescents about their preferences concerning decision making using the tool will facilitate tailoring of the shared decision-making process and optimising the developing autonomy of minors.
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Affiliation(s)
- Petronella Grootens-Wiegers
- Department of Science Communication and Society, Leiden University, Leiden, The Netherlands.,Committee of Medical Ethics, Leiden University Medical Center, Leiden, The Netherlands
| | - Eline G Visser
- Department of Pediatrics, Division of Infectious Diseases and Immunology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Annemarie M C van Rossum
- Department of Pediatrics, Division of Infectious Diseases and Immunology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Claudia N van Waardhuizen
- Theme Sophia, Sector Research Office-Theme Sophia Biobank, Erasmus MC University Medical Center, Rotterdam, The Netherlands.,Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.,Department of Radiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Saskia N de Wildt
- Intensive Care and Department of Pediatric Surgery, Erasmus MC University Medical Center, Leiden, The Netherlands.,Department of Pharmacology and Toxicology, Radboud University, Nijmegen, The Netherlands
| | - Boudewijn Sweep
- Department of Science Communication and Society, Leiden University, Leiden, The Netherlands
| | - Jos M van den Broek
- Department of Science Communication and Society, Leiden University, Leiden, The Netherlands
| | - Martine C de Vries
- Departments of Pediatrics and Ethics and Health Law, Leiden University Medical Center, Nijmegen, The Netherlands
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Vrouenraets LJJJ, Fredriks AM, Hannema SE, Cohen-Kettenis PT, de Vries MC. Perceptions of Sex, Gender, and Puberty Suppression: A Qualitative Analysis of Transgender Youth. Arch Sex Behav 2016; 45:1697-703. [PMID: 27251640 PMCID: PMC4987409 DOI: 10.1007/s10508-016-0764-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 03/14/2016] [Accepted: 03/29/2016] [Indexed: 05/21/2023]
Abstract
International guidelines recommend the use of Gonadotropin-Releasing Hormone (GnRH) agonists in adolescents with gender dysphoria (GD) to suppress puberty. Little is known about the way gender dysphoric adolescents themselves think about this early medical intervention. The purpose of the present study was (1) to explicate the considerations of gender dysphoric adolescents in the Netherlands concerning the use of puberty suppression; (2) to explore whether the considerations of gender dysphoric adolescents differ from those of professionals working in treatment teams, and if so in what sense. This was a qualitative study designed to identify considerations of gender dysphoric adolescents regarding early treatment. All 13 adolescents, except for one, were treated with puberty suppression; five adolescents were trans girls and eight were trans boys. Their ages ranged between 13 and 18 years, with an average age of 16 years and 11 months, and a median age of 17 years and 4 months. Subsequently, the considerations of the adolescents were compared with views of clinicians treating youth with GD. From the interviews with the gender dysphoric adolescents, three themes emerged: (1) the difficulty of determining what is an appropriate lower age limit for starting puberty suppression. Most adolescents found it difficult to define an appropriate age limit and saw it as a dilemma; (2) the lack of data on the long-term effects of puberty suppression. Most adolescents stated that the lack of long-term data did not and would not stop them from wanting puberty suppression; (3) the role of the social context, for which there were two subthemes: (a) increased media-attention, on television, and on the Internet; (b) an imposed stereotype. Some adolescents were positive about the role of the social context, but others raised doubts about it. Compared to clinicians, adolescents were often more cautious in their treatment views. It is important to give voice to gender dysphoric adolescents when discussing the use of puberty suppression in GD. Otherwise, professionals might act based on assumptions about adolescents' opinions instead of their actual considerations. We encourage gathering more qualitative research data from gender dysphoric adolescents in other countries.
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Affiliation(s)
| | - A Miranda Fredriks
- Department of Pediatric and Adolescent Psychiatry, Curium-Leiden University Medical Centre, Endegeesterstraatweg 27, 2342 AK, Oegstgeest, The Netherlands
| | - Sabine E Hannema
- Department of Pediatrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Peggy T Cohen-Kettenis
- Department of Medical Psychology, VU University Medical Centre, Amsterdam, The Netherlands
| | - Martine C de Vries
- Department of Pediatrics, Leiden University Medical Centre, Leiden, The Netherlands
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Jansen-van der Weide MC, Caldwell PHY, Young B, de Vries MC, Willems DL, Van't Hoff W, Woolfall K, van der Lee JH, Offringa M. Clinical Trial Decisions in Difficult Circumstances: Parental Consent Under Time Pressure. Pediatrics 2015; 136:e983-92. [PMID: 26416935 DOI: 10.1542/peds.2014-3402] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Treatments and interventions used to care for children in emergencies should be based on strong evidence. Well-designed clinical trials investigating these interventions for children are therefore indispensable. Parental informed consent is a key ethical requirement for the enrollment of children in such studies. However, if time is limited because of an urgent need for intervention, there are additional ethical challenges to adequately support the informed consent process. The acute situation and associated psychological impact may compromise the ability of parents to give informed consent. Little evidence exists to guide the process of consent seeking for a child's research participation when time is limited. It is also unclear in what circumstances alternatives to prospective informed consent could be applied. This article describes possible options to manage the informed consent process in an appropriate, practical, and, we believe, ethical way when time is limited.
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Affiliation(s)
| | - Patrina H Y Caldwell
- Discipline of Paediatrics and Child Health, University of Sydney, Sydney, Australia
| | - Bridget Young
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, United Kingdom
| | - Martine C de Vries
- Departments of Pediatrics, Medical Ethics and Law, Leiden University Medical Center, Leiden, Netherlands
| | - Dick L Willems
- Section of Medical Ethics, Department of General Practice, Academic Medical Center/University of Amsterdam, Amsterdam, Netherlands
| | - William Van't Hoff
- Clinical Research Facility, Great Ormond Street Hospital, London, United Kingdom; and
| | - Kerry Woolfall
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, United Kingdom
| | - Johanna H van der Lee
- Pediatric Clinical Research Office, Emma Children's Hospital, Academic Medical Center, Amsterdam, Netherlands
| | - Martin Offringa
- Child Health Evaluative Sciences, SickKids Research Institute, University of Toronto, Toronto, Ontario, Canada
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Vrouenraets LJJJ, Fredriks AM, Hannema SE, Cohen-Kettenis PT, de Vries MC. Early Medical Treatment of Children and Adolescents With Gender Dysphoria: An Empirical Ethical Study. J Adolesc Health 2015; 57:367-73. [PMID: 26119518 DOI: 10.1016/j.jadohealth.2015.04.004] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 04/08/2015] [Accepted: 04/08/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE The Endocrine Society and the World Professional Association for Transgender Health published guidelines for the treatment of adolescents with gender dysphoria (GD). The guidelines recommend the use of gonadotropin-releasing hormone agonists in adolescence to suppress puberty. However, in actual practice, no consensus exists whether to use these early medical interventions. The aim of this study was to explicate the considerations of proponents and opponents of puberty suppression in GD to move forward the ethical debate. METHODS Qualitative study (semi-structured interviews and open-ended questionnaires) to identify considerations of proponents and opponents of early treatment (pediatric endocrinologists, psychologists, psychiatrists, ethicists) of 17 treatment teams worldwide. RESULTS Seven themes give rise to different, and even opposing, views on treatment: (1) the (non-)availability of an explanatory model for GD; (2) the nature of GD (normal variation, social construct or [mental] illness); (3) the role of physiological puberty in developing gender identity; (4) the role of comorbidity; (5) possible physical or psychological effects of (refraining from) early medical interventions; (6) child competence and decision making authority; and (7) the role of social context how GD is perceived. Strikingly, the guidelines are debated both for being too liberal and for being too limiting. Nevertheless, many treatment teams using the guidelines are exploring the possibility of lowering the current age limits. CONCLUSIONS As long as debate remains on these seven themes and only limited long-term data are available, there will be no consensus on treatment. Therefore, more systematic interdisciplinary and (worldwide) multicenter research is required.
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Affiliation(s)
| | - A Miranda Fredriks
- Department of Pediatric and Adolescent Psychiatry, Curium-Leiden University Medical Centre, Oegstgeest, The Netherlands
| | - Sabine E Hannema
- Department of Pediatrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Peggy T Cohen-Kettenis
- Department of Medical Psychology, VU University Medical Centre, Amsterdam, The Netherlands
| | - Martine C de Vries
- Department of Pediatrics, Leiden University Medical Centre, Leiden, The Netherlands
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Dekking SAS, van der Graaf R, de Vries MC, Bierings MB, van Delden JJM, Kodish E, Lantos JD. Is a New Protocol for Acute Lymphoblastic Leukemia Research or Standard Therapy? Pediatrics 2015; 136:566-70. [PMID: 26283776 PMCID: PMC4893943 DOI: 10.1542/peds.2014-2327] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/16/2014] [Indexed: 11/24/2022] Open
Abstract
In the United States, doctors generally develop new cancer chemotherapy for children by testing innovative chemotherapy protocols against existing protocols in prospective randomized trials. In the Netherlands, children with leukemia are treated by protocols that are agreed upon by the Dutch Childhood Oncology Group. Periodically, the Dutch Childhood Oncology Group revises its protocols. Sometimes, these revisions are categorized as research, sometimes as treatment. In this Ethics Rounds, we analyze whether enrollment in a new protocol ought to be considered research and, if so, we discuss the implications of that designation. Our discussion highlights the different ways different countries approach complex issues of research ethics.
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Affiliation(s)
- Sara A. S. Dekking
- Julius Center for Health Sciences and Primary Care, Department of Medical Humanities and
| | - Rieke van der Graaf
- Julius Center for Health Sciences and Primary Care, Department of Medical Humanities and
| | - Martine C. de Vries
- Leiden University Medical Center, Department of Pediatrics, Leiden, Netherlands
| | - Marc B. Bierings
- Wilhelmina Children’s Hospital, Department of Pediatric Hematology, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Eric Kodish
- Center for Ethics, Humanities and Spiritual Care, Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio; and
| | - John D. Lantos
- Children’s Mercy Hospital, Kansas City, Missouri,Address correspondence to John D. Lantos, MD, Children’s Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108. E-mail:
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Kant SG, Cervenkova I, Balek L, Trantirek L, Santen GWE, de Vries MC, van Duyvenvoorde HA, van der Wielen MJR, Verkerk AJMH, Uitterlinden AG, Hannema SE, Wit JM, Oostdijk W, Krejci P, Losekoot M. A novel variant of FGFR3 causes proportionate short stature. Eur J Endocrinol 2015; 172:763-70. [PMID: 25777271 DOI: 10.1530/eje-14-0945] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 03/16/2015] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Mutations of the fibroblast growth factor receptor 3 (FGFR3) cause various forms of short stature, of which the least severe phenotype is hypochondroplasia, mainly characterized by disproportionate short stature. Testing for an FGFR3 mutation is currently not part of routine diagnostic testing in children with short stature without disproportion. DESIGN A three-generation family A with dominantly transmitted proportionate short stature was studied by whole-exome sequencing to identify the causal gene mutation. Functional studies and protein modeling studies were performed to confirm the pathogenicity of the mutation found in FGFR3. We performed Sanger sequencing in a second family B with dominant proportionate short stature and identified a rare variant in FGFR3. METHODS Exome sequencing and/or Sanger sequencing was performed, followed by functional studies using transfection of the mutant FGFR3 into cultured cells; homology modeling was used to construct a three-dimensional model of the two FGFR3 variants. RESULTS A novel p.M528I mutation in FGFR3 was detected in family A, which segregates with short stature and proved to be activating in vitro. In family B, a rare variant (p.F384L) was found in FGFR3, which did not segregate with short stature and showed normal functionality in vitro compared with WT. CONCLUSIONS Proportionate short stature can be caused by a mutation in FGFR3. Sequencing of this gene can be considered in patients with short stature, especially when there is an autosomal dominant pattern of inheritance. However, functional studies and segregation studies should be performed before concluding that a variant is pathogenic.
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Affiliation(s)
- Sarina G Kant
- Department of Clinical GeneticsLeiden University Medical Center, PO Box 9600, 2300RC, Leiden, The NetherlandsDepartment of BiologyFaculty of MedicineCentral European Institute of TechnologyMasaryk University, Brno, Czech RepublicDepartment of PediatricsLeiden University Medical Center, Leiden, The NetherlandsDepartment of Internal MedicineErasmus Medical Center, Rotterdam, The NetherlandsDepartment of Orthopaedic SurgeryDavid Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Iveta Cervenkova
- Department of Clinical GeneticsLeiden University Medical Center, PO Box 9600, 2300RC, Leiden, The NetherlandsDepartment of BiologyFaculty of MedicineCentral European Institute of TechnologyMasaryk University, Brno, Czech RepublicDepartment of PediatricsLeiden University Medical Center, Leiden, The NetherlandsDepartment of Internal MedicineErasmus Medical Center, Rotterdam, The NetherlandsDepartment of Orthopaedic SurgeryDavid Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Lukas Balek
- Department of Clinical GeneticsLeiden University Medical Center, PO Box 9600, 2300RC, Leiden, The NetherlandsDepartment of BiologyFaculty of MedicineCentral European Institute of TechnologyMasaryk University, Brno, Czech RepublicDepartment of PediatricsLeiden University Medical Center, Leiden, The NetherlandsDepartment of Internal MedicineErasmus Medical Center, Rotterdam, The NetherlandsDepartment of Orthopaedic SurgeryDavid Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Lukas Trantirek
- Department of Clinical GeneticsLeiden University Medical Center, PO Box 9600, 2300RC, Leiden, The NetherlandsDepartment of BiologyFaculty of MedicineCentral European Institute of TechnologyMasaryk University, Brno, Czech RepublicDepartment of PediatricsLeiden University Medical Center, Leiden, The NetherlandsDepartment of Internal MedicineErasmus Medical Center, Rotterdam, The NetherlandsDepartment of Orthopaedic SurgeryDavid Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Gijs W E Santen
- Department of Clinical GeneticsLeiden University Medical Center, PO Box 9600, 2300RC, Leiden, The NetherlandsDepartment of BiologyFaculty of MedicineCentral European Institute of TechnologyMasaryk University, Brno, Czech RepublicDepartment of PediatricsLeiden University Medical Center, Leiden, The NetherlandsDepartment of Internal MedicineErasmus Medical Center, Rotterdam, The NetherlandsDepartment of Orthopaedic SurgeryDavid Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Martine C de Vries
- Department of Clinical GeneticsLeiden University Medical Center, PO Box 9600, 2300RC, Leiden, The NetherlandsDepartment of BiologyFaculty of MedicineCentral European Institute of TechnologyMasaryk University, Brno, Czech RepublicDepartment of PediatricsLeiden University Medical Center, Leiden, The NetherlandsDepartment of Internal MedicineErasmus Medical Center, Rotterdam, The NetherlandsDepartment of Orthopaedic SurgeryDavid Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Hermine A van Duyvenvoorde
- Department of Clinical GeneticsLeiden University Medical Center, PO Box 9600, 2300RC, Leiden, The NetherlandsDepartment of BiologyFaculty of MedicineCentral European Institute of TechnologyMasaryk University, Brno, Czech RepublicDepartment of PediatricsLeiden University Medical Center, Leiden, The NetherlandsDepartment of Internal MedicineErasmus Medical Center, Rotterdam, The NetherlandsDepartment of Orthopaedic SurgeryDavid Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Michiel J R van der Wielen
- Department of Clinical GeneticsLeiden University Medical Center, PO Box 9600, 2300RC, Leiden, The NetherlandsDepartment of BiologyFaculty of MedicineCentral European Institute of TechnologyMasaryk University, Brno, Czech RepublicDepartment of PediatricsLeiden University Medical Center, Leiden, The NetherlandsDepartment of Internal MedicineErasmus Medical Center, Rotterdam, The NetherlandsDepartment of Orthopaedic SurgeryDavid Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Annemieke J M H Verkerk
- Department of Clinical GeneticsLeiden University Medical Center, PO Box 9600, 2300RC, Leiden, The NetherlandsDepartment of BiologyFaculty of MedicineCentral European Institute of TechnologyMasaryk University, Brno, Czech RepublicDepartment of PediatricsLeiden University Medical Center, Leiden, The NetherlandsDepartment of Internal MedicineErasmus Medical Center, Rotterdam, The NetherlandsDepartment of Orthopaedic SurgeryDavid Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - André G Uitterlinden
- Department of Clinical GeneticsLeiden University Medical Center, PO Box 9600, 2300RC, Leiden, The NetherlandsDepartment of BiologyFaculty of MedicineCentral European Institute of TechnologyMasaryk University, Brno, Czech RepublicDepartment of PediatricsLeiden University Medical Center, Leiden, The NetherlandsDepartment of Internal MedicineErasmus Medical Center, Rotterdam, The NetherlandsDepartment of Orthopaedic SurgeryDavid Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Sabine E Hannema
- Department of Clinical GeneticsLeiden University Medical Center, PO Box 9600, 2300RC, Leiden, The NetherlandsDepartment of BiologyFaculty of MedicineCentral European Institute of TechnologyMasaryk University, Brno, Czech RepublicDepartment of PediatricsLeiden University Medical Center, Leiden, The NetherlandsDepartment of Internal MedicineErasmus Medical Center, Rotterdam, The NetherlandsDepartment of Orthopaedic SurgeryDavid Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Jan M Wit
- Department of Clinical GeneticsLeiden University Medical Center, PO Box 9600, 2300RC, Leiden, The NetherlandsDepartment of BiologyFaculty of MedicineCentral European Institute of TechnologyMasaryk University, Brno, Czech RepublicDepartment of PediatricsLeiden University Medical Center, Leiden, The NetherlandsDepartment of Internal MedicineErasmus Medical Center, Rotterdam, The NetherlandsDepartment of Orthopaedic SurgeryDavid Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Wilma Oostdijk
- Department of Clinical GeneticsLeiden University Medical Center, PO Box 9600, 2300RC, Leiden, The NetherlandsDepartment of BiologyFaculty of MedicineCentral European Institute of TechnologyMasaryk University, Brno, Czech RepublicDepartment of PediatricsLeiden University Medical Center, Leiden, The NetherlandsDepartment of Internal MedicineErasmus Medical Center, Rotterdam, The NetherlandsDepartment of Orthopaedic SurgeryDavid Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Pavel Krejci
- Department of Clinical GeneticsLeiden University Medical Center, PO Box 9600, 2300RC, Leiden, The NetherlandsDepartment of BiologyFaculty of MedicineCentral European Institute of TechnologyMasaryk University, Brno, Czech RepublicDepartment of PediatricsLeiden University Medical Center, Leiden, The NetherlandsDepartment of Internal MedicineErasmus Medical Center, Rotterdam, The NetherlandsDepartment of Orthopaedic SurgeryDavid Geffen School of Medicine at UCLA, Los Angeles, California, USA Department of Clinical GeneticsLeiden University Medical Center, PO Box 9600, 2300RC, Leiden, The NetherlandsDepartment of BiologyFaculty of MedicineCentral European Institute of TechnologyMasaryk University, Brno, Czech RepublicDepartment of PediatricsLeiden University Medical Center, Leiden, The NetherlandsDepartment of Internal MedicineErasmus Medical Center, Rotterdam, The NetherlandsDepartment of Orthopaedic SurgeryDavid Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Monique Losekoot
- Department of Clinical GeneticsLeiden University Medical Center, PO Box 9600, 2300RC, Leiden, The NetherlandsDepartment of BiologyFaculty of MedicineCentral European Institute of TechnologyMasaryk University, Brno, Czech RepublicDepartment of PediatricsLeiden University Medical Center, Leiden, The NetherlandsDepartment of Internal MedicineErasmus Medical Center, Rotterdam, The NetherlandsDepartment of Orthopaedic SurgeryDavid Geffen School of Medicine at UCLA, Los Angeles, California, USA
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Grootens-Wiegers P, de Vries MC, van den Broek JM. Research information for minors: Suitable formats and readability. A systematic review. J Paediatr Child Health 2015; 51:505-511. [PMID: 25363315 DOI: 10.1111/jpc.12762] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/12/2014] [Indexed: 11/28/2022]
Abstract
As children age, their capacity to consent or dissent to research participation increases. Numerous regulations and guidelines require that children should receive information 'according to their capacity of understanding'. In order to gain more insight in the quality of patient information forms for minors, a systematic literature search was performed. Two aspects of quality will be analysed in this paper: the effect of format on understanding and the readability of text in the documents. A systematic search was executed in PubMed, Embase and PsycINFO. Seventeen papers on format were included. Interventions testing information formats indicate that improvement is possible, but outcome measurement varied per study and no apparently successful intervention was repeated. Only three readability papers were found, all indicating a readability gap between patient information forms and children's actual reading level. The results indicate an urgent need for further research on how to adequately inform minors about clinical trials.
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Affiliation(s)
| | - Martine C de Vries
- Department of Pediatrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Jos M van den Broek
- Department of Science Communication & Society, Leiden University, Leiden, The Netherlands
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Dekking SAS, van der Graaf R, Kars MC, Beishuizen A, de Vries MC, van Delden JJM. Balancing research interests and patient interests: a qualitative study into the intertwinement of care and research in paediatric oncology. Pediatr Blood Cancer 2015; 62:816-22. [PMID: 25728244 DOI: 10.1002/pbc.25444] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Accepted: 01/05/2015] [Indexed: 01/03/2023]
Abstract
BACKGROUND Traditionally, in ethical guidelines and in research ethics literature, care and research are clearly separated based on their different objectives. In contrast, in paediatric oncology, research and care are closely combined. Currently, it is unknown how relevant actors in paediatric oncology perceive this combination of research and care. We conducted a qualitative study into the experiences of those involved in Dutch paediatric oncology with the intertwinement of research and care and the dual role of paediatric oncologists as researchers and treating physicians. PROCEDURE A qualitative study approach, using two focus groups and 19 semi-structured, in-depth interviews with paediatric oncologists, research coordinators, parents of children with cancer, and adolescents with cancer. RESULTS Four themes characterize how actors experience the intertwinement of research and care in paediatric oncology. First, research is considered of major importance, and paediatric oncology professionals convey this message to patients and their parents. Second, there is ambiguity about categorization of studies into cancer therapy as either research or treatment. Third, role conflicts appear within the work of the paediatric oncologists. Finally, the various benefits of combining treatment with research are emphasized. CONCLUSIONS Research is regarded as a fundamental and indispensable characteristic of paediatric oncology practice. Paediatric oncology professionals, parents, and patients have a very positive outlook on combining research and care, but they may not be sufficiently critical with respect to potential conflicts. Increased reflection on how to optimally combine research and care could serve as an important protection of the interests of children with cancer and their parents.
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Affiliation(s)
- Sara A S Dekking
- University Medical Centre Utrecht, Julius Centre for Health Sciences and Primary Care, Department of Medical Humanities, Utrecht, The Netherlands
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Oostdijk W, Idkowiak J, Mueller JW, House PJ, Taylor AE, O'Reilly MW, Hughes BA, de Vries MC, Kant SG, Santen GWE, Verkerk AJMH, Uitterlinden AG, Wit JM, Losekoot M, Arlt W. PAPSS2 deficiency causes androgen excess via impaired DHEA sulfation--in vitro and in vivo studies in a family harboring two novel PAPSS2 mutations. J Clin Endocrinol Metab 2015; 100:E672-80. [PMID: 25594860 PMCID: PMC4399300 DOI: 10.1210/jc.2014-3556] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
CONTEXT PAPSS2 (PAPS synthase 2) provides the universal sulfate donor PAPS (3'-phospho-adenosine-5'-phosphosulfate) to all human sulfotransferases, including SULT2A1, responsible for sulfation of the crucial androgen precursor dehydroepiandrosterone (DHEA). Impaired DHEA sulfation is thought to increase the conversion of DHEA toward active androgens, a proposition supported by the previous report of a girl with inactivating PAPSS2 mutations who presented with low serum DHEA sulfate and androgen excess, clinically manifesting with premature pubarche and early-onset polycystic ovary syndrome. PATIENTS AND METHODS We investigated a family harboring two novel PAPSS2 mutations, including two compound heterozygous brothers presenting with disproportionate short stature, low serum DHEA sulfate, but normal serum androgens. Patients and parents underwent a DHEA challenge test comprising frequent blood sampling and urine collection before and after 100 mg DHEA orally, with subsequent analysis of DHEA sulfation and androgen metabolism by mass spectrometry. The functional impact of the mutations was investigated in silico and in vitro. RESULTS We identified a novel PAPSS2 frameshift mutation, c.1371del, p.W462Cfs*3, resulting in complete disruption, and a novel missense mutation, c.809G>A, p.G270D, causing partial disruption of DHEA sulfation. Both patients and their mother, who was heterozygous for p.W462Cfs*3, showed increased 5α-reductase activity at baseline and significantly increased production of active androgens after DHEA intake. The mother had a history of oligomenorrhea and chronic anovulation that required clomiphene for ovulation induction. CONCLUSIONS We provide direct in vivo evidence for the significant functional impact of mutant PAPSS2 on DHEA sulfation and androgen activation. Heterozygosity for PAPSS2 mutations can be associated with a phenotype resembling polycystic ovary syndrome.
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Affiliation(s)
- Wilma Oostdijk
- Department of Pediatrics (W.O., M.C.d.V., J.M.W.), Leiden University Medical Center, 2300 RC Leiden, The Netherlands; Centre for Endocrinology, Diabetes, and Metabolism (J.I., J.W.M., P.J.H., A.E.T., M.W.O., B.A.H., W.A.), School of Clinical and Experimental Medicine, University of Birmingham, Birmingham B15 2TT, United Kingdom; Department of Clinical Genetics (S.G.K., G.W.E.S., M.L.), Leiden University Medical Center, 2300 RC Leiden, The Netherlands; and Department of Internal Medicine (A.J.M.H.V., A.G.U.), Erasmus Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands
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Grootens-Wiegers P, de Vries MC, van Beusekom MM, van Dijck L, van den Broek JM. Comic strips help children understand medical research: targeting the informed consent procedure to children's needs. Patient Educ Couns 2015; 98:518-524. [PMID: 25612801 DOI: 10.1016/j.pec.2014.12.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 11/25/2014] [Accepted: 12/21/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVE Children involved in medical research often fail to comprehend essential research aspects. In order to improve information provision, a participatory approach was used to develop new information material explaining essential concepts of medical research. METHODS A draft of a comic strip was developed by a science communicator in collaboration with pediatricians. The draft was presented to children participating in a clinical trial and to two school classes. Children were consulted for further development in surveys and interviews. Subsequently, the material was revised and re-evaluated in four school classes with children of varying ages and educational levels. RESULTS In the first evaluation, children provided feedback on the storyline, wording and layout. Children thought the comic strip was 'fun' and 'informative'. Understanding of 8 basic research aspects was on average 83% and all above 65%, illustrating that children understood and remembered key messages. CONCLUSION A comic strip was developed to support the informed consent process. Children were consulted and provided feedback. The resulting material was well understood and accepted. PRACTICE IMPLICATIONS Involving children in the development of information material can substantially contribute to the quality of the material. Children were excited to participate and to 'be a part of science'.
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Affiliation(s)
| | - Martine C de Vries
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Mara M van Beusekom
- Department of Science Communication & Society, Leiden University, Leiden, The Netherlands
| | - Laura van Dijck
- Department of Science Communication & Society, Leiden University, Leiden, The Netherlands
| | - Jos M van den Broek
- Department of Science Communication & Society, Leiden University, Leiden, The Netherlands
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Hein IM, Troost PW, Broersma A, de Vries MC, Daams JG, Lindauer RJL. Why is it hard to make progress in assessing children's decision-making competence? BMC Med Ethics 2015; 16:1. [PMID: 25576996 PMCID: PMC4298077 DOI: 10.1186/1472-6939-16-1] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 01/06/2015] [Indexed: 11/10/2022] Open
Abstract
Background For decades, the discussion on children’s competence to consent to medical issues has concentrated around normative concerns, with little progress in clinical practices. Decision-making competence is an important condition in the informed consent model. In pediatrics, clinicians need to strike a proper balance in order to both protect children’s interests when they are not fully able to do so themselves and to respect their autonomy when they are. Children’s competence to consent, however, is currently not assessed in a standardized way. Moreover, the correlation between competence to give informed consent and age in children has never been systematically investigated, nor do we know which factors exactly contribute to children’s competence. This article aims at identifying these gaps in knowledge and suggests options for dealing with the obstacles in empirical research in order to advance policies and practices regarding children’s medical decision-making competence. Discussion Understanding children’s competency is hampered by the law. Legislative regulations concerning competency are established on a strong presumption that persons older than a certain age are competent, whereas younger persons are not. Furthermore, a number of contextual factors are believed to be of influence on a child’s decision-making competence: the developmental stage of children, the influence of parents and peers, the quality of information provision, life experience, the type of medical decision, and so on. Ostensibly, these diverse and extensive barriers hinder any form of advancement in this conflicted area. Addressing these obstacles encourages the discussion on children’s competency, in which the most prominent question concerns the lack of a clear operationalization of children’s competence to consent. Empirical data are needed to substantiate the discussion. Summary The empirical approach offers an opportunity to give direction to the debate. Recommendations for future research include: studying a standardized assessment instrument covering all four relevant dimensions of competence (understanding, reasoning, appreciation, expressing a choice), including a study population of children covering the full age range of 7 to 18 years, improving information provision, and assessing relevant contextual data.
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Affiliation(s)
- Irma M Hein
- Department of Child and Adolescent Psychiatry, Academic Medical Center Amsterdam, Meibergdreef 5, 1105 Amsterdam, AZ, The Netherlands.
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Bredenoord AL, de Vries MC, van Delden JJM. Next-generation sequencing: does the next generation still have a right to an open future? Nat Rev Genet 2013; 14:306. [PMID: 23729034 DOI: 10.1038/nrg3459] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Annelien L Bredenoord
- University Medical Center Utrecht, Julius Center, Department of Medical Ethics, PO Box 85500, 3508 GA Utrecht, The Netherlands.
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de Vries MC, Bresters D, Kaspers GJL, Houtlosser M, Wit JM, Engberts DP, van Leeuwen E. What Constitutes the Best Interest of a Child? Views of Parents, Children, and Physicians in a Pediatric Oncology Setting. ACTA ACUST UNITED AC 2013. [DOI: 10.1080/21507716.2012.757254] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Hein IM, Troost PW, Lindeboom R, de Vries MC, Zwaan CM, Lindauer RJL. Assessing children's competence to consent in research by a standardized tool: a validity study. BMC Pediatr 2012; 12:156. [PMID: 23009102 PMCID: PMC3506483 DOI: 10.1186/1471-2431-12-156] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Accepted: 09/21/2012] [Indexed: 11/17/2022] Open
Abstract
Background Currently over 50% of drugs prescribed to children have not been evaluated properly for use in their age group. One key reason why children have been excluded from clinical trials is that they are not considered able to exercise meaningful autonomy over the decision to participate. Dutch law states that competence to consent can be presumed present at the age of 12 and above; however, in pediatric practice children’s competence is not that clearly presented and the transition from assent to active consent is gradual. A gold standard for competence assessment in children does not exist. In this article we describe a study protocol on the development of a standardized tool for assessing competence to consent in research in children and adolescents. Methods/design In this study we modified the MacCAT-CR, the best evaluated competence assessment tool for adults, for use in children and adolescents. We will administer the tool prospectively to a cohort of pediatric patients from 6 to18 years during the selection stages of ongoing clinical trials. The outcomes of the MacCAT-CR interviews will be compared to a reference standard, established by the judgments of clinical investigators, and an expert panel consisting of child psychiatrists, child psychologists and medical ethicists. The reliability, criterion-related validity and reproducibility of the tool will be determined. As MacCAT-CR is a multi-item scale consisting of 13 items, power was justified at 130–190 subjects, providing a minimum of 10–15 observations per item. MacCAT-CR outcomes will be correlated with age, life experience, IQ, ethnicity, socio-economic status and competence judgment of the parent(s). It is anticipated that 160 participants will be recruited over 2 years to complete enrollment. Discussion A validity study on an assessment tool of competence to consent is strongly needed in research practice, particularly in the child and adolescent population. In this study we will establish a reference standard of children’s competence to consent, combined with validation of an assessment instrument. Results can facilitate responsible involvement of children in clinical trials by further development of guidelines, health-care policies and legal policies.
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Affiliation(s)
- Irma M Hein
- Department of Child and Adolescent Psychiatry and de Bascule, Academic Medical Center Amsterdam, Meibergdreef 5, Amsterdam, 1105, AZ, The Netherlands.
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Caldwell PHY, Dans L, de Vries MC, Newman Ba Hons J, Sammons H, Spriggs M Bioeth M, Tambe P, Van't Hoff W, Woolfall K, Young B, Offringa M. Standard 1: consent and recruitment. Pediatrics 2012; 129 Suppl 3:S118-23. [PMID: 22661757 DOI: 10.1542/peds.2012-0055d] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Patrina H Y Caldwell
- Discpline of Paediatrics and Child Health, University of Sydney, Sydney, Australia
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de Vries MC, Houtlosser M, Wit JM, Engberts DP, Bresters D, Kaspers GJL, van Leeuwen E. Ethical issues at the interface of clinical care and research practice in pediatric oncology: a narrative review of parents' and physicians' experiences. BMC Med Ethics 2011; 12:18. [PMID: 21943406 PMCID: PMC3229434 DOI: 10.1186/1472-6939-12-18] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2011] [Accepted: 09/27/2011] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Pediatric oncology has a strong research culture. Most pediatric oncologists are investigators, involved in clinical care as well as research. As a result, a remarkable proportion of children with cancer enrolls in a trial during treatment. This paper discusses the ethical consequences of the unprecedented integration of research and care in pediatric oncology from the perspective of parents and physicians. METHODOLOGY An empirical ethical approach, combining (1) a narrative review of (primarily) qualitative studies on parents' and physicians' experiences of the pediatric oncology research practice, and (2) comparison of these experiences with existing theoretical ethical concepts about (pediatric) research. The use of empirical evidence enriches these concepts by taking into account the peculiarities that ethical challenges pose in practice. RESULTS Analysis of the 22 studies reviewed revealed that the integration of research and care has consequences for the informed consent process, the promotion of the child's best interests, and the role of the physician (doctor vs. scientist). True consent to research is difficult to achieve due to the complexity of research protocols, emotional stress and parents' dependency on their child's physician. Parents' role is to promote their child's best interests, also when they are asked to consider enrolling their child in a trial. Parents are almost never in equipoise on trial participation, which leaves them with the agonizing situation of wanting to do what is best for their child, while being fearful of making the wrong decision. Furthermore, a therapeutic misconception endangers correct assessment of participation, making parents inaccurately attribute therapeutic intent to research procedures. Physicians prefer the perspective of a therapist over a researcher. Consequently they may truly believe that in the research setting they promote the child's best interests, which maintains the existence of a therapeutic misconception between them and parents. CONCLUSION Due to the integration of research and care, their different ethical perspectives become intertwined in the daily practice of pediatric oncology. Increasing awareness of what this means for the communication between parents and physicians is essential. Future research should focus on efforts that overcome the problems that the synchronicity of research and care evokes.
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Affiliation(s)
- Martine C de Vries
- Department of Pediatrics, Leiden University Medical Center, J6-S, PO Box 9600, 2300 RC Leiden, The Netherlands
- Department of Medical Ethics and Health Law, Leiden University Medical Center, J1-P, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Mirjam Houtlosser
- Department of Medical Ethics and Health Law, Leiden University Medical Center, J1-P, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Jan M Wit
- Department of Pediatrics, Leiden University Medical Center, J6-S, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Dirk P Engberts
- Department of Medical Ethics and Health Law, Leiden University Medical Center, J1-P, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Dorine Bresters
- Department of Pediatrics, Leiden University Medical Center, J6-S, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Gertjan JL Kaspers
- Division of Pediatric Oncology/Hematology, VU University Medical Center, Po Box 7057, 1007 MB Amsterdam, The Netherlands
| | - Evert van Leeuwen
- IQ Healthcare, Section Ethics, Philosophy and History of Medicine, UMC St Radboud, PO Box 9101, 114 6500 HB Nijmegen, The Netherlands
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