Academic Ceremonies September 2015

“Communication and Reasoning on Clinical Teaching Teams; The Genres that Shape Care and Education”

“Private-Sector standards as technical barriers in International trade in goods: in search of WTO disciplines.”

Private-sector standards, i.e. the standards developed, adopted and applied by private players such as supermarket chains, transnational corporations, and manufacturers of goods, are playing an increasingly important role in international trade. Because they are developed, adopted and applied by private entities, these standards are not legally mandatory. However, due to the immense purchasing power of big retail chains and multinational corporations which apply such standards, compliance with these standards may become mandatory for suppliers in order to gain real market access. This PhD dissertation explores the “world” of private-sector standards, as well as those WTO rules which may be relevant for the regulation of these standards and for addressing the challenges they pose. It thus contributes to the clarification and the better understanding of the rules applicable to private-sector standards under the WTO legal framework.

Key words:

private-sector standards; technical regulations; non-governmental acts; WTO law; barriers to trade

“Job Insecurity during Organizational Change: A dynamic perspective on the explanatory mechanisms of job insecurity”

Organisational change gives rise to job insecurity. This dissertation analyses the reasons why and the circumstances in which job insecurity has negative effects. A research model is presented showing two independent but coinciding explanations for negative effects of job insecurity: justice and exhaustion. Therefore, job insecurity does not only lead to exhaustion, but also evokes feelings of injustice, because the social relationship between employer and employee is unbalanced. The results show that these relationships are very complex. The relationship between job insecurity and justice is significant during the initial stages of organisational change in particular, whereas the relationship between job insecurity and exhaustion is most clear during the middle stages of organisational change. The results also indicate that employees who feel insecure about their jobs perform worse, if they think changes are communicated insufficiently. Proper management of organisational change is important and requires a tailor-made approach in particular.

Key words:

organisational change, job insecurity 

“Old and Out? Age, employability, and the role of learning”

Old and out? Not necessarily! The research in this thesis shows how employees stay employable as they age. In contrast to common workplace stereotypes, one's chronological age per se does not matter. Instead, being open to future career opportunities and engaging in learning activities are essential. Especially one's social network of colleagues at work is a powerful source for learning. This, in turn, helps to remain attractive in the labour market. The implications presented in this research project help managers, policy-makers, and older individuals to thrive in midst of the demographic shift.

Key words:

employability aging employee, learning abilities

“The Ins and OUTs of Disc biology”

Back pain is a common and long-term problem worldwide. In general, the only intervention available is pain control. Although it is not clear why people develop back pain, it is known that spinal cells play an important role in this. Van den Akker developed some unique new models allowing these cells to be examined in more detail. It was shown that the spine contains two different types of cells: a sort of stem cell playing a key role in tissue maintenance and a cell causing damage to spinal tissue in certain circumstances. In the future, these stem cells may be stimulated to repair the affected spinal tissue.

Key words:

back pain, spine, stem cells

“Questioning the rater idiosyncrasy explanation for error variance by searching for multiple signals within the noise”

Medical trainees are assessed performing clinical tasks but the examiners’ ratings can be highly variable. It is assumed that examiners assessing the same performance should form similar judgments and provide similar ratings. As such, the psychometric models currently used to analyze the ratings assume there is a single point of consensus. This research, however, found multiple clusters of consensus within the variable assessments provided by examiners for a single performance. This finding was consistent across two samples of participants and two different methodologies. Finding more than one point of consensus challenges the use of psychometric models to analyze examiners’ ratings.

Key words:

rater cognition, medical education, rater-based assessment

“Cardiac Dyssynchrony; structural, functional, transcriptional and pharmacological aspects”

One-quarter of patients with heart failure suffer from a conduction disorder resulting in an impaired cardiac contractility and function. Pacemakers improving their prognosis and reducing their symptoms (so-called cardiac resynchronisation therapy or CTR) are not effective in one-third of these patients. In an attempt to understand the underlying mechanism, Van Middendorp discovered a biomarker that might predict the effects of CRT and the treatment of dyssynchronous heart failure. He also showed that antiarrhythmic drugs should be used even more carefully in people with heart failure who also suffer from a conduction disorder. Furthermore, he showed that Vernakalant, a new antiarrhythmic drug that had initially received a positive evaluation, reduced the pumping ability of the heart to the same extent as the conventional antiarrhythmic drug Flecainide. This study was partially funded by the Dutch Heart Foundation.

Key words:

heart failure, conduction disorder, biomarkers

“Exploration of the sustainability of innovations in hospital care”

This dissertation examines the sustainability of healthcare innovations following their active implementation in a hospital setting. Among other things, it evaluates the extent to which two surgical healthcare programmes that were successfully implemented in different Dutch hospitals are still part of the standard healthcare process years after the quality improvement project. It also presents factors that may influence the success of implementing sustainability. The insights in this dissertation are important for future quality improvement projects and research projects. Two innovations – a short-stay programme for bowel surgery (ERAS) and a short-stay programme for breast cancer surgery (SSP) – were evaluated three to six years after their successful implementation. Both programmes appear to have been reasonably well maintained. The respondents deemed the following aspects of relevance to the sustainability of the ERAS and SSP programmes: trust and faith in the innovation, application of the innovation in different contexts, the possibility to adapting the innovation to suit local needs, the possibility to modify the innovation, the institutionalisation of the innovation, and the short lines of communication within the multidisciplinary team. Grant: ZonMw efficiency research

Key words:

quality improvements, efficiency, implementation, innovation, healthcare, old routines

“Dissecting boundaries”

“Why have so few countries industrialised?”

When countries develop, their economies become industrial, meaning that the goods and services that they produce are increasingly more diversified and complex. Despite progress, many countries in the world have not industrialised yet. This thesis shows that industrial and macroeconomic policies play a key role for industrialisation. A quantification of industrial policy instruments in East Asia and Latin America shows that larger public investments in East Asia spurred industrialisation. The type of government intervention also mattered: by designing an effective policy mix and by targeting strategic industries, East Asian states were more entrepreneurial than Latin American states. Second, firms’ investment behaviours follow business cycles’ fluctuations: by influencing these fluctuations, macroeconomic policies prove to be significant determinants of firms’ investments.

Key words:

industrialization, industrial policies, macroeconomic policies, East Asia, Latin America

“Determinants of Professional Commitment to Environmental Sustainability”

“Economic Evaluations in Healthcare: Methodological Considerations and Applications on Cost-Effectiveness of ACE Inhibitor Treatment for Renal Disease Prevention”

“Adequate antimicrobial treatment in elderly patients”

This dissertation examines the use of antibiotics in elderly patients. Elderly patients use far more antibiotics than younger patients. While the same standard dosages are prescribed for all adult patients, elderly patients tend to have a higher concentration of antibiotics in their blood than younger patients. This is caused by reduced creatinine clearance of the antibiotics as a result of renal impairment. Like children, older patients require a modified dose of antibiotics. Adjusting this dose in older patients can be difficult because it is hard to make an accurate assessment of renal function in these patients, and because of significant individual differences among these patients. This study provides a number of recommendations for adjusting the dose of various types of antibiotics.

Key words:

antibiotics, elderly patients, dose

“Economic preferences and attitudes; Origins, behavioral impact, stability and measurement”

Economic and social preferences such as e.g. risk preferences, trust or reciprocity are at the basis of human decision making. Advances in behavioral economics have documented the heterogeneity in those preferences among individuals and opened up a field of economics that is concerned with the drivers and channels of human motivation. This thesis discusses selected issues on the origin of preferences, their impact on (economic) outcomes, as well as methodological issues, such as the measurement of preferences and their stability over time. 

Key words:

economic behavior, decision making

“Strategy, Division, and Competition”

“The treatment of enterocutaneous fistulas and their metabolic sequelae”

Enterocutaneous fistulas are abnormal connections that develop between the intestinal tract and the skin and constitute a severe form of intestinal failure. They usually occur as a complication of abdominal surgery. In addition to being associated with several other complications, these fistulas have a mortality rate of 10% in specialised centres. This dissertation demonstrates the importance of a structured treatment guideline that is focused on sepsis treatment, optimising nutritional status, providing good wound and stoma care, and allowing enough time before proceeding with surgical options. We noted good quality of life in the long term and were the first to demonstrate how liver failure can occur as a complication of intestinal failure.

Key words:
enterocutaneous fistulas, intestinal failure, treatment

“Survival of the fittest plastics”

“Effects of botulinum toxin A injections and bimanual task-oriented therapy on hand functions and bimanual activities in unilateral Cerebral Palsy”

Children with unilaterally impaired hand function due to spasticity tend to use the affected hand less and less during their development. This phenomenon is called ‘developmental disuse’. This dissertation shows that task-specific bimanual therapy is the first choice of treatment for the prevention of developmental disuse and the improvement of bimanual skills. In this type of therapy, the affected hand is forced to be used in tasks which are meaningful to child and parents, resulting in repetitive hand use in daily life. Botulinum toxin injections are found to reduce strain and improve the quality of movement, which is measured by an instrument specifically designed for this purpose. However, they are shown to have a negative effect on strength and to have no added value to the use of the affected hand in daily life.This dissertation was financially supported by the Johanna Children’s Fund (JKF), Rotterdam Children’s Rehabilitation Fund Foundation/Adriaan Foundation (KFA), the Phelps Foundation for Spasticity, the Vooruit Foundation, the Elisabeth Strouven Foundation and the Kanunnik Salden-Nieuwenhof Foundation.

Keywords:

botulinum toxin (Botox), task-specific bimanual therapy, children with impaired hand function due to spasticity

“Get moving! Self-management support using mobile technology; A monitoring and feedback tool embedded in a counselling protocol to increase physical activity of patients with COPD or type 2 diabetes in primary care: the It’s LiFe! study”

In the dissertations written by Sanne van der Weegen and Renée Verwey a newly developed motion measurement system is being described used as part of the care people suffering from diabetes or COPD are provided with. An evaluative survey carried out among twenty-four GP practices showed that patients tend to exercise an extra eleven minutes daily on average. The motion measurement system connects wirelessly to a smartphone and online coaching system. An app shows the number of minutes a patient has exercised in relation to his or her personal goals. In the GP practice, the nurse practitioner is able to monitor the exercise results by means of a coaching system. The study carried out by van der Weegen focusses on the development and usability testing of the app and the validation of the motion measurement system. This study is co-funded by ZonMw.

Keywords:
motion measurement system, app, exercise programme, diabetes, COPD

“Get moving! Self-management support using mobile technology; A counselling protocol extended with a web-based coaching system to promote physical activity in patients with COPD or type 2 diabetes in primary care: the It’s LiFe! study”

In the dissertations written by Sanne van der Weegen and Renée Verwey a newly developed motion measurement system is being described used as part of the care people suffering from diabetes or COPD are provided with. An evaluative survey carried out among twenty-four GP practices showed that patients tend to exercise an extra eleven minutes daily on average. The motion measurement system connects wirelessly to a smartphone and online coaching system. An app shows the number of minutes a patient has exercised in relation to his or her personal goals. In the GP practice, the nurse practitioner is able to monitor the exercise results by means of a coaching system. The study carried out by Verwey mainly focuses on the development of a supervision protocol for nurse practitioners and the development and testing of the online coaching system. This study is co-funded by ZonMw.

Key words:
motion measurement system, app, exercise programme, diabetes, COPD

“The effect of Lutein on the inflammatory pathways in age-related macular degeneration (AMD)”

“A blind man’s bluff: Choice blindness in eyewitness testimony”

“The role of the different Kunitz domains of TFPI in the down-regulation of the extrinsic coagulation pathway”

Haemophilia is a blood clotting disorder that delays clot formation and can be fatal in patients undergoing operations, accidents or injuries. It is caused by low levels of coagulation protein. Present treatment for haemophilia is to reconstitute patients with missing protein but it is an expensive treatment with a risk of developing side effects. Alternative approach is to inhibit the anticoagulants, the regulatory proteins who inhibit coagulant proteins when they are produced in excess. This thesis focuses on how to inhibit TFPI, one of the most important anticoagulant proteins. The mechanism of inhibition of coagulation proteins was studied at domain (small part of protein) level. This study contributes to the biotech or pharma companies to develop inhibitors that can help haemophilic patients to live longer with cheap medication and no side effects.

Key words:
haemphilia, treatment, protein

“Psychotherapy for Depression Works! But How? Investigating the Effects and Mechanisms of Cognitive Therapy vs. Interpersonal Psychotherapy for Major Depressive Disorder”

Depression is a serious health problem that is paired with significant functional limitations and high social costs. Both cognitive therapy (CT) and interpersonal psychotherapy (IPT) have proven effective in reducing the symptoms associated with depression. Unfortunately, these treatments do not offer sufficient relief for all people with depression, and the risk of relapse is extremely high. Improving these forms of treatment is therefore essential. An important step involves gaining a better understanding of the effects and mechanisms of both treatment interventions. This was the topic of a major treatment study among 182 adults with depression. The research findings reveal that CT and IPT had similarly positive effects on reducing the symptoms of depression and that these effects were greater than those in a control group that placed participants on a waiting list. Unfortunately, the underlying mechanisms of these therapeutic effects remain unclear.

Keywords:
depression, psychotherapy, effectiveness, underlying mechanisms, treatment research

“De Ruimtetoerist – vragen over technologie en toekomst”

“Cognition and Type 2 diabetes; the interplay of risk factors”

Type 2 diabetes is a risk factor for dementia. Over a period of twelve years, a more rapid decline in cognitive function was found in people suffering from diabetes compared to people who did not suffer from this disease. It was shown, among other things, that cognitive impairment in people suffering from diabetes was associated with high blood pressure as well as low blood pressure. In elderly women, larger amounts of fat and muscle tissue were found to be associated with a lower risk of developing dementia. In men, only larger amounts of muscle tissue were found to be associated with a lower risk of developing dementia. These findings could lead to new ways to delay or prevent dementia. Furthermore, it was shown that an impaired understanding of words was associated with the presence of cardiovascular disease, neuralgia and lower levels of physical fitness. Therefore, doctors should be aware of the level of education reached by their diabetes patients.

Keywords:

diabetes, dementia, cognitive function

“The effect of D&O insurance on managerial risk taking”

Excessive risk taking of managers is associated with corporate failure. Researchers argue that insurance against personal liability of a manager (Directors and Officers liability insurance) would weaken his incentive to take care and partly causes excessive risk taking. Because only little is actually known about D&O insurance, this thesis analyses how D&O insurance should work ideally and how it currently works. 
This thesis observes that: (i) The value of investment decisions seems to rise with D&O coverage when competitive pressure is high enough; (ii) the insured manager benefits banks, provided that the corporation purchases an average insurance coverage; (iii) the D&O insurer settles disputes differently than courts, taking into account the degree of bad publicity in the media; and (iv) in times of financial instability, D&O insurance is the best analysed compensation measure in safeguarding firm performance. Hence, smaller corporations that do not carry D&O insurance yet would greatly benefit from it. 

Keywords:

D&O insurance, manager liability, risk taking, corporate liability, risk aversion

“The Application of the theory of efficient breach in contract Law; A Comparative Law and Economics Perspective”

This thesis analyzes the theory of efficient breach in three different legal systems, including English sales law, European Union contract law and Chinese contract law. The existing legal systems provide contract parties with more solutions, other than “efficient breach” to avoid inefficient performance. Generally, all the three systems allow parties to stipulate liquidated damages for breach of contract and expectation damages are chosen as the basic damages measures by English law and EU law. In this sense, paying monetary equivalence to performance is one option to contract promisors for avoiding inefficient contracts. Besides shaping contract parties’ incentives to perform or breach a contract via remedy rules, all the three legal systems have set out specific rules dealing with the circumstances where performance of a contract is inefficient. 

Key words:

legal systems, contract, breach

“Creating new perspectives on work-home interface; A cross-cultural comparison of Malta, Serbia and the Netherlands”

Cultural context plays an important role in the way employees combine work and home duties. Insights in the role of cultural context are highly relevant for setting up effective interventions and policies to reduce negative work home interface and improve health and well-being of individuals. Data for the studies in this thesis were collected in Malta, Serbia and The Netherlands. Besides work and home characteristics, such as work demands and family situation, cultural context plays an important role. The role of culture is impacting the negotiation of combining work and home demands, and this negotiation is intertwined with the cultural norms and expectations, gender and age. Different aspects appear to be relevant in different cultures. For example, colleague support is important in the Netherlands, and in other contexts it is not. Convergence of policies at EU level will not contribute to better work-home interface. A culturally sensitive approach in policies and interventions is called for.

Key words:

work home interface, cultural context, Malta, Serbia, The Netherlands

“How cardiac myofibers keep pace; Mathematical Modeling Of Adaptive Myofiber Reorientation and Electromechanics”

In order to improve the diagnosis and management of heart failure, Pluijmert developed a 3D computer model of the human right and left ventricles. Next, tests on the CRT pacemaker were carried out, deciding the best position for the left ventricular electrode in particular. A CRT pacemaker has little or no effect in one-third of the patients who are eligible for this method. It was shown that the ability to pump blood was increased most when activation of the entire left ventricle took place as quickly as possible. This result could be achieved by placing the electrode in the middle of the left ventricular free wall. This is a different position from the one included in the current European and American guidelines on CRT.

Key words:

CRT pacemaker, 3D computer model, heart failure

“Crescentic glomerulonephritis in ANCA associated vasculitis”

ANCA vasculitis is an example of an autoimmune disease that affects the smallest blood vessels in the body. It is a rare disease that can result in kidney failure. This dissertation is a compilation of studies on ANCA vasculitis. As the level of initial kidney damage predicts whether kidney failure is likely to develop, early detection of the disease is of paramount importance. A substance in the blood called CTGF is indicative of kidney scarring, which also contributes to the development of kidney failure. Patients are at increased risk of developing thrombosis during treatment. Unfortunately, the majority of patients suffering from ANCA vasculitis have a genetic profile that leads to a rapid recurrence of the disease after treatment has finished.

Keywords:

autoimmune diseases, ANCA vasculitis, kidney failure

“Autophagy in hypoxia and radioresistance: Regulation and Functional implications”

As a result of an abnormal architecture of blood vessels in a tumour, some tumour cells are insufficiently supplied with oxygen and are surrounded by a hostile tumour environment hindering the effectiveness of treatments. These cells depend on a process called autophagy, in which they break their own cell components into elements reusable for the production of energy, for instance. This doctoral study shows that the ULK1 protein plays an important role in the autophagy process and the survival of tumour cells in an oxygen-poor tumour environment. This insight into the role of ULK1 protein could lead to new therapeutic strategies to make these cells more sensitive to a lack of oxygen and to improve treatment results, if radiation therapy is part of the treatment given to the patient. Furthermore, it was shown that the recycling effect of autophagy in irradiated tumour cells did not influence the levels of resistance to radiation therapy. Funded by the Dutch Cancer Society (KWF Kankerbestrijding), STOPhersentumoren.nl, the Zeldzame Ziekten Fonds and the European Research Council (ERC).

Key words:

cancer, autophagy, radiation therapy

“The odd one out: exploring the nature of the association between minority status and psychosis”

Minorities have a substantially increased risk of developing schizophrenia, a psychiatric disorder that is characterised by a distorted perception of reality. This dissertation supports the hypothesis that social exclusion can literally make people sick. A population study revealed that discrimination can increase the risk of psychotic episodes in homosexuals. A potential biological mechanism was also discovered: higher levels of the messenger substance dopamine were detected in the brains of a socially isolated group, in this case young people with hearing difficulties. These young people were also more susceptible to experiencing social anxiety in their daily lives. Contrary to expectations, this susceptibility to stress was not found in men of Dutch-Moroccan descent, despite this minority group being at an increased risk of developing schizophrenia.

Key words:
social exclusion, minorities, schizophrenia, psychosis

“Structural and functional aspects of sensory-motor Interaction in the urinary bladder”

Urinary incontinence is a social problem for various patients, particularly those with Alzheimer's disease. This dissertation aims to examine the sensory information and motor output of the bladder on a functional and structural level. A study was conducted using several animal models, including a model for Alzheimer's disease. Various sensory nerves were discovered in the bladder wall. Using functional studies, we were able to detect bladder contractions that indicate a local sensory-motor system in the bladder. We also discovered an unusual anatomy of the bladder wall and unusual urinary patters in the model for Alzheimer's disease.

Keywords:

urinary incontinence, Alzheimer's disease, sensory information, motor output

“Opgelucht door de eerste lijn”

“Accurate Non-Iterative Modelling and Inference of Longitudinal Neuroimaging Data”

In recent years, increasing efforts have been made to collect longitudinal neuroimaging data in order to study how brains change over time. However, the popular methods used to analyse such kind of data may not always be appropriate (e.g., overly sensitive to model misspecifications, difficult to specify adequately or prohibitively slow to compute) and may sometimes lead to erroneous conclusions.  Motivated by these shortcomings, in this dissertation, we have proposed and studied the use of an alternative method, referred to as “the Sandwich Estimator method”, and have demonstrated that it is a fast, easy-to-specify and accurate option to analyse longitudinal or repeated-measures neuroimaging data. 

Key words:
Neuroimaging, longitudinal data analysis, Sandwich Estimator

“Improving dietary intake patterns among adults; the potential of targeting self-regulation and environmental-level factors in Web-based computer-tailored nutrition education interventions”

“Aandeelhoudersverantwoordelijkheid: De positieve rol van de aandeelhouder en aandeelhoudersvergadering”

Shareholders have specific rights, duties, and responsibilities relative to their shareholding company and other stakeholders. This study focuses on the responsibility of individual shareholders and the shareholders' meeting. The prevailing view is that shareholders inherently represent their own interests. But how and to what extent is this assumption limited? This dissertation identifies and describes the relevant circumstances, namely: the size of the share, the power of the shareholder, the background of the shareholder, the nature of the company, the company's current situation, the nature of the governing legislation, and the decision to be made. It also describes the possibility for others to 'correct' the shareholder's behaviour.

Key words:

shareholders' meeting, responsibilities, interests