[Discussing and evaluating professional behaviour. 1. Academic Centre for Oral Health Groningen]. / Bespreken en beoordelen van professioneel gedrag. 1. Centrum voor Tandheelkunde en Mondzorgkunde Groningen.

Professionalism is considered as a core competency for dentists. As a result of changes in the healthcare sector, it is becoming increasingly important for dentists to be more transparent to the community in their delivery of care. The ability'to provide justification' thus becomes an important skill. To train dentists to become professionals who can account for their actions, we developed an educational programme in Groningen which trains students in the following professional skills: 1. make explicit; 2. concretize; 3. analyze; 4. diagnose; 5. generalize; and 6. formulate learning points and experiment with them. This educational programme is given, under the supervision of a coach (generally a practicing dentist), during the entire curriculum, in small groups. Professionalism is integrated with other course programmes (work placement, working in the clinic), because professionalism is a competency which is only expressed by practicing other competencies. The professionalism of the student is also assessed.

[Electives at the dental school in Groningen]. / Keuzeonderwijs binnen de opleiding Tandheelkunde Groningen.

To offer a more comprehensive curriculum in various dental topics, the dental school of the University of Groningen developed electives. This article gives an overview of the learning objectives of the different electives, the program and the way in which students are examined. Attention is also paid to some experiences of students and teachers with this kind of education. The electives seem to effectively prepare students for specific parts of dentistry, and they give an orientation on the scientific aspects of dentistry. Students and teachers are positive about the electives. The electives give good opportunities to the assessment of professional behavior.

The association of genetic markers and malaria infection in the Brazilian Western Amazonian region.

Almost all individuals (182) belonging to an Amazonian riverine population (Portuchuelo, RO, Brazil) were investigated for ascertaining data on epidemiological aspects of malaria. Thirteen genetic blood polymorphisms were investigated (ABO, MNSs, Rh, Kell, and Duffy systems, haptoglobins, hemoglobins, and the enzymes glucose-6-phosphate dehydrogenase, glyoxalase, phosphoglucomutase, carbonic anhydrase, red cell acid phosphatase, and esterase D). The results indicated that the Duffy system is associated with susceptibility to malaria, as observed in other endemic areas. Moreover, suggestions also arose indicating that the EsD and Rh loci may be significantly associated with resistance to malaria. If statistical type II errors and sample stratification could be ruled out, hypotheses on the existence of a causal mechanism or an unknown closely linked locus involved in susceptibility to malaria infection may explain the present findings.

The association of genetic markers and malaria infection in the Brazilian Western Amazonian region

Almost all individuals (182) belonging to an Amazonian riverine population (Portuchuelo, RO, Brazil) were investigated for ascertaining data on epidemiological aspects of malaria. Thirteen genetic blood polymorphisms were investigated (ABO, MNSs, Rh, Kell, and Duffy systems, haptoglobins, hemoglobins, and the enzymes glucose-6-phosphate dehydrogenase, glyoxalase, phosphoglucomutase, carbonic anhydrase, red cell acid phosphatase, and esterase D). The results indicated that the Duffy system is associated with susceptibility to malaria, as observed in other endemic areas. Moreover, suggestions also arose indicating that the EsD and Rh loci may be significantly associated with resistance to malaria. If statistical type II errors and sample stratification could be ruled out, hypotheses on the existence of a causal mechanism or an unknown closely linked locus involved in susceptibility to malaria infection may explain the present findings

Ethnic admixture composition of two western Amazonian populations.

A small riverine community, Portuchuelo (8 degrees 37'S, 63 degrees 49'W), and a rural county, Monte Negro (10 degrees 15'S, 63 degrees 18'W), both in the state of Rondjnia, Brazil, were studied for the purposes of ascertaining health conditions and the causes of the variability of some infectious diseases. The sample included 181 inhabitants of Portuchuelo and 924 of Monte Negro. Data on 11 blood polymorphisms (ABO, Rh, MNSs, Kell, Fy, haptoglobin, hemoglobin, ACP1, PGM1, GLO1, and CA2) were used to determine the ethnic composition of the inhabitants of Portuchuelo and Monte Negro. The contributions of Africans, Amerindians, and Europeans to the ethnic composition of the studied populations were, respectively, 0.21 +/- 0.046, 0.44 +/- 0.064, and 0.35 +/- 0.069 in Portuchuelo; and 0.25 +/- 0.032,0.12 +/- 0.046, and 0.63 +/- 0.054 in Monte Negro.

Medical students' experiences of diseases in internal medicine in university and community hospitals.

Because medical students in The Netherlands should achieve common national objectives, it is important to know whether clinical experiences in different hospitals are comparable. The research questions were: (1) Do students achieve learning experiences of the required diseases during the internship in Internal Medicine and to what extent do they achieve these experiences? (2) Are there differences between the diseases experienced at a university hospital and at community hospitals? Completed logbooks of students were analysed; the percentage of students that achieved the required diseases and the mean number of experiences of diseases were calculated. A t-test was done to test for differences. Medical students in the university and in community hospitals get broad experience (76-131%) of the required diseases. In both hospitals there are many students who are not achieving the requirements, but the mean number of experiences of students at the community hospitals is higher than those at the university hospital. To eliminate the differences between students from the university hospital and the community hospitals, the educational programmes within both hospitals should be adjusted.

A rural community in a Brazilian Western Amazonian Region: some demographic and epidemiological patterns.

Some demographic and epidemiological patterns of the rural population of Monte Negro, locality situated in the State of Rondônia (Brazil), Western Amazonia, are described based on a sample of 924 randomly selected individuals, approximately 10% of the whole population. The main features of this sample are (1) the illiteracy rates in the parental generation were 23% for fathers and 20% for mothers. Among children, this figure dropped to 6%; (2) housing in Monte Negro is characterized by being constructed with wood (92%), and also a floor (75%). Nevertheless, only 32% of these houses had electric energy; (3) the mean ages for the parental generation were 41.9 for males and 36.3 for females. These values for the offspring generation were 12.2 and 10.5, respectively; (4) the sex-ratio of the offspring generation was 1.32;(5) the bioassay of kinship was estimated as.033 for this long range migrant population; (6) the prevalence of some macrophage dependent infectious disease was conspicuously high; (7) the reported number of malarial episodes among males and females was statistically different, suggesting that malaria may be, in part, a "professional" disease; (8) the prevalence of serum-positive reactions against B-hepatitis is distressing. It has a strong age dependence and reaches 74% among adult males. Conversely, signs of active infection (AgHbs) rises to 16% among children.

A rural community in a Brazilian Western Amazonian region: some demographic and epidemiological patterns

Some demographic and epidemiological patterns of the rural population of Monte Negro, locality situated in the State of Rondônia (Brazil), Western Amazonia, are described based on a sample of 924 randomly selected individuals, approximately 10 percent of the whole population. The main features of this sample are (1) the illiteracy rates in the parental generation were 23 percent for fathers and 20 percent for mothers. Among children, this figure dropped to 6 percent; (2) housing in Monte Negro is characterized by being constructed with wood (92 percent), and also a floor (75 percent). Nevertheless, only 32 percent of these houses had electric energy; (3) the mean ages for the parental generation were 41.9 for males and 36.3 for females. These values for the offspring generation were 12.2 and 10.5, respectively; (4) the sex-ratio of the offspring generation was 1.32;(5) the bioassay of kinship was estimated as .033 for this long range migrant population; (6) the prevalence of some macrophage dependent infectious disease was conspicuously high; (7) the reported number of malarial episodes among males and females was statistically different, suggesting that malaria may be, in part, a "professional" disease; (8) the prevalence of serum-positive reactions against B-hepatitis is distressing. It has a strong age dependence and reaches 74 percent among adult males. Conversely, signs of active infection (AgHbs) rises to 16 percent among children

Mannan-binding lectin enhances susceptibility to visceral leishmaniasis.

Levels of the serum opsonin mannan-binding lectin (MBL) were directly correlated with the probability of developing visceral leishmaniasis. Monocytes infected with MBL-opsonized Leishmania chagasi promastigotes secreted higher levels of tumor necrosis factor alpha and interleukin-6 than cells infected with nonopsonized parasites. Our findings indicate that MBL can modulate the clinical outcome of infection with L. chagasi and the function of infected macrophages.

The reliability of logbook data of medical students: an estimation of interobserver agreement, sensitivity and specificity.

OBJECTIVE: Logbooks are widely used in medical schools as an evaluation tool to assess students' progress towards objectives. To estimate whether students fill in their logbooks reliably, we measured interobserver agreement by comparing doctors' data and students' data. METHOD: Completed logbooks were collected at two subdivisions of the department of Internal Medicine at the University Hospital of Groningen. The logbook contains 231 preprinted diseases. Doctors and students recorded the diseases they had encountered. Interobserver agreement, expressed by the Jaccard coefficient (J), was calculated for the complete set of diseases and for a subset of core diseases. To assess the kinds of errors which students made, sensitivity and specificity were determined. RESULTS: Logbook data of doctors and students are not fully consistent (mean J for the complete set of diseases was.23 and for the core diseases.36). The quality of the logbook data is high in the sense that students do not record many false identifications (mean specificity for the complete set of diseases and for the core diseases were.96 and.93, respectively); the quality is poor in the sense that students do not record all the diseases which could be seen at the department (mean sensitivity for the complete set of diseases is.36 and for the core diseases it is.51). CONCLUSION: This study shows inconsistencies in recording diseases in a logbook by students compared with doctors. In particular the diseases which are present at a department are under-reported by students. Supervision and feedback are important mechanisms to optimize the students' use of (1) all diseases which could be encountered and (2) the logbook.

No evidence of linkage between Mitsuda reaction and the NRAMP1 locus.

Thirty sib-pairs were ascertained through unrelated lepromatous probands. They consisted of 22 healthy individuals and 8 leprosy patients. The Mitsuda reactions of all sibs were evaluated both macroscopically and histologically, and high molecular weight genomic DNA was extracted from the white blood cells of all sib-pairs. Three DNA polymorphisms identified by polymerase chain reaction (274C/T, D543N, 1729 + 55del4) were used as chromosome markers at the NRAMP1 locus. Sib-pair comparisons did not disclose any sign of close linkage between the Mitsuda reaction and the genetic markers.

Malaria control in an agro-industrial settlement of Rondônia (Western Amazon region, Brazil).

A malaria control pilot project was developed in the Urupá agro-industrial farm that is situated in the State of Rondônia (Western Amazon Region, Brazil). Around 180 inhabitants had been surveyed for the past five years. The control measures were based on (1) training a community agent to perform on the spot microscopical diagnosis of malaria and to treat the uncomplicated cases of malaria; (2) limiting the use of insecticides to a short period before the high transmission season. This resulted in a significant reduction in the time between the onset of clinical symptoms and specific chemotherapy which fell from 3.5 to 1.3 days. In relation to the previous three reference years the total number of malaria cases was reduced to 50% in the first year and to 25% in the second year. The introduction of these measures coincided with pronounced reduction in the frequency of Plasmodium falciparum infections but this was less marked for P. vivax infections. In the second year of the pilot experiment there was no P. falciparum transmission on the farm. During the last decade there was a general decrease in the endemicity of malaria in the State of Rondônia. The linear regression coefficient values indicate that the decline was more pronounced in Urupá than in the general municipality and that the falciparum malaria API in Urupá farm is significantly lower than in the general municipality of Candeias were the farm is situated.

Objectives for an internship internal medicine: from the Dutch Blueprint (Raamplan 1994) to implementation into a practical logbook.

BACKGROUND: The Dutch Blueprint 1994 (Raamplan 1994) describes the objectives of undergraduate medical education. The Blueprint, developed in order to improve medical education in the Netherlands, is accepted by all Dutch medical schools and has been legislated. AIM: Translation of global objectives of the Blueprint into specific requirements of a Logbook (guideline and evaluation tool) for the internship Internal Medicine. DESCRIPTION: The Blueprint as such is impracticable as a guideline during the Internal Medicine internship. The content covers the objectives for the entire field of medicine, and the volume dedicated to Internal Medicine is too large to fit in with a twelve week internship. The practicability of the Blueprint leaves much to be desired because it is complex, and not easily accessible. So, the Blueprint was adapted on three points: (1) selecting those objectives out of the whole content, which are specifically relevant to Internal Medicine; (2) decreasing the volume Internal Medicine by clustering and defining the requirements; (3) making the Logbook usable as a guideline and evaluation instrument. CONCLUSION: The Logbook is a good starting-point to evaluate whether students meet the objectives of the Blueprint related to the discipline Internal Medicine.

[Determination of monitor radiation scattering contribution in photon radiation of clinical electron linear accelerators]. / Bestimmung des Monitorrückstreubeitrags im Photonenbetrieb klinischer Elektronenlinearbeschleuniger.

BACKGROUND: Modern linear accelerators permit the use of irregular fields due to their flexible collimator systems with separately movable jaws or multileaf collimators. When using such irregular fields in the clinical practice output factors have to be corrected for enhanced backscatter to the dose monitor as compared with the conventional block shieldings. METHODS: A method is presented to detect the monitor backscatter contributions to the output factor for irregular field settings. RESULTS: The monitor backscatter factors have been measured using a telescopic device for 2 different treatment head geometries (Varian Clinac 2100C/D, General Electric Saturne 15) and for 3 photon radiation qualities (nominal energies X6, X18, X12). A method is introduced to calculate the monitor backscatter for arbitrary irregular treatment fields from the experimental data for square or rectangular fields. CONCLUSIONS: Besides the corrections for changes in phantom scatter and changes in the aperture, corrections for monitor backscatter have to be taken into account in many clinical cases. They can contribute up to more than 10% compared with the monitor values for free regular fields.

Causal analysis of the variability of IgA, IgG, and IgM immunoglobulin levels.

The interindividual variability of IgA, IgG, and IgM immunoglobulin levels was studied using path analysis in a northeastern Brazilian sample (nuclear families) to determine the genetic and/or environmental causes of their variation. The path analysis model decomposes the phenotype into genetic causes (autosomal and X-chromosome-linked genes) and environmental causes. A significant familial aggregation, mainly resulting from autosomal components, was detected for the 3 immunoglobulin levels. The values of genetic heritability were h2 = 0.410 +/- 0.030 for IgA, h2 = 0.617 +/- 0.020 for IgG, and h2 = 0.540 +/- 0.023 for IgM, and the values for environmental-cultural heritability were c2 = 0.085 +/- 0.034 for IgA, c2 = 0.084 +/- 0.027 for IgG, and c2 = 0.023 + 0.023 for IgM. Our results did not show a heritable component resulting from X-chromosome-linked genes on IgM levels, as suggested by some studies (Wood et al. 1969; Grundbacher 1972; Purtilo and Sullivan 1979). Some additional results were that (1) age and IgA concentration were positively correlated, with IgA level increasing gradually from childhood to adulthood (p < 0.001); (2) sex and the age X sex interaction act on IgG concentration (p < 0.01); (3) age and IgM concentration are correlated (with children presenting lower levels than adults, especially in males, p < 0.01); and (4) a significant association exists between sex and IgM level (with females presenting higher levels than males, p < 0.001).

The epidemiology of malaria in Rondonia (Western Amazon region, Brazil): study of a riverine population.

We report on a longitudinal study concerning the incidence of malaria in a riverine population (Portuchuelo) settled on the riverbanks of Rio Madeira, in the State of Rondonia, Brazil. We found the incidence of malaria to be seasonal, prevailing in the dry months of June and July. The Annual Parasite Index (API) was 292/1000 inhabitants, almost three times that of the state of Rondonia for the same period. In contrast with other studied Rondonian populations, malaria in Portuchuelo was more prevalent in youngsters < 16 years old, particularly in the 0-1 year age group. Adults were relatively spared, particularly those over 50 years. Besides being indicative of indoor transmission, these facts may suggest the existence of a certain degree of acquired resistance to infection and/or of lessened symptoms in older people. Riverine populations are spread over the entire Amazon region where most of its members were born. Due to the permanent presence of malaria among riverine populations, we are proposing that they may act as perennial reserves of malaria and, therefore, as sources of infection for migrants or eventual settlers at their vicinity. To date, the opposite view has been generally held. Anopheles darlingi, the main vector species in the area, is essentially sylvatic, which contributes to make the control of malaria highly problematic. The only hopes for control rest on permanent surveillance and the prompt treatment of patients, which are also problematic considering the vastness of the Amazon region and the remoteness of some of its riverine settlements.

Lack of evidence of a major gene acting on postaxial polydactyly in South America.

Data on polydactyly were obtained from two large samples: the Latin American Collaborative Study of Congenital Malformations (ECLAMC), and from a migrant Northeastern Brazilian population of rural origin (Hospedaria). ECLAMC is a case-control clinical epidemiological program comprising 10,035 individuals distributed among 2,030 segregating nuclear families. Hospedaria data consisted of 6,586 examined individuals belonging to 1,040 nuclear families. Using complex segregation analysis methodology we found no evidence of two loci (a major gene and a modifier locus) acting on postaxial polydactyly in the present study. Very high heritability values (in a classical multifactorial model) of postaxial polydactyly were detected, for several sets of analyses in ECLAMC and in Hospedaria. For the whole ECLAMC sample there is a peculiar suggestion of a major recessive gene effect responsible for the trait; however, no comparison with a model involving transmission probabilities (tau) was possible in this highly heterogeneous sample. If the whole ECLAMC sample is divided in subsamples, according to Black admixture proportions, the same multifactorial picture emerges. Two different inheritance patterns were verified for hand (HP) and foot (FP) postaxial polydactyly: For HP there is evidence of a non-Mendelian transmission mechanism, while for FP the parental/sib transmission appears to be due only to multifactorial causes.

A comparison of the Dutch Blueprint standards (theory) with the experiences of students in clerkships in Groningen (practice).

BACKGROUND: A comparison was made between the Dutch national objectives for the education of medical doctors (in terms of clinical experiences and skills) which are stated in the Blueprint, and the extents to which the objectives were realized in six clerkships at the Faculty of Medical Sciences in Groningen. METHODS: From each clerkship, 40 complete logbooks were analyzed. RESULTS: On the average, the clerkships did not fully meet the national objectives, but they did offer clinical experiences and skills that are not mentioned in the formal objectives. Students varied significantly in their clinical experiences. CONCLUSIONS: The design of the clerkships should be improved to make them more concordant with national goals. This relates to both cancer education and medical education in general.

Hormonal and experiential correlates of maternal responsiveness during pregnancy and the puerperium in human mothers.

Two studies were undertaken (1) to determine whether human mothers undergo a change in maternal responsiveness during pregnancy before the birth of the baby, as shown for other mammalian species, and (2) to establish whether a relation exists between changes in maternal feelings and attitudes and changes in hormones. In both studies prospective first-time mothers completed an extensive set of questionnaires, covering a broad range of issues, including a set of 76- to 100-item likert scales concerning attitudes toward infants, childbirth, pregnancy, caretaking, and other interpersonal relationships. In the first cross-sectional study, mothers completed the questionnaires at one of seven time points, ranging from prior to pregnancy to 3 months postpartum. In the longitudinal study, questionnaires were completed repeatedly throughout this same time period. In addition, blood was taken at these same time points and assayed by RIA for plasma concentrations of the steroids, estradiol, progesterone, testosterone, and cortisol. The primary findings are (1) feelings of nurturance grow during pregnancy and from pregnancy to postpartum; in the cross-sectional study, for most of the factors relating to infants or mothering, pregnancy and postpartum responses were more positive than prepregnancy responses; in the longitudinal study, many of these factors also showed elevations across pregnancy itself, as well as further elevations with the birth of the infant. (2) Pregnancy hormones were not related to the growth of attachment to the infant across pregnancy. (3) However, the pattern of change in the ratio of estradiol to progesterone from early to late pregnancy was related to postpartum attachment feelings. (4) Finally, hormonal correlates of attachment feelings may reflect effects both on feelings of nurturance directly and, indirectly, on mothers' feelings of well-being.

[A proposal for dosage and volume specification and documentation in HDR brachytherapy]. / Vorschlag zur Dosis- und Volumenspezifikation und Dokumentation in der HDR-Brachytherapie.

BACKGROUND: Modern computer-aided brachytherapy techniques and the various clinical and radiobiological methods require a review and standardization of dose specification and documentation in brachytherapy. METHOD: The methods and the extent of the dose specification and documentation have been analysed on the base of known international and national procedure. A new modified report has been prepared for the standardized dose specification for HDR-brachytherapy techniques. RESULT: Brachytherapy treatments are supposed to be documented in 3 different levels (I to III), the extent of which depending on the treated volume, the therapeutic aim and the equipment available. CONCLUSION: The extent of documentation and dose specification proposed in this paper requires the close cooperation of radio-oncologists and medical physicists. It seems to be advantageous to use prepared sheets or computer prints in order to minimize the time and efforts for a sufficient documentation.