Improved competence after a palliative care course for internal medicine residents.

Residents report that they received inadequate teaching in palliative care and low levels of comfort and skills when taking care of dying patients. This study describes the effects of a problem-based palliative care course on perceived competence and knowledge in a representative Dutch cohort of residents in internal medicine. Before and after the course, we carried out a questionnaire survey and knowledge test in 91 residents. The results show that many residents felt they had limited competence or were incompetent when taking care of patients in the palliative care phase. This was particularly true with respect to communication concerning euthanasia and physician-assisted suicide or hastened death (86% and 85% respectively reported limited competence or incompetence). Participants reported that they received inadequate training in palliative care and believed that specific education would make them feel more competent. The number of times that residents were engaged in palliative care situations and the years of clinical experience had a positive influence on perceived competence. Participating in the course improved perceived competence and knowledge in palliative care. No correlation was found between perceived competence and knowledge of palliative care.

Who does become an internist?

Internal medicine is a broad medical speciality and choosing the residency programme opens up a variety of career tracks. Despite this broad choice of subspecialities, we found that within our residency programme for internal medicine in the Nijmegen region between 1981 and 2000, 29% of the residents did not become internists but switched to other medical specialities. To further complicate the efficiency of the residency programme, about 20% of the residents who became internists did not finish within six years, but had a delay of two years due to combined internal medicine/PhD tracks (the training for internist/clinical investigator). In another 20% there is a delay of six to 12 months due to part-time training tracks as well as to (multiple) pregnancies of female residents and parental leave of both sexes. Our data imply that nationwide data are urgently needed to re-evaluate the manpower planning for internal medicine by taking into consideration not only the number of residents starting in the residency programme but also to include the number of residents who actually do become internists.

[Part-time medical specialist training; experiences with job-sharing for trainee internists]. / De medisch-specialistische opleiding in deeltijd; ervaringen met de duobaan in de internistenopleiding.

Due to various factors such as social changes, an increasing number of couples with two incomes, and a growing proportion of female doctors, there has been a growing demand for part-time work in recent years. This is also true for resident physicians. Objections such as a discontinuity in care and the decline in the quality of education frequently prevent resident physicians from working part-time. Over the past two years, the University Medical Centre Nijmegen, the Netherlands, has experimented with job-sharing on clinical wards for resident physicians in internal medicine. This approach works well in practice, as long as a number of conditions, including the proper transfer of medical information and good communication, are satisfied. Job-sharing is one means of satisfying the growing demand for part-time work among resident physicians and specialists.

Why don't medical textbooks teach? The lack of logic in the differential diagnosis.

Medical textbooks are an important aid in the process of diagnosing and treating patients. Medical students use these books to acquire the skills necessary for this process, while medical teachers and experienced doctors use them for teaching these competences. We posed the question whether medical textbooks are structured in such a way that medical students are taught to structure knowledge and to make a differential diagnosis in a logical way. Five major textbooks were compared with regard to four clinical problems (gastrointestinal bleeding, anaemia, oedema and heart failure). The presentation appeared to be very variable in respect of logic and systematic arrangement. In fact, it was disappointing that even in well-reputed textbooks, a systematic approach is lacking. We feel there is a need for improvement, in order to facilitate the learning of medical students and to enhance their abilities in clinical problem solving.

[Broader indication for treatment with statins; the 'heart protection study']. / Ruimere indicatie voor behandeling met statinen; de 'heart protection study'.

The introduction of statins has been a breakthrough in the treatment of hypercholesterolaemia. Statins are safe and effective in reducing the risk of coronary heart disease in the general population. The 'Heart protection study' has provided evidence for the benefit of statin treatment in much broader populations than is presently indicated in the Dutch national guidelines, i.e. also in high-risk persons with diabetes mellitus, and irrespective of age or cholesterol level. The use and cost of statins, which have been referred to as 'lifestyle-drugs' in the lay press, have risen enormously. Recently, the Dutch College of Healthcare Insurers issued a report in which recommendations concerning the reimbursement of the costs for cholesterol-lowering drugs are based on 'generally accepted insights into the appropriate use of these drugs'. Lifestyle and/or age are not exclusion criteria for treatment with statins. The expiration of patents of some statins and modifications to the reimbursement system in 2003 could lead to cost reductions.

Familial chylomicronemia caused by a novel type of mutation in the APOE-CI-CIV-CII gene cluster encompassing both the APOCII gene and the first APOCIV gene mutation: APOCII-CIV(Nijmegen).

Apolipoprotein CII (ApoCII) deficiency is a relatively rare cause of the chylomicronemia syndrome, a disorder characterized by severe fasting hypertriglyceridemia and massive accumulation of chylomicrons in plasma. Here we present a case which is the first example of apoCII deficiency caused by a major rearrangement in the APOCII gene. Southern blot analysis revealed an approximately 7.5-kb deletion disrupting the APOCII gene including the promotor region and first exon. Interestingly, the deletion also encompasses the APOCIV gene, a recently discovered novel gene upstream of APOCII. This deletion is the first mutation to be reported in the APOCIV gene.

Clinical problem analysis (CPA): a systematic approach to teaching complex medical problem solving.

The authors describe and discuss clinical problem analysis (CPA), an approach to solving complex clinical problems. They outline the five steps of the CPA model and the essential elements of each step. Next, they discuss the value of CPA's content-independent (methodical) approach and argue that teaching students to use CPA will enable them to avoid some common diagnostic reasoning errors and pitfalls. Finally, they compare CPA with two existing approaches to clinical problem solving.

Tolerability and effects of high doses acipimox as additional lipid-lowering therapy in familial hypercholesterolemia.

BACKGROUND: Acipimox, a derivative of nicotinic acid, lowers serum lipid levels by reducing the production of very-low-density and low-density lipoproteins (LDL). METHODS: We studied the additional lipid-lowering effect of high doses of acipimox in 12 patients with severe familial hypercholesterolemia (FH) who were on treatment with an HMG CoA reductase inhibitor, in some cases in combination with a resin. RESULTS: There was a significant reduction in total serum cholesterol (-9%), LDL-cholesterol (-9%) and serum triglycerides (-21%) when the standard doses of acipimox (750 mg/day) was added to treatment with simvastatin (and a resin). However, higher doses had no further hypolipidemic effect. In concordance with the reduction of serum cholesterol and LDL-cholesterol there was a significant decrease in apolipoprotein (apo)-B (-11%). There was no change in HDL-cholesterol, apo-A1 and lipoprotein(a). Acipimox in high doses up to 2250 mg/d was well tolerated except for initial gastric complaints and of flushing; because of these side effects one patient dropped out of the study. CONCLUSIONS: Acipimox in high doses, which were well tolerated, has no additional lowering effect on LDL-levels compared to the standard dose in patients with severe FH who are already treated with simvastatin.

Beta-VLDL accumulation in familial dysbetalipoproteinemia is associated with increased exchange or diffusion of chylomicron lipids to apo B-100 containing triglyceride-rich lipoproteins.

To gain more insight into the accumulation of beta-very low density lipoprotein (beta-VLDL) in familial dysbetalipoproteinemia (FD), we followed the courses of the levels of retinyl palmitate (rp), alpha-tocopherol (alpha-T) and apolipoprotein (apo) B-48 in various lipoprotein fractions for up to 48 h in eight patients with FD and six normolipidemic control subjects after an oral fat load (50 g fat/m2 containing 150000 IU of rp and 5000 IU of alpha-T). Alpha-T was added because of its rapid transfer to other lipoproteins. Fasting apo B-48 concentration in FD was normal to strongly elevated, dependent on the fasting lipid concentrations. 3 h after fat loading, total apo B-48 content did not abnormally increase; while the apo B-100 content in the triglyceride-rich lipoprotein fraction remained stable. The levels of both vitamins increased considerably, especially in the remnant fraction (Sf 15-100), which in due course exclusively contained apo B-100 in most hyperlipidemic patients. This, together with the observation that peaks for rp and alpha-T were observed 3-6 h later than for apo B-48 strongly suggests that both vitamins transfer or diffuse rapidly towards the apo B-100 containing VLDL. RP is thus more a marker for this process, which also comprises chylomicron lipids, than a specific marker for chylomicrons. This process, first described here, appears decisive in the pathogenesis of FD.

[Health Council Report'Preoperative evaluation: reconsideration of basic assumptions]. / Gezondheidsraad-rapport 'Preoperatief onderzoek: een herijking van uitgangspunten'.

In February 1997 the Health Council of the Netherlands published the report 'Preoperative evaluation'; it contains recommendations about the content and organization of preoperative evaluation. The aim is to reduce expenses and to increase efficiency. For a preoperative assessment of an otherwise healthy patient history taking and physical examination will do; minimal additional examination is necessary only in certain cases. Selective additional examination may be needed in patients showing signs of disease that may adversely affect the perioperative course; routine consultations of other specialists are redundant. The surgeon and the anaesthesiologist share the responsibility for the preoperative evaluation, but the anaesthesiologist collects the data. Outpatient facilities for anaesthesiologist contribute to improvement in quality. The report is well-documented; it deserves attention of the medical staff and implementation in the hospitals.

Effects of ketoconazole on plasma lipids and lipoprotein(a) in familial hypercholesterolaemia, compared with simvastatin.

BACKGROUND: Ketoconazole is an imidazole derivative that is active as a broad-spectrum antifungal agent. It is also an inhibitor of cholesterol production both in vivo and in vitro. METHODS: We compared the effect of low-dose ketoconazole (200 mg/day) or simvastatin (20-40 mg/day) on lipids, lipoproteins and lipoprotein(a) [Lp(a)] in 10 patients with familial hypercholesterolaemia. RESULTS: Ketoconazole reduced serum total cholesterol and low-density lipoprotein (LDL)-cholesterol by 7.6 and 9.7%, respectively. Simvastatin was more effective, the respective changes being -34.4 and -40.6%. Serum triglycerides and high-density lipoprotein (HDL) were unchanged by ketoconazole therapy, whereas simvastatin decreased triglyceride levels by 33.8% and increased HDL-cholesterol levels by 8.7%. Median Lp(a) levels tended to increase during simvastatin and to decrease during ketoconazole therapy. However, due to the wide range of baseline concentrations of Lp(a), these changes were not significant. CONCLUSIONS: Ketoconazole has some hypocholesterolaemic potential, but the effect of simvastatin is much more pronounced. The increase in Lp(a) during simvastatin therapy has been reported earlier, whereas ketoconazole does not exhibit an effect on the level of Lp(a).

[Residents not-in-training and hospital physicians: the pariahs in the hospital?]. / Assistent-geneeskundigen niet in opleiding (AGNIO's) en ziekenhuisartsen: de paria's in de kliniek?

Patient care in Dutch hospitals is performed by medical specialists and residents in training for the various specialties. In addition there is an increasing number of young physicians who are not (yet) in training: this category has arisen because of a restriction of the number of medical specialists. Recently a new career has been put forward in advertisements, offering training for positions at a level below that of the traditional medical specialists. This development is worrisome in view of the quality of patient care and the perspectives of young doctors.

Long-term experience (6 years) with simvastatin in patients with heterozygous familial hypercholesterolaemia.

OBJECTIVE: To study the long-term efficacy and safety of the cholesterol synthesis inhibitor, simvastatin, in the treatment of familial hypercholesterolaemia. METHODS: This is an open long-term follow-up of patients treated for 5 years or more in the Nijmegen University lipid clinic. Forty-four patients with heterozygous familial hypercholesterolaemia (mean baseline serum cholesterol level 11.5 mmol/l) were treated with simvastatin alone (monotherapy group) in doses ranging from 20 to 80 mg/day, or in combination with other lipid-lowering agents (combination-therapy group). RESULTS: Over the intervention period of 6 years the mean overall reduction of the serum cholesterol level was 37.8% for the total group, 37.7% for the monotherapy group and 42.6% for the combination-therapy group. The reduction of the low-density lipoprotein (LDL)-cholesterol in the three groups was 45.0, 44.6 and 50.3%, respectively. The serum triglyceride concentration was reduced by 14.0, 20.5 and 12.5%, respectively. The increase in the high-density lipoprotein (HDL)-cholesterol level was 14.4, 16.2 and 14.0%, respectively. One patient died from a myocardial infarction and 2 patients had a non-fatal cardiac event. Two patients stopped taking medication due to side-effects (dizziness and insomnia). Biochemical adverse effects were confined to elevations of the alanine aminotransferase level and the creatine phosphokinase level and did not lead to discontinuation of therapy. CONCLUSIONS: Simvastatin proves to be a safe and effective lipid-lowering drug during long-term treatment.