Written case reports as assessment of the elective student clerkship: consistency of central grading and comparison with ratings of clinical performance.

The assessment of the elective clerkship at the University of Groningen consists of a written case report, graded by one of four independent reviewers, and a rating of clinical performance by the students' supervisors. This study analyses the grades of 710 case reports and 189 ratings. The grades were found to be normally distributed, similar for the reviewers and consistent over the years, but inter- or intra-observer variation was not studied. The ratings of clinical performance were skewed towards 'excellent'. There was a low correlation between the two assessments (Spearman's r = 0.25; p = 0.001). This may be attributed among other things to the large number of supervisors and the face-to-face assessment of clinical performance versus the distant assessment of a written document. A more relevant explanation, however, is that the case reports measure primarily cognitive aspects, as compared with overall clinical performance.

[Signs of miliary tuberculosis: which diagnostic tests and when to treat?]. / Aanwijzingen voor miliaire tuberclose: welke diagnostiek en wanneer behandelen?

Three patients, men aged 21, 57 and 53 years, presented with variable non-specific symptoms such as general malaise, weight loss, elevated temperature, abdominal pain, cough, pulmonary crepitations and elevated liver enzymes. Diffuse fine nodular infiltration was seen on chest radiography in the last two cases. The first patient refused to be tentatively treated with tuberculostatics and died. Mycobacterium tuberculosis complex grew on Löwenstein medium a week later. The two other patients received tuberculostatic treatment. The second patient recovered, while the third patient suffered a cerebrovascular accident on top of emaciation and respiratory insufficiency and died. In the Netherlands, currently more than one hundred patients with tuberculosis disease die each year. The disease is mostly seen in people from the high-risk groups for tuberculosis such as asylum seekers and immigrants. Even after extensive diagnostic procedures it can be difficult to obtain rapid bacteriological confirmation. When miliary tuberculosis is suspected it is important to carry out the complete range of tests (Ziehl Neelsen microscopy, PCR, Löwenstein cultivation) and to start therapy immediately and not to await the results of the diagnostic tests. However, in many cases this may still be too late, with an estimated mortality of 20%.

Disseminated intravascular coagulation as an unusual presentation of an Epstein-Barr virus infection.

Epstein-Barr viral (EBV)-infection usually presents as fever, sore throat, fatigue, lymphadenopathy and atypical lymphocytosis. We describe a patient with disseminated intravascular coagulation as the presenting symptom caused by a primary EBV infection.

Chronic mesenteric ischaemia: diagnostic challenges and treatment options.

OBJECTIVES: A description of the clinical presentation, diagnostic procedure and mode of therapy in three patients suffering from chronic mesenteric ischaemia. DESIGN AND INTERVENTIONS: In all cases, the diagnosis was made on the basis of abdominal complaints in combination with angiographic findings. The primary treatment objective was restoration of blood flow via a revascularization procedure, for the patient in whom this could not be accomplished an enteral feeding programme was undertaken. RESULTS: One patient had a panmalabsorption syndrome which was treated with an aortomesenteric bypass operation, the second one presented with multiple gastric ulcerations which only improved after a percutaneous transluminal angioplasty. In the third patient, neither surgery or angioplasty were feasible and a tentative enteral feeding programme was given, after which the ability to consume a normal oral diet without abdominal distress was regained. CONCLUSIONS: These three cases illustrate the diverse clinical pictures by which chronic mesenteric ischaemia may present itself. This diagnosis should be kept in mind when other more common causes of a patient's abdominal complaints cannot be found, hence giving consideration to abdominal angiography as the next diagnostic procedure. With respect to therapy, restoring blood flow through surgery or angioplasty is the primary form of treatment. However, if neither of these therapeutic options is feasible, it is suggested that such patients may benefit from a nutritional training programme.

Acute pancreatitis in a patient with familial benign hypercalcaemia.

A patient with familial benign hypercalcaemia (FBH) who developed relapsing pancreatitis is presented. She underwent distal partial pancreas resection with surgical removal of pancreatic duct stones, and a pancreaticojejunostomy. No further causes for the pancreatitis were found. The present case is remarkable since it is an example of the occurrence of pancreatitis in a previously known patient with hypercalcaemia, and it underlines the severity of the pancreatitis when it occurs in this syndrome.

Successful long-term control of idiopathic hypereosinophilic syndrome with etoposide.

A 38-year-old man with idiopathic hypereosinophilic syndrome had an inadequate response to steroids and severe side effects from hydroxyurea treatment, which necessitated withdrawal of the treatment. Successful control of clinical symptoms and eosinophil counts was obtained with etoposide (VP16-213) for 18 months. VP16-213 may be valuable in idiopathic hypereosinophilic syndrome treatment.

Digoxin infusion versus bolus injection in rapid atrial fibrillation: relation between serum level and response.

Using available data on time-concentration and time-effect relationships in normal persons the results of infusion of digoxin in various time periods were simulated and compared with administration of digoxin by bolus injections, using a three-compartment pharmacokinetic model to which a separate small side-effect compartment was subsequently added. The validity of the simulations was tested in 11 patients with rapid atrial fibrillation. Serum digoxin concentrations, ventricular rate and side effects were monitored in a double-blind study comparing an infusion of 1.5 mg digoxin over 6 h with administration of three bolus injections of 0.5 mg digoxin 8 h apart. In agreement with the predictions of the model, the maximal fall in ventricular rate was reached after 8-9 h in the infusion group and after 19-20 h in the bolus injection group, without any detectable difference in side effects. There were certain discrepancies between the results of the clinical study and the predictions of the model, e.g. in serum digoxin concentrations, perhaps due to impaired clearance in the patients. However, it is concluded that the tested model is valid in elderly patients with rapid atrial fibrillation.

Meta-[I-131]iodobenzylguanidine uptake in a nonsecreting paraganglioma.

In a patient with a paraganglioma at the carotid bifurcation, intense uptake of meta-[I-131]iodobenzylguanidine (I-131 MIBG) in the tumor was found. There was no clinical or biochemical evidence for catecholamine secretion by the tumor, although analysis of the tissue revealed that catecholamine biosynthesis took place. We conclude that accumulation of I-131 MIBG may occur in a paraganglioma, but does not necessarily indicate endocrine activity of the tumor.