[Medical disciplinary boards punish more often and more severely; an observational study of 10 years of medical disciplinary law]

OBJECTIVE

To examine if the medical disciplinary law in the Netherlands is becoming tougher.

DESIGN

Observational study.

METHOD

We read the annual reports of the Dutch Disciplinary Committees for the Healthcare Sector 2007-2017, and registered the numbers of disciplinary cases and those cases upheld, the measures imposed and the degree of consistency in the event of an appeal. Over 400 medical disciplinary cases were reviewed in more detail. Based on these cases, we determined those variables that increase or decrease the likelihood of conviction, such as the gender of the defendants, the region in which the disciplinary case was heard, and if objective norms and professional practice guidelines had been used in arriving at the verdict.

RESULTS

Each year a disciplinary case is brought against an average of 0.4% of all health care providers - mainly physicians (an average of approximately 1400 disciplinary cases each year). One-third of all disciplinary cases were dealt with in court and about half of them were upheld. Over time, the number of disciplinary cases has increased (36%), as has the percentage of cases that are upheld (27%). Additionally, heavier measures were more often imposed and the degree of consistency between the initial ruling and the ruling on appeal also increased (56%). Those factors that increased the likelihood of a case being upheld were: being a physician of male gender, the disciplinary case being heard in The Hague or Eindhoven, and the non-implementation of an objective norm or professional practice guideline in arriving at the verdict.

CONCLUSION

Since 2007 the Dutch medical disciplinary boards have been punishing more often and more severely. This may be because the subjective demands made on health care professionals have changed. Arriving at an opinion subjectively is not a problem when it comes to verifying compliance with standards of due care. However, if this method is used to determine the penalty, the health care system will become defensive - and this will not improve the quality of care.

Abstract 213: Human Genetic Variations in Neuroimmune Guidance Cues and their Role in Premature Atherosclerosis

Introduction: Neuroimmune guidance cues (NGCs), a family of proteins originally known for controlling neuronal migration, have been shown to be involved in atherosclerosis in mice models by regulating adhesion of monocytes to the vascular endothelium. The NGC family consists of multiple receptors and ligands enabling an interplay between inflammatory cells and the vasculature endothelium. We set out to investigate the role of NGCs in atherosclerosis in humans.

Methods and results: We sequenced a total of 77 NGC genes in a unique cohort of 89 patients with premature atherosclerotic (PAS), in whom no clear CVD risk factor was present. A total of 178 rare variants were identified and we classified the pathogenicity of these rare (MAF<0.05) variants by high Combined Annotation Dependent Depletion (CADD) scores. Based on literature and cosegregating pedigrees of the 88 possible deleterious variants we chose two variants in Netrin1 (NTN1) and EphrinB2 (EFNB2) to explore and validate their causality in human atherosclerosis. The expression of both these genes is regulated by flow and inflammatory stimuli. Under atherosclerotic conditions endothelial cells upregulate EFNB2 while NTN1 is downregulated. In addition, using immunohistochemical staining on human aorta’s, we found that NTN1, which is normally expressed on human endothelial cells, is less abundant in increasing stages of atherosclerosis. For EFNB2, a cell surface transmembrane ligand for Eph receptors, we performed several functional assays using HUVEC cells that overexpress EFNB2 , showing that EFNB2 is affecting endothelial cell barrier function, as well as proliferation.

Conclusion: In patients with PAS rare missense variants in NGC genes were identified. Further functional- and expression assays showed an effect of NTN1 and EFNB2 on different aspects of the human atherosclerotic process. The results obtained from these studies substantiate the role of NGCs in human atherosclerotic disease and may further identify NGCs as novel potential therapeutic targets in our strive against cardiovascular disease.

Small sample sizes in high-throughput miRNA screens: A common pitfall for the identification of miRNA biomarkers

Since the discovery of microRNAs (miRNAs), circulating miRNAs have been proposed as biomarkers for disease. Consequently, many groups have tried to identify circulating miRNA biomarkers for various types of diseases including cardiovascular disease and cancer. However, the replicability of these experiments has been disappointingly low. In order to identify circulating miRNA candidate biomarkers, in general, first an unbiased high-throughput screen is performed in which a large number of miRNAs is detected and quantified in the circulation. Because these are costly experiments, many of such studies have been performed using a low number of study subjects (small sample size). Due to lack of power in small sample size experiments, true effects are often missed and many of the detected effects are wrong. Therefore, it is important to have a good estimate of the appropriate sample size for a miRNA high-throughput screen. In this review, we discuss the effects of small sample sizes in high-throughput screens for circulating miRNAs. Using data from a miRNA high-throughput experiment on isolated monocytes, we illustrate that the implementation of power calculations in a high-throughput miRNA discovery experiment will avoid unnecessarily large and expensive experiments, while still having enough power to be able to detect clinically important differences.

A novel lamin A/C mutation in a Dutch family with premature atherosclerosis

OBJECTIVE

We report a novel lamin A/C (LMNA) mutation, p.Glu223Lys, in a family with extensive atherosclerosis, diabetes mellitus and steatosis hepatis.

METHODS

Sequence analysis of LMNA (using Alamut version 2.2), co-segregation analysis, electron microscopy, extensive phenotypic evaluation of the mutation carriers and literature comparison were used to determine the loss of function of this mutation.

RESULTS

The father of three siblings died at the age of 45 years. The three siblings and the brother and sister of the father were referred to the cardiovascular genetics department, because of the premature atherosclerosis and dysmorphic characteristics observed in the father at autopsy. The novel LMNA mutation, p.Glu223Lys, was identified in the proband and his two sons. Clinical evaluation revealed atherosclerosis, insulin resistance and hypertension in the proband and dyslipidemia and hepatic steatosis in all the patients with the mutation.

CONCLUSION

Based on the facts that in silico analysis predicts a possibly pathogenic mutation, the mutation co-segregates with the disease, only fibroblasts from mutation carriers show nuclear blebbing and a similar phenotype was reported to be due to missense mutations in LMNA we conclude that we deal with a pathogenic mutation. We conclude that the phenotype is similar to Dunnigan-type familial partial lipodystrophy.

APOE1 mutation in a patient with type III hyperlipoproteinaemia: detailed genetic analysis required

We present the case of a patient with clinical features of familial dysbetalipoproteinaemia (FD) including high levels of total cholesterol, hypertriglyceridaemia and the presence of palmar xanthomas. Whereas genotype analysis identified the APOE3E3 isoform, sequence analysis revealed the presence of one APOE1 allele due to a mutation, p.Lys164Glu, which leads to loss of function of apolipoprotein E (ApoE), a rare cause of dominant FD.

Monocyte gene expression signature of patients with early onset coronary artery disease

The burden of cardiovascular disease (CVD) cannot be fully addressed by therapy targeting known pathophysiological pathways. Even with stringent control of all risk factors CVD events are only diminished by half. A number of additional pathways probably play a role in the development of CVD and might serve as novel therapeutic targets. Genome wide expression studies represent a powerful tool to identify such novel pathways. We compared the expression profiles in monocytes from twenty two young male patients with premature familial CAD with those from controls matched for age, sex and smoking status, without a family history of CVD. Since all patients were on statins and aspirin treatment, potentially affecting the expression of genes in monocytes, twelve controls were subsequently treated with simvastatin and aspirin for 6 and 2 weeks, respectively.

By whole genome expression arrays six genes were identified to have differential expression in the monocytes of patients versus controls; ABCA1, ABCG1 and RGS1 were downregulated in patients, whereas ADRB2, FOLR3 and GSTM1 were upregulated. Differential expression of all genes, apart from GSTM1, was confirmed by qPCR. Aspirin and statins altered gene expression of ABCG1 and ADBR2. All finding were validated in a second group of twenty four patients and controls. Differential expression of ABCA1, RSG1 and ADBR2 was replicated. In conclusion, we identified these 3 genes to be expressed differently in CAD cases which might play a role in the pathogenesis of atherosclerotic vascular disease.

Obesity and target organ damage: the kidney

Obesity is a risk marker for progressive renal function loss in patients with known renal disease. There is, however, increasing evidence that obesity may also damage the kidney in otherwise healthy subjects. There appears to be an intriguing parallel between the renal effects of obesity and those of diabetes. First, an increased renal blood flow and glomerular filtration rate has been described in obesity and, second, microalbuminuria is found to be related to obesity. These two events are known to predict future loss of renal function in diabetes. The mechanism responsible for the renal damage in obesity has not been established but there is evidence suggesting that this might be related to both hormonal changes as well as low-grade inflammation.

Low levels of urinary albumin excretion are associated with cardiovascular risk factors in the general population

Microalbuminuria is associated with both an increased prevalence of cardiovascular risk factors and greater renal and cardiovascular morbidity. We questioned whether in the general population such associations can be found at lower levels of urinary albumin excretion than that of classically defined microalbuminuria. To that purpose urinary albumin concentration was measured in 40619 subjects aged 28 to 75 years. The subjects filled in a questionnaire on cardiovascular risk factors and events and were divided in deciles according to their urinary albumin concentration. Smoking was associated with albuminuria in the fifth or higher decile of urinary albumin concentration, that is with an albumin concentration of 5.1 mg/l and higher. The lower cut-off point for a positive association with hypertension was 8.8 mg/l, and for diabetes 11.2 mg/l. Family history for cardiovascular disease and hyperlipidaemia were not associated with albuminuria. We conclude that urinary albumin concentrations far below the microalbuminuric range are associated with increased prevalence of established cardiovascular risk factors. Family history for cardiovascular disease and hyperlipidaemia seems to behave differently. These data emphasize the need for more studies on the impact of albuminuria on the prediction of cardiovascular and renal disease in the general population.

Reduction in left ventricular messenger RNA for transforming growth factor beta(1) attenuates left ventricular fibrosis and improves survival without lowering blood pressure in the hypertensive TGR(mRen2)27 Rat

Angiotensin II recruits transforming growth factor beta(1) (TGFbeta(1)) and is related to left ventricular fibrosis. However, it is unclear whether chronic in vivo reduction in left ventricular TGFbeta(1) expression blunts fibrosis and improves outcome in angiotensin II-dependent hypertension. Four-week-old male hypertensive TGR(mRen2)27 (Ren2) rats received either normal food, low-dose losartan (0.5 mg. kg(-1). d(-1)), or tranilast (a nonspecific TGFbeta inhibitor; 400 mg. kg(-1). d(-1)) (n=10 for each group) for 12 weeks and were compared with Sprague-Dawley control rats. The effect of tranilast on survival was evaluated in 34 additional untreated homozygous Ren2 rats. Tranilast or low-dose losartan did not lower blood pressure. However, the increase in left ventricular weight (Ren2 versus SD 3.1+/-0.16 versus 2.1+/- 0.06 mg/g body wt; P<0.05) was significantly (P<0.05) blunted by both tranilast (2.7+/-0.05) and losartan (2.7+/-0.07). Both drugs prevented the increase in left ventricular TGFbeta(1) mRNA and fibronectin mRNA and blunted the increase in hydroxyproline content and the increase in perivascular fibrosis. The perivascular fibrosis score correlated significantly with the level of expression of TGFbeta(1) (r=0.62; P=0.019). In situ hybridization demonstrated increases in TGFbeta(1) mRNA, predominantly in perivascular and nonmyocyte areas. Both drugs did not prevent the decrease in systolic or diastolic dP/dt, but tranilast significantly improved the survival of untreated Ren2 rats (P=0.029). In conclusion, TGFbeta(1) mRNA expression is increased predominantly in nonmyocyte regions in the hypertrophied left ventricle in this angiotensin II-dependent model of hypertension. This increase is probably due to high angiotensin II levels rather than to hypertension. This is the first study to suggest that chronic inhibition of TGFbeta(1) expression attenuates left ventricular hypertrophy and fibrosis, even without lowering blood pressure.

Smoking is related to albuminuria and abnormal renal function in nondiabetic persons

BACKGROUND

Smoking induces albuminuria and accelerates progression to renal failure in persons with diabetes, but little is known about the relation between smoking and renal function in nondiabetic persons.

OBJECTIVE

To investigate whether smoking is related to albuminuria and abnormal renal function in nondiabetic persons.

DESIGN

Cross-sectional study.

SETTING

Groningen, The Netherlands.

PARTICIPANTS

7476 participants in the PREVEND (Prevention of REnal and Vascular ENd stage Disease) Study.

MEASUREMENTS

Microalbuminuria and high normal albuminuria were defined as urinary albumin excretion of 30 to 300 mg/24 h and 15 to 30 mg/24 h, respectively. Elevated or decreased glomerular filtration rate (GFR) was defined as a creatinine clearance that exceeded or was less than two times the standard deviation of the mean value in nondiabetic, nonsmoking participants who had an albumin excretion of 0 to 15 mg/24 h, adjusted for age and sex.

RESULTS

Current smokers had a higher median albumin excretion than nonsmokers and were more likely to have microalbuminuria and high normal albuminuria with elevated or decreased GFR. After adjustment for several potential confounding factors, persons who smoked 20 or fewer cigarettes/d and persons who smoked more than 20 cigarettes/d, respectively, showed a dose-dependent association between smoking and high normal albuminuria (relative risk, 1.33 [95% CI, 1.10 to 1.61] and 1.98 [CI, 1.49 to 2.64]), microalbuminuria (relative risk, 1.92 [CI, 1.54 to 2.39] and 2.15 [CI, 1.52 to 3.03]), elevated GFR (relative risk, 1. 82 [CI, 1.31 to 2.53] and 1.84 [CI, 1.12 to 3.02]), and decreased GFR (relative risk, 1.53 [CI, 1.04 to 2.24] and 1.83 [CI, 1.05 to 3. 20]), respectively. Quitting smoking was associated only with microalbuminuria.

CONCLUSIONS

Smoking is associated with albuminuria and abnormal renal function. However, these associations are less pronounced or absent in former smokers.

A role for endothelin in the pathogenesis of hypertension: fact or fiction?

Endothelin-1 (ET-1) was discovered 10 years ago. Because it is one of the most potent vasoconstrictors in vivo, a pathophysiological role for the peptide as a mediator of hypertension has been postulated. Several clinical studies, however, have been unable to identify elevated ET levels in the plasma of hypertensive patients, suggesting that it does not play a prominent role in this disease. More recently, evidence has been presented that ETs act predominantly at the autocrine/paracrine level and that measurements of plasma levels can give only an indirect view of the activity of the system. In addition, transgenic technology has uncovered new actions of the peptide systems in recent years, which point to a key function of the system in prenatal development. Moreover, investigation of conditions associated with hypertensive end-organ damage, such as chronic renal failure, has led to a re-evaluation of the role of the ET system in hypertension. This article discusses this recent evidence and defines the exact role of the ET system in hypertension and hypertensive end-organ damage.

Effects of c-myc oncogene modulation on differentiation of human small cell lung carcinoma cell lines

Amplification and over-expression of oncogenes of the myc family are related to the prognosis of certain solid tumors such as small cell lung cancer (SCLC). For SCLC, c-myc is the oncogene most consistently found to correlate with the end stage behaviour of the tumour, in particular with survival after chemotherapeutic treatment. C-myc is important in many cellular processes such as proliferation, differentiation and apoptosis. In the present study the relationship between c-myc and differentiation was analyzed by down-regulation of endogenous c-myc protein, using two approaches: first by coculturing with antisense (AS) oligodeoxynucleotides (ODN) in the human SCLC cell line GLC4 and its 6-fold cisplatin resistant subline GLC4-CDDP, second by stable transfection of GLC4-CDDP with a dexamethasone-inducible AS c-myc expression vector. Basic characterization of the differentiation status of GLC4 and GLC4-CDDP showed a decrease in neuroendocrine differentiation in GLC4-CDDP compared to GLC4 Cytokeratin was absent in both cell lines. No significant differences in expression of adhesion molecules or myeloid antigens were observed between the lines. Vimentin expression was higher in GLC4-CDDP compared to GLC4 (AS c-myc ODN)-induced growth inhibition and down-regulation of endogenous c-myc protein further decreased neuroendocrine differentiation (CD57 positive cells) in GLC4-CDDP without affecting the expression of other antigens such as vimentin (intermediate filament),CD15 (myeloid antigen) and VLA-alpha 4 (adhesion molecule) and did not alter the expression of these antigens in GLC4 (AS c-myc RNA)-induced growth inhibition did not significantly affect the expression of the tested antigens in the AS c-myc transfected GLC4-CDDP/AS cell line. No effect of nonsense c-myc ODN or dexamethasone-induced control RNA (controls) was observed.