What are the characteristics of the competent general practitioner trainer?

BACKGROUND

Increasing attention is being given to the training of doctors to become teachers. This does not apply only to the schooling of teachers in undergraduate medical education: at the postgraduate level, general practitioner trainers (GP-trainers) receive special schooling to prepare them for their role. Yet the skills, knowledge and traits that should be expected in the competent GP-trainer have not been elucidated precisely.

OBJECTIVES

The aim of this research project is to determine the traits, knowledge and skills required for a competent GP-trainer.

METHOD

We used a qualitative method to answer the question. Ten focus-group meetings were held involving three Departments of Vocational Training in The Netherlands. Each group consisted of GP-trainers, GP-trainees or staff members. The transcriptions of these meetings were analysed, resulting in a description of what makes a competent GP-trainer.

RESULTS

Five hundred items were obtained from the focus-group meetings, each of which was formulated in the form "A good GP-trainer is/can/knows. ", etc. These items were divided into the following categories: teaching knowledge, teaching skills, teaching attitude and personality traits of the GP-trainer. A competent GP-trainer must understand basic teaching methods and be able to apply this knowledge. The skill to give good feedback was seen as an important asset for a competent GP-trainer, as were observation skills, the skill to analyse and the skill to foster reflection in the trainee. The teaching attitude of a competent GP-trainer is characterized by giving latitude to and having respect for and interest in the trainee, and being available for consultation, while the teaching approach should be individualized. Enthusiasm, flexibility, patience and self-insight were some of the personality traits identified.

CONCLUSION

Many characteristics were identified as a result of this research. The next logical step will involve a Delphi consensus procedure to obtain a profile of the competent GP-trainer. This profile will then be suitable in setting the standards for curricula for future GP-trainers.

Limited role of meta-iodobenzylguanidine scintigraphy in imaging phaeochromocytoma in patients with multiple endocrine neoplasia type II

OBJECTIVE

To compare diagnostic applicability of combined computed tomography (CT) and magnetic resonance imaging (MRI), with that of meta-iodobenzylguanidine (MIBG) scintigraphy in the preoperative localisation of MEN II related phaeochromocytoma.

DESIGN

Retrospective study

SETTING

University hospital, The Netherlands.

MATERIALS

17 patients with MEN II patients (33 adrenal glands) who were operated on for phaeochromocytoma. MIBG scintigraphy, CT and MRI were used to localize phaeochromocytoma. Histopathologically, an adrenomedullary lesion more than 1 cm in size was classified as a phaeochromocytoma.

MAIN OUTCOME MEASURES

Sensitivity, specificity, and diagnostic accuracy of combined CT and MRI and MIBG scintigraphy, compared with histopathological findings.

RESULTS

Sensitivity of combined CT and MRI (27 adrenal glands) was 87%, with a specificity of 100% and a diagnostic accuracy of 89%. MIBG scintigraphy (31 adrenal glands) had a sensitivity of 92%, a specificity of only 17%, and a diagnostic accuracy of 77%.

CONCLUSION

If unilateral adrenalectomy is done when only one adrenal gland contains a phaeochromocytoma, then MRI should be the method of choice for localising MEN type II related phaeochromocytoma. MIBG scintigraphy can be restricted to those patients in whom MRI does not show a tumour.

Complications after bilateral adrenalectomy for phaeochromocytoma in multiple endocrine neoplasia type 2--a plea to conserve adrenal function

OBJECTIVE

To evaluate the complications of the adrenocortical supplementation that is needed after bilateral adrenalectomy for phaeochromocytoma in patients with multiple endocrine neoplasia (MEN) type 2 syndrome.

DESIGN

Retrospective study.

SETTING

University hospital, The Netherlands.

MATERIALS

28 patients with MEN 2 who underwent total adrenalectomy for phaeochromocytoma between 1972 and 1996.

MAIN OUTCOME MEASURES

Perioperative morbidity and mortality, histopathological findings, complications of adrenocortical supplementation therapy.

RESULTS

22 patients had bilateral phaeochromocytomas on histopathological examination (79%) and 6 patients had initially unilateral phaeochromocytomas There was no operative mortality or substantial morbidity except for one splenic injury that necessitated splenectomy. During a mean follow-up period of 14 years (range 1-26) nine patients (32%) had a total of 19 Addisonian crises that necessitated admission to hospital. One patient died of an unrecognised Addisonian crisis.

CONCLUSION

Complications of adrenocortical supplementation therapy are considerable, but they can be reduced when unilateral adrenalectomy is done for a unilateral phaeochromocytoma in patients with MEN 2 syndrome, provided that they are carefully followed up.

Oncological implications of RET gene mutations in Hirschsprung's disease

BACKGROUND

Germline mutations of the RET proto-oncogene identical to those found in the tumour predisposition syndrome multiple endocrine neoplasia type 2A (MEN2A), were detected in 2.5-5% of sporadic and familial cases of Hirschsprung's disease. Some patients with Hirschsprung's disease may therefore be exposed to a highly increased risk of tumours.

AIMS

To define clinical use of RET gene testing in Hirschsprung's disease and related patient management from an oncological point of view.

METHODS

Sixty patients with Hirschsprung's disease were screened for RET mutations. In three, MEN2A type RET mutations were detected. Case reports for these three patients are presented.

RESULTS AND CONCLUSIONS

Only 22 families or sporadic patients with Hirschsprung's disease and MEN2A type RET mutations have been reported. Therefore, it is difficult to predict tumour risk for patients with familial or sporadic Hirschsprung's disease, and their relatives, who carry these mutations. For these mutation carriers, periodic screening for tumours as in MEN2A is advised, but prophylactic thyroidectomy is offered hesitantly. RET gene testing in familial or sporadic Hirschsprung's disease is not recommended at present outside a complete clinical research setting. In combined MEN2A/Hirschsprung's disease families RET gene testing, tumour screening, and prophylactic thyroidectomy are indicated as in MEN2A.

[Primary peritonitis due to Streptococcus pneumoniae in childhood]

Three patients, two boys of 5 months and 6 years and one girl aged 4 years, presented with acute abdominal pain, vomiting and fever, suggesting peritonitis. Imaging examinations (abdominal survey roentgenogram and (or) echography), exploratory laparotomy (in two patients) and blood cultures with growth of Streptococcus pneumoniae led to the diagnosis of primary peritonitis. Intravenous antibiotics led to recovery, in one patient complicated by paralytic ileus, which was treated surgically. Primary peritonitis is a rare condition which should be considered in the differential diagnosis of children with an acute abdominal syndrome. Conditions requiring surgery should be excluded by imaging examinations or laparotomy. When the diagnosis is confirmed by paracentesis or laparotomy, antibiotic treatment has to be started.

[Better postoperative pain management in children by introduction of guidelines; a prospective study]

OBJECTIVE

To investigate the influence of recommendations on the quality of postoperative pain management in children.

DESIGN

Prospective.

SETTING

University Hospital Groningen, the Netherlands.

METHOD

After interdisciplinary recommendations on postoperative pain were developed, the quality of postoperative pain management was investigated before implementation (phase I; n = 50 children aged 0-14 who underwent elective surgery), three months after the implementation (phase II; n = 51), and nine months later (phase III; n = 50). Quality was defined by a pain score (for ages 0 to 4 with the 'Children's Hospital of Eastern Ontario pain scale' (CHEOPS) and for ages 4-14 with the Oucher scale) and the prescription of analgetics: kind, dose, frequency, prescription by anaesthetist and doctor on the ward. Pain was scored every 2 hours during the first 24 hours after surgery. A CHEOPS score < or = 6 an Oucher score < or = 50 was defined as adequate; higher scores were defined as inadequate.

RESULTS

Pain measurement showed a statistically significant improvement of pain scores in time (phase II and III compared with phase I: odds ratio: 2.5; 95% confidence interval: 1.03-6.00; p < 0.01). Searching for factors that could be responsible for this improvement, like medication, we found no statistically significant differences in everyday practice in phase II and III compared with phase I. However, children who could score their pain by self-report (Oucher) showed the best results in all 3 phases of the study. The youngest children, i.e. less than 6 months old, showed inadequate results during the whole study. The greatest improvement in time during the first 12 hours was seen in the group of children older than 6 months. The recommendations were followed more strictly in younger children, and when continuous morphine was given.

CONCLUSION

Pain scores in children improved after the introduction of recommendations on postoperative pain. However, the improvement could not be attributed to factors like medication. Factors like a change in attitude towards pain could be responsible for this change.

[Results of 25-year pheochromocytoma treatment in the Groningen Academic Hospital]

OBJECTIVE

To evaluate 25 years' experience with the localisation techniques, operative management and results of treatment for phaeochromocytoma.

DESIGN

Retrospective

SETTING

Groningen University Hospital, the Netherlands.

METHOD

Localisation results, per- and postoperative morbidity, mortality and treatment results were evaluated in all 59 patients treated for phaeochromocytoma in the period 1970-1995; 41 patients underwent unilateral adrenalectomy, 18 underwent bilateral adrenalectomy.

RESULTS

From the introduction of MIBG scintigraphy all tumour sites were correctly diagnosed preoperatively. The transabdominal operation lead to considerable morbidity and minimal mortality. All MEN type 2 patients (n = 5) treated with unilateral adrenalectomy developed phaeochromocytoma in the contralateral gland and needed total adrenalectomy 7 to 14 years after the initial operation.

CONCLUSION

A retroperitoneal approach in surgical treatment of phaeochromocytoma is to be preferred. In MEN type 2 patients bilateral adrenalectomy is still mandatory.

[Surgical treatment of lymphadenitis caused by non-tuberculous mycobacteria in children]

A retrospective study was made of 43 consecutive cases of children with the diagnosis of non-tuberculous mycobacterial lymphadenitis treated in our surgical department between 1976 and 1992. In 16 of the 42 children the diagnosis was initially missed and these children elsewhere underwent incision and drainage resulting in a chronic sinus. In 37 children the disease was localized in the head-and-neck area, while in the other 6 inguinal or axillary lymph nodes were involved. All 43 children underwent a regional lymph node dissection with a partial parotidectomy in three. In 5 children recurrent disease developed within 4 months after dissection. The recurrences were all successfully treated with additional surgery. In none of the children did the dissection result in permanent damage of nerves, especially not of the facial nerve. The cosmetic results were good but depended on the possibilities of entering the neck through a cosmetically ideal incision. Early recognition of the disease is of the utmost importance for an adequate surgical and cosmetically desirable result. An aggressive surgical therapy is advocated and will not result in permanent damage provided the surgeon has the technical skill required for neck dissections.

Bilateral split hand/foot malformation and inv(7)(p22q21.3)

A boy with typical tetramelic split hands and feet is described. In addition, there was a large arteriovenous malformation of the right arm. Chromosome studies showed a pericentric inversion of chromosome 7: 46,XY,inv(7)(p22q21.3). Inspection of the extremities and chromosome studies in the parents were normal. This case confirms the suggested localisation of a locus, important for early limb differentiation, on the long arm of chromosome 7, most probably in the chromosomal region 7q21.2-7q21.3. Previously reported cases are reviewed briefly.

Changing patterns in graduate surgical education in The Netherlands

An overview is presented of the organization, outline, and contents of graduate surgical training programs in The Netherlands. Adaptations of these programs to changes in demands in surgical practice and health care delivery systems are discussed. Special emphasis is given to the relation of surgery and the surgical specialties, additional training, theoretic training, and manpower planning. The principal questions regarding the optimal way to respond to changing concepts in the field of surgery are presented and discussed in the context of the situation in The Netherlands, but they seem to be similar in the surgical communities of many countries.

[Comparison of iodine scintigraphy and computerized tomography in the localization of pheochromocytoma]

A comparison is made of the results of CT scanning and MIBG scintigraphy in the localization of phaeochromocytoma. In 21 out of 24 patients with clinically diagnosed phaeochromocytoma in the University Medical Hospital, Groningen in 1983-1990, MIBG scintigraphy provided accurate localization, while in 16 out of 18 patients with phaeochromocytoma who underwent CT scanning a correct localization was obtained. False negative results were mainly present when lesions were smaller than 2 cm. There were no false positive results. It is concluded that the sensitivity of the two methods in the localization of phaeochromocytoma is about equal. The use of one of the methods rather than of both is advised.

Enterocolonic fistula due to incarcerated inguinal hernia

A 2 1/2-year-old boy presented severely underweight and with an extremely distended abdomen. He was born prematurely and at age 6 months had an incarcerated inguinal hernia, which had been treated conservatively. Laboratory investigations at the time of presentation showed evidence of bacterial overgrowth. Barium studies revealed a fistula between the jejunum and sigmoid colon. Resection of the fistula was followed by complete recovery. We suggest that the incarcerated hernia underlies this fistula. Until now, this series of events has not been published.

Prognosis of extrahepatic biliary atresia

We carried out a retrospective investigation of the 89 patients with extrahepatic biliary atresia born in The Netherlands during a 10 year period. Of these 89 patients 10 had a diagnostic laparotomy only. Eight patients had an anastomosis between the proximal bile duct and the intestine, and the remaining 71 had hepatic portoenterostomies. Bile drainage was re-established in 46 (65%). After successful hepatic portoenterostomy the development of cholangitis was the most important determinant of long term survival; five year survival was 54% in the 19 patients who had cholangitis and 91% in the 27 who did not. In the whole group of 71 patients the five year survival was 47%. Seventeen patients were at least 5 years of age at the time of writing, three of whom had had liver transplantation. Three patients have cirrhosis and hyperbilirubinaemia, and the other 11 have normal bilirubin concentrations and normal or slightly raised transaminase activities. To improve these results early surgical intervention in all children with extrahepatic biliary atresia is necessary, as are better methods of prophylaxis and treatment of cholangitis.

[Cystic dilatation of the choledochus. 9 cases]

A retrospective study of 9 cases of extra-hepatic biliary cyst is presented. Prior to admission to our hospital, 5 patients had been operated upon elsewhere. This initial operation proved to be of great importance. In 4 patients initial excision of the cyst was performed resulting in complete regression of symptoms, and no further surgery was required. In 5 patients the cyst was not excised initially and cysto-enterostomy was performed. Recurrence of symptoms and complaints, with major morbidity, occurred in all but one of these patients. After several operations, only final excision of the cyst definitively suppressed the symptoms, but in one patient the cyst could no longer be excised. Cysto-enterostomy results in recurrent symptoms and cholangitis and should be avoided. Early excision of extra-hepatic biliary cysts should be performed whenever technically feasible, not only to prevent these complications but also because of the risk of malignant degeneration related to the cyst.

Maternoembryonic transfusion and congenital malformations: an experimental study using rat embryos

In an experimental study, using an in vitro whole rat embryo culture, the effects of a maternoembryonic transfusion and immunologic interaction on the development of ten-day-old rat embryos (stages 8 to 10 somites) has been studied. Transplacental transfusion has been simulated by embryonic intracardiac microinjection of 0.1 to 0.5 microL immunologically active rat serum. After an incubation of 24 and 48 hours, respectively, the embryos were killed. All tested embryos have survived the incubation period. On microscopic examination of the tested embryos those that were taken from the incubator after 24 hours showed no signs of pathogenic cell degeneration, while the embryos that were taken from the incubator after 48 hours all had localized lesions with pathogenic cell degeneration in one or multiple major structures. The neurectoderm and endoderm seem to be the most sensitive tissues in this period of organogenesis. The results suggest that immunologic reaction to transplacental transfusion of maternal serum may lead to congenital malformations.

Nesidioblastosis and endocrine hyperplasia of the pancreas: a secondary phenomenon

Diffuse endocrine cell proliferation (nesidioblastosis) and islet cell hyperplasia are considered causes of organic hyperinsulinism but have not been distinguished (by histometric or immunohistologic methods) from the normally variable pancreatic islet cell population during development and in adults. Therefore, in this study morphologic, immunohistologic (to detect insulin, glucagon, somatostatin, and pancreatic polypeptide), and morphometric features were evaluated in 1) normal pancreases (from fetal to adult; n = 49); 2) pancreases from patients with nesidioblastosis (n = 5); and 3) tumor-associated pancreases (TAP) from patients with insulin-producing islet cell tumors (n = 8). The study of normal postnatal development revealed that all features of fetal development remain present after birth and that the diagnosis of any diffuse endocrine disorder should therefore be based essentially on quantitative histometric parameters (total endocrine area, islet size distribution, distribution of each endocrine cell type). With these parameters endocrine cell hyperplasia was demonstrated in TAP from adults due to increased numbers of A and D cells. However, in the cases previously diagnosed as pathologic nesidioblastosis, all parameters were within the normal range. Thus, nesidioblastosis does not appear to be a pathologic entity. Careful re-examination of the pancreases, prompted by these data, revealed small islet cell tumors in three of these five cases. It is concluded that the endocrine pancreas can react rapidly, both morphologically and functionally, to changes in hormonal feedback, e.g., islet cell tumors. Therefore, the observation of a diffuse islet cell disorder in a patient with hyperinsulinism should not be considered an indication that an islet cell tumor is not present.

Undescended testes and puberty. Orchidopexia or orchiectomy

In 35 consecutive patients who were over 11 years of age, surgical exploration was preformed for unilateral undescended testes. To evaluate the quality of spermatogenesis all testes were biopsied. In two patients with macroscopically normal testes a malignancy was detected, one seminoma and one carcinoma in situ with micro-infiltrative carcinoma. In all patients considerable loss of spermatogenesis could be demonstrated and in all but three patients severe degenerative changes were present. On the basis of this study we would consider orchiectomy rather than orchidopexia in patients with unilateral undescended testes presenting at puberty or later.

Surgical treatment of organic hyperinsulinism in infancy. Surgical procedure in the absence of a demonstrable insulinoma and a peroperative diagnosis of nesidioblastosis

This study consists of a review of 5 children operated on for organic hyperinsulinism. The diagnosis could be established by demonstrating the repeated presence of elevated serum insulin levels during hypoglycaemia and/or a rapid glucose disappearance. From our experience with this series and by a review of the literature the following data are relevant to the management of these children. Because of the risk of brain damage there is no justification for prolonged diagnostic and therapeutic trials. Surgical exploration of the pancreas is indicated without delay. When during exploration no localised lesion can be found, the diagnosis "nesidioblastosis" can be established by frozen section evaluation. Whether a diagnosis of nesidioblastosis has been established or not, a 90-95% subtotal pancreatectomy has to be performed subsequently, because this operation will cure most of the children with organic hyperinsulinism, has negligible complications and preserves normal exocrine and endocrine pancreatic function. A near-total pancreatectomy has to be performed without delay in patients with recurrent hypoglycaemia caused by persisting organic hyperinsulinism after the first operation.

Portal hypertension in children due to thrombosis of the portal vein

The case histories of seven children with prehepatic portal hypertension are presented. An umbilical vein catheter was introduced in six of the seven patients during the neonatal period for administration of fluids, including hypertonic and alkaline solutions. There appears to be a relationship between umbilical vein catheterization and thrombosis of the portal system. The methods of treating this condition are controversial. The most important sign is bleeding from oesophageal varices. Elective portosystemic shunts give the best operative results. A conservative policy, however, does not appear to have a higher mortality and probably results in a lower morbidity. Our present management is therefore conservative.

Colon-interposition as replacement for the esophagus. A follow-up study

The longterm results of the use of colon-interposition as a substitution for the esophagus have been studied. Colon-interposition was carried out in eleven patients. There was one operative death. A second child died of an unknown cause nine years and eight months after operation. Nine patients could be studied from sixteen years and nine months to thirteen months after the operation. In six patients a satisfactory result has been achieved. One child is staying in a psychiatric infirmary. Feeding problems due to recurrent fistulae have led to growth retardation in another patient, while a third patient has regurgitation symptoms. A study of the case histories gives insight into the many early and late complications which occur in this operative procedure. The colon-interposition is a complicated procedure and should only be carried out in centers for pediatric surgery, because of its specific indication, its technique and the occurrence of complications afterwards. The development of alternative, less complicated, methods leaves a restricted indication for colon-interposition.

The use of paediatric cadaver kidneys for transplantation in adult recipients

In view of the shortage of cadaveric donors a retrospective study has been performed to determine the results of transplantation of paediatric cadaver donor kidneys into adult recipients. Graft- and patient survival and renal function in the 31 cases analysed in this study showed no adverse effect of the use of paediatric donor kidneys. No vascular complications were encountered. Ureteric leakage occurred in only one case and it was treated successfully. It is concluded that paediatric age is no criterion for donor exclusion and that paediatric donors are to be regarded as a valuable source of cadaveric kidneys for transplantation.