[Physicians and scientific research: slight decline of the numbers of physicians with a doctoral degree]. / Artsen en wetenschappelijk onderzoek: lichte teruggang van het aantal gepromoveerde artsen.

OBJECTIVE: To establish whether the number of physicians interested in a career in academia (i.e. research) is declining. DESIGN: Descriptive. METHOD: The researchers analysed the pre- and post-doctoral careers of PhD students at 3 university medical centres (VU Amsterdam, Nijmegen and Maastricht) in 4 separate reference years (1989, 1994, 1999 and 2003), using information from doctoral dissertations and the Dutch medical address book. The researchers recorded the gender of the students and the timing of the doctorate in relation to specialist training, university education and employment, as applicable. RESULTS: The total number of dissertations produced at the 3 medical faculties in the 4 reference years increased gradually by nearly a factor of 2 (1989: 112; 1994: 152; 1999: 198; 2003: 213). In terms of absolute numbers, the number of dissertations authored by physicians increased from 1989 to 1994 and again in 1999 (64, 90 and 105), but decreased slightly in 2003 (96). The percentage of female physicians obtaining a doctorate doubled during this period (1989: 9/64 (14); 2003: 28/96 (29)). Increasingly, physicians prepared their dissertation before or during their training as specialists or general practitioners (1989: 15/64 (23%); 2003: 51/96 (53%)). Ofthe clinical specialists who had received their doctorate, approximately half continued to work in an academic setting after obtaining their degree. This percentage remained approximately the same in all reference years (1989: 13/26 (50); 1994:19/35 (54); 1999: 21/45 (47); 2003: 21/40 (53)). CONCLUSION: Although the number of physicians performing scientific research as part of their doctoral degree project declined slightly in 2003 following an initial rise, our data indicate no cause for major concern. One reason may be increased interest in Clinical Research Fellow programmes. However, the future of medical research would look brighter if young physicians with doctorates had better career prospects within academic centres. To follow the academic careers of clinicians in The Netherlands, a national registry is needed to collect the type of data analysed in this study continually.

[Dutch medical specialists as authors of scientific publications in English on clinical drug research (1997/'03)]. / Nederlandse medisch specialisten als auteur van artikelen over klinisch geneesmiddelenonderzoek in engelstalige tijdschriften, 1997/'03.

OBJECTIVE: To determine the number and type of medical specialists in Dutch hospitals that were authors of scientific papers published in English in the field of clinical drug research in the period 1997/'03. DESIGN: Descriptive. METHOD: PubMed was searched for articles on clinical drug research published in February 1997-January 2003. (Co)authors were included if they were registered in the Geneeskundig Adresboek 2002-2003 (Medical Address Book 2002-2003) as a medical specialist working in a hospital. Hospitals were categorized as academic, non-academic teaching, general or non-affiliated. Journals were categorized by the type of published research: fundamental or biomedical, disease-specific, or specialty-specific. RESULTS: A total of 1776 articles in 426 journals were retrieved with at least 1 medical specialist listed as a (co)author. 1728 medical specialists were identified as authors, which represents 11% of the 16.065 registered medical specialists in The Netherlands. Most authors were involved in the nonsurgical specialties, primarily internist subspecialties, followed by paediatrics, cardiology, and neurology. The authors were employed in nearly all Dutch hospitals. The 1728 specialists had a total of 4952 authorships; 57% of the authors and 70% of the authorships came from academic hospitals. The average impact factor, the number of articles and the number ofauthorships were greatest in the disease-specific journal category. In the period 1997/'03 the number of authorships from non-academic teaching hospitals and general hospitals decreased, while the number of authorships from academic hospitals increased, particularly with regard to the number of co-authorships.

[A case of fraud in a neurological pharmaceutical clinical trial]. / Een geval van fraude bij farmaceutisch onderzoek in de neurologie.

This paper describes the laborious and lengthy path to clarification and disclosure in a case of fraud in a neurological pharmaceutical clinical trial in the Netherlands. A Dutch neurologist was suspected of irregularities within the context of the 'European stroke prevention study 2' (ESPS-2), a multicentre study into medicinal prophylaxis in patients who had suffered a stroke. The Netherlands Society of Neurology (NVN) established an independent inquiry committee for further investigation of the case. The identity of 425 of the 438 patients (97%) included in the trial by the neurologist could be retrieved. The majority of these patients were known to the neurologist with cerebral infarct. For a sample of 115 patients, the general practitioners (GPs) were contacted by means of a questionnaire. Ninety percent of the responding GPs were unaware of their patients' participation in the pharmaceutical clinical trial. A total of forty patients were asked by their GP about participation: 36 (90%; 95%-CI: 76-97) indicated that they had not participated in the trial, and 4 could not remember. The committee concluded that the neurologist had committed fraud, in the sense that he had used the names of existing patients without these patients actually being enrolled in the study. The report of the independent committee was not made public; the committee and the NVN board differed in opinion on the interpretation and implications of the agreements regarding this subject. Following prolonged legal action, the regional Disciplinary Board suspended the neurologist from practice for one year and the court of law sentenced him to 180 days imprisonment or a fee of 130,000 Euro. Based on the experience gained from this case, recommendations in case of suspicion of fraud are discussed, such as the timely appointment of an independent inquiry committee and the establishment of unambiguous agreements regarding the disclosure of the results of the investigation. Possible legal implications should be considered in advance by the organisations involved; statutes should provide regulations for procedural rules. In the Netherlands there now exists a National Body for Scientific Integrity and a committee for the Scientific Integrity of Healthcare Research to prevent scientific misconduct and to stimulate reporting and appropriate handling of this problem.

[Reporting of scientific misconduct in health care research]. / Melden van wetenschappelijk wangedrag in gezondheidsonderzoek.

The incidence of scientific dishonesty in the Netherlands is not known, yet experiences at both the NWO (the Netherlands Organization for Scientific Research) and Nederlands Tijdschrift voor Geneeskunde (Dutch Journal of Medicine) indicate that there must be several cases per year. For scientific fraud to be prevented students and researchers should receive thorough teaching, and in research laboratories an emphasis should be placed upon integrity. The Academic Medical Centre in Amsterdam has published a research protocol which is perfect for internal use. The Royal Netherlands Academy of Arts and Sciences publishes brochures on good research practice for researchers, teachers and students. The NWO and the Vereniging van Universiteiten (Dutch Association of Universities) have set up a committee for scientific integrity to function as a fallback mechanism and to assess the institutional procedures or to repeat the inquiries. As healthcare research institutions other than universities are involved since authorities are not always objective, an independent committee has been established to assess complaints about scientific dishonesty, the Scientific Integrity Health Research. Like the Committee on Publication Ethics it will publish its cases anonymously on an annual basis. Its judgments will be communicated to the people involved and the proper authorities.

[A comparative study of the expenditures on health research in 7 western countries in 1997 places the Netherlands at the bottom of the list]. / Vergelijking van de uitgaven aan gezondheidsonderzoek in 7 westerse landen in 1997: Nederland op de laatste plaats.

OBJECTIVE: To compare the expenditures on health research in the Netherlands with those in other Western countries. DESIGN: Descriptive. METHOD: The expenditures on health research in 1997 were determined for the Netherlands, the United Kingdom, Germany, Norway, Denmark, Sweden and the USA and subsequently classified into: governmental funding for research in medical faculties or clusters; grants from MHRCs and other bodies; and private funding from industry and charities. The sources of information were the total research budgets 2002 of the Dutch Ministry of Education, Culture and Science, annual reports from charities, the Dutch Central Statistical Bureau and, for foreign countries, MHRCs or comparable institutions. RESULTS: In 1997, the Netherlands spent the equivalent of 855 million US dollars on health research (extremes of the investigated countries: 382 (Norway)-32,283 (USA)). This was less than in the other countries, whether calculated per capita, in US dollars (55 (Netherlands)-159 (Sweden)), as a promillage of the gross national product (2.27 (Netherlands)-5.84 (Sweden)), or as a percentage of the total expenditures for health care (2.62 (Netherlands)-7.54 (UK)). Especially the industrial expenditures on health research in the Netherlands were low, but the governmental expenditures were also lower than in the other countries.

[Research proposals submitted to the Dutch Investigative Medicine Fund; evaluation of the scientific quality by the Council for Scientific Research (NWO)]. / Aanvragen Ontwikkelingsgeneeskunde: de beoordeling van de wetenschappelijke kwaliteit door de Nederlandse Organisatie voor Wetenschappelijk Onderzoek (NWO).

The Council for Medical and Health Research (MW-NWO) assessed the scientific quality of research proposals submitted to the Dutch Investigative Medicine Fund, and analysed if there had been changes over time in the proportion of proposals which the MW-NWO advised to reject, the role of reports of external reviewers and the most important methodological flaws. In the period 1995-1999 'reject' had been advised for an average of 50% of the proposals, with a tendency to a smaller proportion in recent years. In nearly half of the proposals the judgements of external reviewers were not in agreement with each other. There was only a weak correlation between the judgements of the reviewers and the final advice of NWO. Among the most important flaws mentioned in the NWO advice were: efficacy not proven (a prerequisite for the Fund), proposed study not needed to solve the policy problem and methodological flaws, e.g. design and power calculation not adequate, deficiencies of inclusion and exclusion criteria.

[The SGO Health Research Promotion Program. XIV. Final evaluation]. / Het stimuleringsprogramma Gezondheidsonderzoek (SGO). XIV. Eindevaluatie.

In the Netherlands, the SGO Health Research Promotion Programme was carried out from 1986 until 1997. The aim of the programme was to strengthen patient-oriented clinical research in specific fields of medicine. Some of the programme sections certainly produced a number of good publications in established national and international journals, but the programme advisory committee's main objective was to bring about a cultural change in the field of health care investigation: awareness of the principle that scientific and notably patient-centred investigation has a place in its own right in research, education and care. This resulted in a large diversity of methods of stimulation ranging from stimulation of co-operation between researchers, training of physician researchers, support of methodology development, stimulation of education and postgraduate training, to establishment of actual institutes for clinical scientific research. Patient-oriented research is the necessary link within the continuum of health research, medical education and care. Changing social and demographic developments ask for continuous innovation of this type of research. Top-down steering, as practised by the SGO, can be necessary and effective to reach this innovation.

[AGIKO (Clinical Research Fellow); a training model aimed at enhancement of clinical scientific research]. / 'Assistent-geneeskundige in opleiding tot klinisch onderzoeker' (AGIKO); opleidingsmodel ter versterking van klinisch-wetenschappelijk onderzoek door huisarts en specialist.

The enhancement of clinical scientific research in the Netherlands is being stimulated to a substantial extent by the introduction and stimulation of a training model aimed at the combined training of physicians to both a general practitioner or specialist and a clinical researcher, the AGIKO (Clinical Research Fellow). The model has been recognized by the Central College for Recognition and Registration of Medical Specialists. Extra stimulation by the section Medical Sciences of the Netherlands Organization for Scientific Research (MW-NWO) makes it possible to appoint AGIKOs on second or third flows of funds but also within the first flow of funds. During the last two years, 25 AGIKO applications from ten medical specialisms have been approved. The AGIKO model may help to meet (expected) needs for future clinical-medical research workers in specific research areas.

Different characteristics of ferrochelatase in cultured fibroblasts of erythropoietic protoporphyria patients and normal controls.

Ferrochelatase activity was measured in crude extracts of fibroblasts, obtained from erythropoietic protoporphyria patients and healthy controls. The enzyme activity in erythropoietic protoporphyria fibroblasts was about 50% lower, compared to the controls. The sulfhydryl-oxidising reagent diamide inhibited the normal enzyme by about 50%, whereas ferrochelatase from erythropoietic protoporphyria fibroblasts was completely insensitive to the reagent. Pb2+ inhibits ferrochelatase activity by reacting with essential sulfhydryl groups. Low concentrations of Pb2+ inhibited the normal enzyme by 56%, but the mutant enzyme by only 8%. The photodynamic activity of bound mesoporphyrin substrate caused a biphasic inactivation of the normal enzyme. During the first 5 min of illumination a fast decrease of enzyme activity occurred to about 60% of the initial value. Experimental evidence indicates that this first phase of inactivation is caused by photooxidation of sulfhydryl groups. During further illumination inactivation continued at a much slower rate. With ferrochelatase from erythropoietic protoporphyria fibroblasts only the second, slow phase of photodynamic inactivation was observed. These observations suggest a mutation of ferrochelatase in erythropoietic protoporphyria, affecting the reactivity of sulfhydryl groups, involved in the catalytic activity of the enzyme.

Exclusion of the dysplastic nevus syndrome (DNS) locus from the short arm of chromosome 1 by linkage studies in Dutch families.

Familial dysplastic nevus syndrome (DNS) is an autosomal dominant premalignant condition characterized by multiple large moles of variable size and color and a strongly increased risk for cutaneous malignant melanoma. In order to determine the chromosomal localization of the DNS gene, linkage studies were initiated in six large Dutch families. No support was obtained for linkage between the loci for DNS and the rhesus blood group on chromosome 1. Data from additional markers (DNF15S1, D1Z2, FUCA1, D1S17, D1S57, and PGM1) make it possible to exclude the DNS gene from the short arm of chromosome 1 in these Dutch families.

A Pro----Leu substitution in codon 369 of the alpha-1-antitrypsin deficiency variant PI MHeerlen.

The molecular defect has been elucidated in the alpha-1-antitrypsin (PI) gene of a patient with a serum level of only 5 mg/100 ml and a PI M-like phenotype, designated PI MHeerlen. The restriction fragment patterns obtained by probes covering the whole gene and flanking sequences were normal, suggesting no major rearrangements. The nucleotide sequence of the exons, intron/exon junctions, and a part of the promoter region is similar to that of a PI M1(Ala213) gene except for an C----T mutation in codon 369, causing a Pro----Leu substitution. Haplotype analysis and oligonucleotide hybridization studies demonstrated the homozygous state of the mutation in the index case. It is most likely that the Pro369----Leu substitution is responsible for the low serum alpha-1-antitrypsin concentration of the patient because this mutation is solely confined to the PI MHeerlen allele and no other relevant mutations could be revealed. As proline is important for the secondary and tertiary structure of proteins, the mutation may cause an abnormal processing of the nascent polypeptide. The same mutation was observed in two unrelated subjects known to carry a PI allele giving a low serum alpha-1-antitrypsin level.

Cloning and characterization of an alpha 1-antitrypsin like gene 12 KB downstream of the genuine alpha 1-antitrypsin gene.

Cosmid clones containing alpha 1-antitrypsin (alpha 1AT) gene sequences were observed to contain alpha 1AT-like sequences approximately 12 kb downstream of the authentic alpha 1AT gene. Restriction mapping suggested the alpha 1AT-like gene lacks promoter sequences. Cosmid clones from one library contained a truncated alpha 1AT-like gene with a deletion encompassing 1745 bp, including the whole exon IV and part of exon V. Sequencing of exon II of this truncated gene revealed a nucleotide homology of 76% but included critical mutations in the start codon (ATG - greater than ATA) and the 3' exon-intron junction. These results strongly suggest that the truncated alpha 1AT-like gene is a pseudogene, which is present at a frequency of 0.30 in the Dutch population.

Linkage studies in facioscapulohumeral muscular dystrophy.

Possible linkage between the locus for autosomal dominant facioscapulo-humeral muscular dystrophy and the locus for the constant region of the heavy chains of the IgG immunoglobulins (Gm) was tested in 1 kindred (23 affected and 18 unaffected sibs) using the polymorphic DNA probe D14S1, which is known to be closely linked with Gm. No linkage between the loci for the disease and the probe was found, and the lod scores suggested that the locus for facioscapulohumeral muscular dystrophy is not situated on the distal part of the long arm of chromosome 14.

Interactions among stimulated human polymorphonuclear leucocytes, released elastase and bronchial antileucoprotease.

1. We investigated the effect of stimulated human polymorphonuclear leucocytes (PMN's) on both the antitrypsin and anti-elastase activity of bronchial antileucoprotease (ALP). 2. Incubation of ALP with stimulated human PMN's resulted in a rapid loss of anti-elastase activity which paralleled that of the antitrypsin activity, suggesting that both inhibitor activities are represented by the same active site. 3. The myeloperoxidase-oxidizing system was found to be responsible for the inactivation of ALP. 4. The oxidized inhibitor was unable to form stable complexes with PMN elastase but was resistant to breakdown by proteolytic enzymes from stimulated PMN's. 5. It was observed that stimulated cells are capable of releasing elastase which shows full activity in the presence of a large molar excess of ALP. 6. We conclude from this study that stimulated PMN's are able to inactivate ALP by which released elastase is able to express enzymatic activity in spite of the presence of this low-molecular-weight inhibitor. Thus, inactivation of ALP by triggered PMN's may contribute to destructive processes in which elastase is thought to be a mediator.

The flaccid lung syndrome and alpha 1-protease inhibitor deficiency.

We examined breathing mechanics and alpha 1PI deficiency in 1,850 unrelated male subjects with various lung complaints. The loss in lung elasticity appeared to be significantly more pronounced in ZZ individuals as compared to MM, MS and also MZ individuals. The MZ group did not differ significantly in this respect from MM individuals. This implies that the excess risk of developing a flaccid lung (C greater than 1 kPa-1) due to the partial alpha 1-antitrypsin deficiency is negligible. PI MZ and PI ZZ frequencies are significantly higher in the population with flaccid lung compared to control subjects. Furthermore, it was found that the increase in residual volume in smokers is independent of the PI type.

Alpha-1-antitrypsin phenotypes and serum concentrations in duodenal ulcer patients in The Netherlands.

Hereditary alpha 1-antitrypsin (alpha 1-AT) deficiency has been suggested to be associated with peptic ulcer disease. Since the serum concentration of the enzyme is the result of both hereditary and nonhereditary factors, we have studied not only the serum levels but also the alpha 1-AT electrophoretic variants in 177 Dutch patients with duodenal ulcer disease and compared with 357 healthy blood donors. No relation was found between any of the alpha 1-antitrypsin phenotypes and duodenal ulcer disease. Serum levels of alpha 1-AT were significantly higher than in the controls in the patients. This study does not support an association between hereditary alpha 1-AT deficiency and duodenal ulcer disease, and makes therefore a possible role of such a deficiency in the etiology of peptic ulcer disease highly unlikely.

Rare apolipoprotein E variant cosegregating with a unique APOE-C1-C2 haplotype in a normolipidemic family.

The genes coding for the apolipoproteins E, C1 and C2 are clustered on the long arm of chromosome 19 in a region of approximately 45 kilobases (kb). In a normolipidemic individual, we detected a new apoE variant with an isoelectric point between that of E3 and E4. As this variant lacks cysteine residues and has probably arisen from an E*4 allele, it is designated E4*. To gain further insight into the origin of the mutation, the haplotypes of the propositus were extended by restriction fragment length polymorphism (RFLP) analysis of the family. The apoE variant cosegregates with the H2 allele of the HpaI polymorphism visualized with an APOE probe and with a new rare 4.5-kb fragment (T3) of the TaqI RFLP detectable with an APOC2 probe. As the propositus and the first-degree relatives with this unique haplotype are normolipidemic, this apoE variant does not seem to be associated with disturbances in the lipoprotein metabolism.

Apolipoprotein gene cluster on chromosome 19. Definite localization of the APOC2 gene and the polymorphic Hpa I site associated with type III hyperlipoproteinemia.

Recently, using an APOE cDNA probe, we discovered an Hpa I restriction fragment length polymorphism (RFLP) that appeared to be strongly associated with the expression of type III hyperlipoproteinemia (Klasen et al. 1987). In the present report it is shown that the same Hpa I RFLP can be revealed with both the APOC1 and APOC2 cDNA probes. This enabled us to localize the polymorphic Hpa I site between the APOE and APOC1 genes and to localize the APOC2 gene approximately 22 kb 3' of the APOC1 pseudogene on chromosome 19.