Use of 360-degree assessment of residents in internal medicine in a Danish setting: a feasibility study.

BACKGROUND: The aim of the study was to explore the feasibility of 360 degree assessment in early specialist training in a Danish setting. Present Danish postgraduate training requires assessment of specific learning objectives. Residency in Internal Medicine was chosen for the study. It has 65 learning objectives to be assessed. We considered 22 of these suitable for assessment by 360-degrees assessment. METHODS: Medical departments of six hospitals contributed 42 interns to the study. Each resident was assessed by ten persons of whom one was a secretary, four were nurses and five senior doctors. The assessors spent 14.5 minutes (median) to fill in the forms. RESULTS: Of the 22 chosen objectives, 15 could reliably be assessed by doctors, 7 by nurses and none by secretaries. CONCLUSIONS: The method was practical in busy clinical departments and was well accepted by the assessors. Reliability of the method was acceptable. It discrimintated satisfactorily between the good and not so good performers.

Correlations between insulin sensitivity and bone mineral density in non-diabetic men.

AIMS: To investigate relationships between bone mineral density (BMD), insulin secretion and insulin sensitivity, controlling for body composition, in view of data suggesting that hyperglycaemia [corrected] leads to decreased osteoblast proliferation and a negative calcium balance and that insulin stimulates osteoblast differentiation and collagen synthesis, with no clear evidence if this response in impaired in insulin resistance. METHODS: Femur and whole body (WB) BMD was measured in 55 male patients with ischaemic heart disease and 40 healthy men, using a Hologic QDR-2000 densitometer. Insulin sensitivity (Si) was estimated as the rate of glucose disappearance divided by the area under the insulin curve during an intravenous glucose tolerance test. RESULTS: Insulin and C-peptide levels were not correlated with BMD, but Si was a significant predictor of femur (log, r = 0.35) and WB BMD (log r = 0.29, both P<0.01), even after controlling for weight and age. Fat mass (FM) was a predictor of BMD (femur: r = 0.33 P<0.01, WB: r = 0.43 P<0.001). In the femur the association with FM disappeared when log(Si) was entered in the regression. Lean body mass (LBM) contributed significantly to BMD (r = 0.50 and r = 0.66, both P<0.001). CONCLUSIONS: These results are compatible with a direct influence of lean body mass on bone, while the impact of fat mass may consist of insulin resistance with increased insulin exposure of bone. It is hypothesized that patients with insulin resistance in the metabolic pathway do not exhibit resistance to the skeletal actions of insulin.

Dyslipidemia and coronary artery disease. Prevalence and treatment in patients referred for coronary arteriography.

UNLABELLED: A reduction in serum total cholesterol (T-C) levels has been shown to reduce mortality in patients with coronary artery disease and to decrease the need for revascularization. To examine the prevalence and treatment of lipid disorders in patients referred for their first coronary angiogram, medical history and fasting blood samples were collected in 108 consecutive patients. Ninety-one patients (84.3%) fulfilled the criteria for dyslipidemia. Hypercholesterolemia had previously been demonstrated in 53 patients (49.1%), and 34 (64.2%) of these patients still had T-C > 6.0 mmol/l at the time of admission. Among 55 patients who were unaware of any lipid disorders at admission, 28 (50.9%) had T-C > 6.0 mmol/l. CONCLUSION: The majority of patients referred for their first coronary angiogram and possible revascularization suffered from dyslipidemia. Many patients with previously recognized dyslipidemia were insufficiently treated.

Nickel patch test reactivity and the menstrual cycle.

Premenstrual exacerbation of allergic contact dermatitis and varying allergic patch test responses have been reported at different points of the period. Using a dilution series of nickel sulphate, we studied the variation in patch test reactivity in nickel allergic women in relation to the menstrual cycle. Twenty women with regular periods were tested on day 7-10 and on day 20-24. Ten nickel patch tests with different concentrations were applied using the TRUE test assay, and the threshold concentration of nickel sulphate eliciting an erythematous reaction was determined. Half of the women were tested first on day 7-10 and the other half first on day 20-24. There was no difference in the degree of patch test reactivity, when the results from day 7-10 and day 20-24 were compared (p > 0.4). However, when we compared the patch test results from the first and second test procedure, we found an increased nickel sensitivity at the second patch test (0.02 < p < 0.05), suggesting a booster effect from the first patch test procedure. In conclusion, we could not demonstrate an increased sensitivity to nickel sulphate patch tests premenstrually in 20 nickel allergic women, but we found that elicitation of positive patch tests led to an increased skin reactivity towards the same allergen, when the patients were retested weeks later.

The basis for common reference intervals for serum potassium.

In order to investigate the relevance of the currently used lower reference limit for S-Potassium in Danish hospital laboratories, analytical bias in the measurement of S-Potassium was compared with the lower reference limit in each of 52 Danish hospital laboratories. The acceptable bias range was estimated according to Gowans et al on the basis of the result of two different reference sample groups. The estimated acceptable 0.95 bias range was 0.24 mmol/L, so the observed bias range of 0.23 mmol/L was within this limit. As all preanalytical errors tend to increase the measured S-Potassium, all acceptable bias should be in the direction of decreasing the measured value. It can be concluded that analytical performance allows for more uniform (even common) reference interval(s) in all Danish and perhaps Nordic hospital laboratories, provided that preanalytical errors can be controlled.

Reference intervals based on hospitalized 'healthy' patients and medical students in relation to analytical bias for serum potassium.

The reliability of reference intervals for measurements of serum (S)-potassium in Danish hospital laboratories was investigated (i) by estimation of reference interval based on two different, healthy subpopulations and (ii) by comparison of reference intervals for S-potassium with analytical bias in each of 52 Danish laboratories. (i) The reference values from 227 hospitalized 'healthy' patients were obtained during the period 1979 to 1987 from the first-drawn serum specimen from the hospitalized patients, who were later discharged from the hospital without a diagnosis. The estimated 0.95 reference interval was 3.34 to 4.52 mmol l-1. The other reference sample group consisted of 314 medical students from whom blood was collected in the period from 1983 to 1987. Here the estimated reference interval was from 3.44 to 4.53 mmol l-1. The concentration values from both reference sample groups were corrected for analytical bias (+0.05 mmol l-1). (ii) The 52 Danish laboratories revealed a considerable variability in reference intervals which, regarding the lower reference limit, ranged from 3.2 to 3.7 mmol l-1 in strong contrast to the analytical bias (ranging from -0.08 to +0.15 mmol l-1) in 50 laboratories (two outliers). There was no relationship between lower reference limit and analytical bias in the individual laboratories. It is concluded that analytical performance allows for more uniform (even common) reference intervals throughout the Danish and perhaps Nordic hospital laboratories.

Nickel contact sensitivity in the guinea pig. An efficient open application test method.

Nickel contact sensitivity was successfully induced in guinea pigs using an open epicutaneous application method. Immediately after pretreatment with 1% aqueous sodium lauryl sulfate, upper back skin was treated daily for 4 weeks with 0.3%-3% nickel sulfate in either a 1% lanolin cream (Vaseline, pH 5 SAD crème) or hydroxypropyl cellulose. Weekly intradermal injections with aluminium potassium sulfate were used as adjuvant. The animals were challenged twice with a one week interval, with nickel sulfate 2% in water and 1% in petrolatum, respectively. The response rates in the test groups treated with nickel sulfate 1% or 3% in the lanolin cream or 1% in hydroxypropyl cellulose were significantly different from the response rate in the control group. Considering both readings at both challenges, the frequency of sensitization was 57-93% (8 of 14 to 13 of 14 animals) in the group treated with 1% in the lanolin cream, 60-100% (9/15 to 15/15 animals) in the group treated with 3% in the lanolin cream, and 67-75% (8/12 to 9/12 animals) in the group treated with 1% in hydroxypropyl cellulose. Rechallenge of initially sensitized animals 10 weeks later confirmed that a lasting contact allergy had been obtained.

Nickel-sulphate-induced contact dermatitis in the guinea pig maximization test: a dose-response study.

Nickel sulphate is a sensitizer in guinea pigs, but the frequency of sensitization varies from study to study. The dose-response relationship for NiSO4.6H2O was evaluated in the guinea pig maximization test in this study. 6 intradermal (0.01%-3.0% aq.) and 6 topical (0.25%-10.0% pet.) concentrations were chosen for induction and NiSO4.6H2O 1% pet. was used for challenge, based on the absence of skin irritation in a pilot study. Blind reading was performed. A logistic dose-response model was applied to the challenge results. At 48 h, a linear relationship was obtained between the intradermal induction dose (but not topical dose) and the response, resulting in a maximum sensitization rate of 40% after 3% i.d. The reactivity disappeared at re-challenge 1 week later. Following a booster closed patch on day 35, using NiSO4 10% pet., the animals were challenged with NiSO4 2% pet. and statistical analyses of 72-h readings revealed a non-linear dose-response relationship, giving a maximum response frequency of 40% after initial induction with NiSO4 3% i.d. and 2% topical.

Pachyonychia congenita: therapeutic and immunologic aspects.

A 4-year-old girl with pachyonychia congenita was followed from birth. During childhood, slow progression of the nail hypertrophy was seen because she was not willing to have the nails ground or cut. After grinding of her nails under general anesthesia, the child has had acceptable nail thickness, and continued regular grinding without anesthesia. The child had recurrent oral and cutaneous candidiasis. Investigations showed a weakly positive response to Candida albicans in the lymphocyte transformation test, and absence of a delayed hypersensitivity skin test response to Candida. The secondary infection due to Candida seemed to prevail because of an immune defect.

Hypotension during exercise caused by venodilatation.

A 54-year-old woman without organic heart disease presented with presyncopal symptoms during work. A decreased cardiac output was demonstrated by haemodynamic measurements during exercise. Treatment with fludrocortisone and ephedrine was initiated with a good haemodynamic and symptomatic result.

[Fatal thrombocytopenia triggered by quinidine]. / Kinidinudløst trombocytopeni med letalt forløb.

A woman aged 60 years receiving anticoagulation treatment on account of artificial mitral and aortic valve prostheses developed severe thrombocytopenia three weeks after the commencement of quinidine treatment. The results of investigations suggested severe thrombocytopenia precipitated by quinidine. The severe thrombocytopenia persisted despite intensive treatment and the condition ended fatally on account of cerebral haemorrhage. The combination of quinidine and oral anticoagulation treatment is not unusual and it is important to bear in mind that both of these preparations may cause increased haemorrhagic tendencies.

[The effect of beta blockers combined with thiazides on serum electrolytes]. / Virkningen af beta-blokkere kombineret med tiazider på serumelektrolytter.

The case reports of a total of 9,670 patients admitted to a medical department were reviewed manually. From this material, all patients receiving treatment with beta-blockers alone, bendroflumethiazide alone or combinations of these were selected. In addition, a control group was selected. The patients should have received treatment for at least seven days and they should not be "ill". Patients receiving treatment with beta-blockers had higher S-K+ (4.2 mmol/l) and lower standard bicarbonate levels (23 mmol/l) than matched controls. Patients receiving treatment with bendroflumethiazide had low S-K+ (3.6 mmol/l) and high standard bicarbonate (26 mmol/l). Patients receiving treatment with both bendroflumethiazide and beta-blocker had low S-K+ (3.4 mmol/l) and the same standard bicarbonate as patients who received bendroflumethiazide alone. A more limited group chosen according to stricter criteria confirmed the above mentioned results. The investigation demonstrated that treatment with both beta-blocker and bendroflumethiazide caused deterioration of the hypokalaemia induced by bendroflumethiazide despite the higher S-K+ during beta-blockade. This may be due to renal excretion of potassium during beta-blockade.

[Cauda equina syndrome developing during anticoagulant therapy]. / Cauda equina syndrom under antikoagulationsbehandling.

A woman aged 70 years with rheumatic heart disease developed the cauda equina syndrome (CES) seven days after commencement of anticoagulation therapy. Investigation suggested an intraspinal haematoma with subarachnoid haemorrhage. The patient was considered to be inoperable. The untreated CES resulted in permanent neurological deficits.