[Health advocacy in medical student education]. / Maatschappelijk betrokken in de artsenopleidingen.

The introduction of the CanMEDS method to qualify training and ongoing education for healthcare providers in terms of competencies has provided a clear framework for medical schools' curricula. Different roles are outlined, and one of these is health advocacy. Physicians are accountable to society to use their knowledge and expertise to improve health. Even before the introduction of CanMEDS, physicians took responsibility for improving health by tackling issues in society that negatively affected the health of many; one obvious example is the provision of clean water and sewage systems to prevent epidemics of infectious diseases such as cholera. The role of the health advocate is now addressed within medical education in graduate and postgraduate medical training curricula. If they are to be really effective, trainers should provide proper role models on how to be a health advocate; even though each doctor does not have to become a politician to change the world, all doctors should look further than the individual patient in their surgery.

[Being a supervisor demands other skills than being a doctor]. / Opleiden vraagt andere competenties dan dokteren.

Engagement with being a doctor is not an automatic qualification for being a good supervisor. But engagement with being a teacher is linked to a better evaluation as supervisor by trainees. Different personality traits are related to these different roles. Engagement is not only influenced by personality traits, however. The work environment can have a positive effect on engagement as well. If there are proper job resources that support the teacher's role, engagement with being a teacher will increase. In addition to proper teaching resources, supervisors also need training. It is important that supervisors get used to lifelong learning, just as doctors have to. Teaching competencies should be part of medical training. This might help to shape a working environment that is well equipped for teaching.

[Diversity and quality in medical training]. / Diversiteit en kwaliteit in de geneeskundestudie.

Ethnocultural diversity among medical students is important in order to guarantee a true reflection of society in the medical profession. It is known that students from ethnic minority groups perform less well in assessments during medical training. This is partly due to language problems but also to differences in culture. In order to keep these students in medical training, assessments should ideally be free of ethnocultural prejudice. Furthermore, it is important to ensure that there is no discrimination. To get a valid impression of these students it is important that multiple assessments be performed by several assessors. Then the real problems can be exposed and students from ethnic minority groups can get the support they need to become good physicians.

[Peer feedback for trainers in general practice]. / 'Peer feedback' voor huisartsopleiders.

In medical specialist training programmes it is common practice for residents to provide feedback to their medical trainers. The problem is that due to its anonymous nature, the feedback often lacks the specificity necessary to improve the performance of trainers. If anonymity is to be abolished, there is a need for residents to feel safe in giving their feedback. Another way to improve the performance of trainers might be peer feedback. For peer feedback it is necessary that trainers observe each other during their training sessions with the residents. In speciality training in general practice peer feedback is done in group sessions of 12 trainers. They show videos of their training sessions and get feedback from their fellow trainers. Trainers also visit each other in their practices to observe training sessions and provide feedback. In order to improve trainer performance there is a need for more focus on peer feedback in medical specialist training programmes.

[Diagnostic delay of pulmonary embolism]. / Diagnostische delay bij longembolie.

OBJECTIVE: To quantify the different stages of diagnostic delay of pulmonary embolism (PE) in patients and to identify other clinical factors associated with this delay. DESIGN: Case series. METHOD: Medical records were reviewed for all patients diagnosed with PE in the period 1 January 2008 and 31 December 2009 in Isala Hospital in Zwolle (the Netherlands), and data was collated for: the dates of symptom onset, presentation to a GP, referral to secondary care, and diagnosis respectively. The relationship between diagnostic delay and other clinical parameters such as gender, age, risk factors, symptoms and co-morbidities was tested using multivariate logistic regression analysis. RESULTS: For the 261 patients included in the analysis, the average total delay was 8.6 days. Patient delay (4.2 days average) and delay in primary care (3.9 days) were the major contributors to this delay. Chest pain and symptoms of deep venous thrombosis were associated with an early diagnosis. Patient delay was shorter in patients with chest pain and longer in patients with dyspnoea. In primary care, chest pain and rales were associated with an early referral, whereas the presence of co-morbidity led to a delayed referral. Delay in secondary care was shorter when the patient presented with dyspnoea. CONCLUSION: The diagnostic delay of PE is substantial, especially patient delay and delays originating in primary care. Further research is needed to identify clinical factors that raise suspicion of PE in primary care, to aid the development of improved diagnostic models.

Association between group A beta-haemolytic streptococci and vulvovaginitis in adult women: a case-control study.

Guidelines for the management of vaginal discharge mention Candida albicans, Trichomonas vaginalis, bacterial vaginosis, Chlamydia trachomatis and Neisseria gonorrhoeae as causes and do not recommend full microbiological culture. The role of non-group B beta-haemolytic streptococci in vaginal cultures is unclear, except for group A streptococci that are known to cause vulvovaginitis in children. In a case-control study, we investigated the association between non-group B beta-haemolytic streptococci and vulvovaginitis in adult women. Cases were women with recurrent vaginal discharge from whom a sample was cultured. Controls were asymptomatic women who consented to submitting a vaginal swab. Group A streptococci were isolated from 49 (4.9%) of 1,010 cases and not from the 206 controls (P < 0.01). Isolation rates of group C, F and G streptococci were low and did not differ statistically between cases and controls. Group A beta-haemolytic streptococci are associated with vaginal discharge in adult women. The other non-group B streptococci require more study. For the adequate management of vaginal discharge, culturing is necessary if initial treatment fails. Guidelines should be amended according to these results.

[Should antibiotics be used for acute rhinosinusitis? The argument is not yet settled]. / Wel of geen antibiotica voor acute rinosinusitis: her pleit nog niet beslecht.

Antibiotics have little effect on acute rhinosinusitis in primary care. This was recently confirmed by a meta-analysis with individual patient data. These findings do not represent the final decision concerning the treatment of acute rhinosinusitis in primary care. In 1996 it was shown that antibiotic treatment had a considerable effect on acute rhinosinusitis diagnosed by CT scan in primary care. Although CT-scan will never become a diagnostic tool in daily practice, this study showed that there may be a subgroup of patients with acute rhinosinusitis that does benefit from antibiotic treatment. A return to diagnostic research in a large group of patients should be the next step to find this subgroup. In order to develop a diagnostic model, CT scans, sinus puncture, C-reactive protein and procalcitonin measurements and bacterial cultures should be performed and data on clinical signs and symptoms should be collected.

Pneumococcal vaccines for preventing otitis media.

BACKGROUND: Acute otitis media (AOM) is one of the most common diseases in early infancy and childhood. Long term effects of recurrent episodes of otitis media, rapid emergence of drug resistant bacteria associated with AOM worldwide and huge estimated direct and indirect annual costs associated with otitis media have emphasized the need for an effective vaccination program to prevent episodes of AOM. OBJECTIVES: The object of this review was to assess the effect of pneumococcal vaccination in preventing AOM in children up to 12 years of age. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (issue 2, 2003) which contains the Cochrane Acute Respiratory Infection Group's specialised register (30th June 2003), MEDLINE (January 1966 to June 2003), EMBASE (January 1990 to June 2003) and reference lists of all studies and review articles retrieved. We also contacted two vaccine manufacturers and first or corresponding authors of some of the included studies. SELECTION CRITERIA: Randomised controlled clinical trials of pneumococcal vaccination with prevention of AOM as outcome in children aged 12 years or younger and a follow-up of at least six months after vaccination. DATA COLLECTION AND ANALYSIS: Five reviewers independently assessed trial quality and two reviewers extracted data. Two study authors were contacted. MAIN RESULTS: Eight trials on 8-to 14-valent pneumococcal polysaccharide vaccine (PPV) and four trials on 7-to 9-valent pneumococcal conjugate vaccine (PCV) were included. The highest efficacy of PPV was found in children aged 24 months and older: the rate ratio was 0.779 [95% CI: 0.625-0.970]. PPV has little effect on the prevention of AOM in children without documented prior episodes of AOM and only a moderate effect in the group of children with documented AOM episodes prior to vaccination. Pooled results of the four PCV trials in infants vaccinated as early as two months of age and toddlers attending daycare and toddlers with recurrent AOM showed only a small effect on prevention of AOM (rate ratio 0.921; 95% CI: 0.894-0.950). REVIEWER'S CONCLUSIONS: Based on the currently available results of the effectiveness of pneumococcal vaccination for the prevention of AOM, a large scale use of pneumococcal polysaccharide and conjugate vaccination for this specific indication is not yet recommended. So far, pneumococcal conjugate vaccinations are not indicated in the management of recurrent AOM in toddlers and older children. The results of currently ongoing trials of 9- and 11-valent conjugate vaccines should provide more information as to whether pneumococcal vaccines are more effective in specific high-risk populations like infants and older children with recurrent AOM or immunodeficiency.