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It is important that junior doctors in training conduct research for a number of years, culminating in a PhD. This is crucial to their development as critical and versatile doctors, which is exactly what is required now, in 2014. Hospitals are keen to have doctors with a broad education, and conducting scientific research is an enrichment for the investigators themselves. It is not necessarily undesirable that they do this principally to increase their chances of trainee posts; even those who have almost completed a PhD can be rejected for trainee positions if they do not seem to be competent.

We describe the course of two complaints that were filed by patients to the Dutch Medical Disciplinary Board against two internal medicine residents. In the procedure following the complaints the supervisor and the teacher were actively involved, which resulted in one complaint being dropped. We describe the importance of adequate moral support in such cases, as the complaint may lead to loss of work satisfaction or self-esteem, especially for those in training. We make some recommendations on how the resident and the supervisor/head of the department should engage in complaints filed to the Medical Disciplinary Board. In addition, we suggest that routine 'error-meetings' may help to provide an open atmosphere where disclosure of errors and the various procedures at the hospital or disciplinary boards are promoted.

Weight loss is recommended for overweight or obese patients with type 2 diabetes on the basis of short-term studies, but the long-term effects of weight loss on cardiovascular disease are unknown. The recently published Look AHEAD (Action for health in diabetes) study investigated the 10-year effect of an intensive lifestyle intervention designed to achieve weight loss on cardiovascular morbidity and mortality among overweight or obese adults with type 2 diabetes. In this commentary, we discuss the results and clinical implications of this study.

The Dutch legislator has adopted the point of view that people with diabetes and hypoglycaemia unawareness are unfit for driving a motor vehicle because hypoglycaemia unawareness carries with it an unacceptable risk for traffic accidents. There is no legal obligation for people in possession of a driving license to report changes to their state of health such as the appearance of hypoglycaemia unawareness. We argue that patients with newly diagnosed diabetes should inform the Driving Test Organisation about changes to their health status for moral reasons, and for reasons of judicial liability. This subject should be included in patient education, as should be strategies to minimise the risk of hypoglycaemia. In exceptional cases, the physician may opt to breech medical confidentiality and report the presence of hypoglycaemia unawareness in order to avert immediate, severe danger.

Here we describe two patients attending the internal medicine out-patient clinic. The first patient, a 43-year-old male, consulted a resident in internal medicine with irritable bowel syndrome and complications a year after surgery. The second patient, a 39-year-old female, was referred with medically unexplained symptoms. No treatable cause was found for either of these patients, and the encounters were unsatisfying for both the patient and the physician. According to the literature, 1 in 6 medical encounters is labelled as 'difficult' by the physician. Patients with medically unexplained or psychiatric disorders are frequently labelled as difficult, and young and inexperienced doctors more often report encounters as difficult. These difficult encounters have a negative influence on patients' satisfaction and physicians who experience many of their patients as difficult are more likely to experience burnout. More training in communication skills and psychosocial medicine may be helpful in reducing the number of difficult encounters.

The treatment of diabetes mellitus is focused on the prevention of micro- and macrovascular complications. The target HbA(1c) should therefore be 7% or lower. However, a recent study advised a HbA(1c) of 7.5%, since it was found that mortality increased with an HbA(1c) below 7.5%. This was probably caused by hypoglycaemia. A higher mortality in patients with a low HbA(1c) has been described before, but the causes were never understood. It is true that a lower HbA(1c) leads to more hypoglycaemia, but there are no indications that this is the cause of the increased mortality. Changing the target HbA(1c) based on one epidemiological retrospective study is unwise. Taking into account historic prospective studies such as the United Kingdom Prospective Diabetes Study, we think the target HbA(1c) should remain 7% or lower in the treatment of diabetes mellitus.

In-hospital adult cardiopulmonary resuscitation is successful in only approximately 20% of cases and may result in permanent neurological damage. Two reasons justify not commencing resuscitation: either the patient does not want to be resuscitated, or resuscitation is considered medically futile by the doctor. This subject should be discussed timely with all chronically ill patients who are likely to be admitted to hospital, preferably in the outpatient clinic setting, and results must be communicated with all doctors involved (e.g. general practitioners). Here we describe 3 cases that demonstrate the need to discuss possible restrictions on cardiopulmonary resuscitation with all chronically ill patients, regardless of their age. The first was a 45-year-old HIV-positive male with chronic clinical depression who refused ICU care, the second a 75-year-old patient whose initial 'do no resuscitate' order was reversed based on the wishes of her daughter and the third a 45-year-old female with sickle cell disease who expressed a sustained wish not to be treated in the ICU or to be resuscitated.

Patients demand that their doctors receive regular certification, just like the pilots of the aircrafts they travel on. There are many arguments against regular certification: having the correct attitude and other skills are far more important than knowledge; immediate knowledge is not necessary because doctors can easily look up the knowledge they need; continuing education renders regular certification unnecessary; it is impossible to put together the right exams for doctors. This article argues that the right attitude can never be a substitute for knowledge, that immediate knowledge is essential in treating acute illnesses in busy departments, that continuing education is no guarantee that knowledge has been acquired at all and finally that it obviously should be possible, albeit difficult, to formulate suitable questions for regular doctors' exams.

Objective: To investigate the relation between diabetes and food consumption on a population level., Design: Retrospective, descriptive., Method: Data were collected from the archives of the Public Health Service of Amsterdam and the diabetes aftercare outpatient clinic ('Diabetes Nazorg') in Utrecht, the Netherlands, to determine the incidence of diabetes between 1940 and 1950. The number of outpatient visits for newly-diagnosed diabetes in Amsterdam and Utrecht were used to investigate whether the incidence of diabetes decreased during World War II, when food was scarce., Results: Between 1940 and 1945 there was a considerable decrease in the incidence of diabetes in the Netherlands. The number of outpatient consultations at the Public Health Service of Amsterdam for newly-diagnosed diabetes declined from 140 in 1940 (18% of the total number of consultations) to only 3 in 1940 (2%). This figure rose to 112 (21%) in 1949., Conclusion: The marked decrease in the number of new cases of diabetes during the last years ofWorld War II supports the hypothesis that shortage of food induced a decrease in the incidence of type 2 diabetes in The Netherlands.

The excess mortality in the group of intensively treated patients in the 'Action to control cardiovascular risk in diabetes' (ACCORD) study casts doubts on the safety ofglycated haemoglobin (HbA(1C)) levels below 7%. However, comparison of the ACCORD study with the 'Action in diabetes and vascular disease: preterax and diamicron-MR controlled evaluation' (ADVANCE) trial, which showed no excess mortality, indicates that not a low HbA(1C) level per se, but the method by which it was achieved, was responsible for the adverse outcome. Although no specific cause was identified, the excessive use of rosiglitazone, and the combination of up to 5 glucose-lowering drugs, most strikingly distinguishes the ACCORD study from other studies. Thus, the data from ACCORD added to previously voiced concerns about the safety of rosiglitazone and polypharmacy. Several large studies have failed to prove that improved glycaemic control reduces macrovascular events. However, the beneficial effects on microvascular events are undisputed. Thus, the benefits of HbA(1C) levels below 7% should be weighed against the risks of 'modern' polypharmacy.

Recently, it was observed that rosiglitazone increased the risk of myocardial infarction. The American Food and Drug Administration therefore issued a safety alert. The practice guideline 'Diabetes mellitus type 2' of the Dutch College of General Practitioners only leaves room for the use of another thiazolidinedione, pioglitazone, and even that advice has been questioned. The new information on the serious adverse effects of rosiglitazone may further reduce the willingness to prescribe this drug for patients with type 2 diabetes.

Patients who are admitted to an intensive care unit for 3 days or longer have an increased survival rate if their blood-glucose levels are strictly controlled by means of intensive insulin therapy. This is true of patients admitted for either surgical or non-surgical indications. For patients undergoing cardiac surgery, strict peri- and postoperative glycaemic control lowers the postoperative complication rate and possibly also mortality. Patients suffering from an acute myocardial infarction, and possibly also patients with acute ischaemic stroke, are likely to benefit from strict glycaemic control. The value of treating hyperglycaemia in other patient groups has not been established. The workload on the nursing staff and the risk of prolonged and serious hypoglycaemia are the most important disadvantages of strict glycaemic control. The optimal duration of strict glycaemic control and the precise target range are not well defined and may well differ per patient group.

A 39-year-old woman with type-2 diabetes mellitus presented with metabolic acidosis due to an attempted suicide with metformin. Despite treatment with activated charcoal and laxation, she experienced cardiac arrest, which required resuscitation. After transfer to another hospital, she was treated with high-volume continuous venovenous haemofiltration. However, she died due to multiple organ failure. Metformin is the most widely used oral antidiabetic agent in the world and the first-choice treatment for patients with type-2 diabetes mellitus. Metformin overdose can cause lactic acidosis, which usually manifests as abdominal pain, vomiting and diarrhoea. Although rare, metformin-associated lactic acidosis carries a high mortality risk. The treatment of choice is immediate haemodialysis and orally administered activated charcoal. If a patient treated with metformin presents with metabolic acidosis, lactic acidosis due to metformin overdose should be suspected and appropriate treatment should be initiated immediately.

In three patients, aged 79, 58 and 59 years, respectively, iron-deficiency anaemia (IDA) was diagnosed. All three had a right-sided colonic adenocarcinoma. In the first patient, a cardiologic cause was looked for instead of a simple laboratory investigation of the anaemia. The second patient received iron supplementation without sufficient diagnostic evaluation, and in the third patient the abdominal X-ray was inadequate for evaluation of the ascending colon; moreover, she responded well to iron supplementation therapy. IDA is a common problem in clinical practice that may have various causes. In the Netherlands, gastrointestinal bleeding is the major cause of IDA in men and women over 50 years of age. The three patients described illustrate that IDA should be considered a clinical sign. An accurate evaluation of the IDA to detect a convincing explanation is therefore necessary. Various causes can be found on duodenoscopy and colonoscopy, e.g. neoplasms, ulcers, angiodysplasia or polyps. Carcinoma of the ascending colon is a frequent cause of IDA, especially in those over 50 years of age and without upper gastrointestinal symptoms. Evaluation to exclude a right-sided carcinoma of the colon has a high priority in these cases.

Concurrent with the increasing incidence of diabetes mellitus, the incidence of diabetic retinopathy is also rising. Timely recognition with the aid of screening, followed by laser therapy, can prevent the greater part of the resulting visual impairment and blindness. However, many patients with diabetes are not screened or not screened adequately. The necessary screening frequency is annually or biannually, depending on the degree of retinopathy and the presence of risk factors, of which glycaemic control, duration of diabetes, blood pressure, lipid profile, and race are the most important. Digital 2-field fundus photography, preferably in mydriasis, is of sufficient quality for routine screening. The impact of screening programmes can be further improved by applying the optimal method and by initiating an active implementation strategy.

The revised guideline 'Diabetes mellitus type 2' contains several improvements. The HbA1C target level has been lowered to 7% or less. The universal first step in oral therapy has become metformin. The target level for the treatment of hypertension is now a systolic pressure below 140 mmHg. Statins should be prescribed to almost every patient. Finally, ACE-inhibitors are now suggested for all patients with microalbuminuria and hypertension. Some choices made in the present guideline are not evidence-based, e.g. the advice to prescribe pioglitazone to patients with both a body mass index above 27 kg/m2 and cardiovascular disease, but without heart failure. Still, in general, the updated guideline is an important document which has been greatly improved in comparison to the former one.

The number of indications for the medical use of melatonin is slowly increasing. Melatonin is produced by the pineal gland and is a key signal in the circadian rhythm of the body. Melatonin plays an obvious role in the pathophysiology and treatment of sleep disorders and jetlag. Recent research has also demonstrated its favourable effect on blood-pressure regulation. By analogy, melatonin may play a role in a variety of other circadian processes. However, research into the precise effects is still insufficient.

The PROactive study was a multicentre, multinational, double-blind, placebo-controlled randomised trial that was intended to show a benefit of pioglitazone in the secondary prevention of cardiovascular disease in patients with diabetes. However, the result for the primary composite endpoint was not significant. The most important secondary endpoint (time to death, myocardial infarction or cerebrovascular accident) did show a significant reduction of 16%, but any potential benefit was outweighed by a major increase in the incidence ofhospitalisation for heart failure in the pioglitazone-treated group. Moreover, in this secondary prevention trial, there was marked undertreatment with statins while no effect of pioglitazone was observed in those who did receive a statin. Finally, no adjustment was made for the poorer glycaemic control in the placebo group. Based on these data, broadening the indication for pioglitazone in patients with diabetes cannot be recommended.

Vitamin B12 (cobalamin) deficiency is a common disorder with potential irreversible haematological and neurological consequences. Currently used diagnostic tests such as the evaluation of serum vitamin B12 and the Schilling test are insufficient, e.g. the positive predictive value of a low serum vitamin B12 level for actual vitamin B12 deficiency (i.e. tissue deficiency) is low. Insufficient availability of vitamin B12 will lead to the accumulation of methylmalonic acid and homocysteine in the body. Nearly all patients with vitamin B12 deficiency also have substantially increased levels of methylmalonic acid and homocysteine. New tests of serum methylmalonic acid and homocysteine are highly sensitive for vitamin B12 deficiency and may obviate the need for the somewhat cumbersome Schilling test.

Continuous subcutaneous insulin infusion (CSII) was initiated in 3 patients with diabetes mellitus type I who experienced difficulties with their glucose regulation: a woman aged 26 years and two men aged 56 and 41 years. 2 patients responded very well, while the third, the youngest man, did not benefit. Although interest in CSII has been growing in recent years, considerable uncertainty exists about which patients will benefit from it. In most studies, patients have attained a lower HbA,, and fewer blood glucose fluctuations. Recently, the advantages of CSII have been confirmed in 2 large studies in patients with diabetes mellitus type I. Motivated patients in poor glycaemic control seem to benefit most from CSII. Some questions remain, especially whether these advantages can be confirmed in studies comparing CSII with injection regimens using the new long-acting insulin analogues. Motivated patients in poor control and those with an unpredictable daily life, needing a flexible mode of therapy, should not be denied a trial of CSII.

In the last few years short-acting insulin analogs have become increasingly popular. Their introduction has unmasked serious deficiencies in the capacity of isophane insulin to provide a stable basal insulinaemia. The long-acting insulin analogs, insulin glargine and insulin detemir, have been developed as alternatives to isophane insulin. Insulin glargine has a long duration of action and has demonstrated its usefulness in diabetes type 2, specifically a lower incidence of (nocturnal) hypoglycaemia compared to isophane insulin, in clinical practice. Insulin detemir has a very low variability in absorption and also seems to reduce the risk of nocturnal hypoglycaemia in diabetes type 1. More studies are, however, needed. Because of the higher costs of these novel insulins, the decision to switch a patient from isophane insulin to an insulin analog has to be made on an individual basis.

In three patients with an unusual presentation of diabetes mellitus, the classification of their diabetes was troublesome. An adolescent male with slightly elevated blood-glucose levels turned out to have excellent glycaemic control on sulphonylurea derivatives only. When he was 40 years of age, his diabetes was finally diagnosed as 'maturity onset diabetes of the young' (MODY). A non-obese 41-year-old man was initially diagnosed with type-2 diabetes. Therapy with oral hypoglycaemic agents was unsuccessful and he was subsequently classified as having 'latent autoimmune diabetes of adults' (LADA) based on the presence of antibodies against glutaminic acid decarboxylase. A 29-year-old man presented with severe ketoacidosis and was initially believed to have type-1 diabetes. The patient himself discontinued insulin therapy and he was eventually diagnosed as having type-2 diabetes. A careful classification may have clinical consequences. Patients with MODY3, for example, respond to sulphonylurea derivatives. In MODY2, treatment with diet alone is often sufficient. In patients with LADA, insulin therapy is the treatment of choice. The recognition of diabetes mellitus type 2 as the underlying illness in some patients who present with ketoacidosis means that these patients can be specifically treated for their basic problem, which is insulin resistance. For them, weight reduction is essential and metformin is the drug of choice as far as pharmacotherapy is concerned, but of course attention must also be given to cardiovascular risk factors such as hypertension and dyslipidaemia.

Funduscopic examination according to the classification of Keith, Wagener and Barker has been used since 1939 to assess retinal damage in patients with hypertension. Improved treatment possibilities and the screening of patients with hypertension seem to have led to a decrease in the incidence and severity of the retinal abnormalities found. The following findings have been published during the past ten years. The assessment of retinopathy is subject to a large interobserver-variability, especially with respect to venous-crossings and arteriolar narrowing of retinal vessels. The positive and negative predictive value of retinopathy for high blood pressure is low. The association of retinopathy with other predictive indicators for organ damage is inconsistent and its association with cardiovascular complications is weak. These findings indicate that the usefulness of funduscopic examination as an instrument for assessing organ damage in patients with hypertension is limited. Therefore it should not be used as a routine diagnostic tool unless a hypertensive crisis is indicated.

In a 64-year-old man who was suffering from chronic obstructive pulmonary disease, recurrent airway infections, dysphagia, and weight loss, achalasia was diagnosed on the basis of endoscopic and radiological examinations. Afterwards he underwent flexible bronchoscopy, which revealed a benign looking fistula between trachea and oesophagus. This appeared to be a congenital tracheo-oesophageal fistula. The fistula was closed surgically. Three months later breathlessness and a sputum-producing cough were the only remaining symptoms. This rare anomaly is mostly diagnosed during childhood, but can also manifest itself in adulthood. If a tracheo-oesophageal fistula is suspected, the diagnostic procedures of choice are a barium oesophagogram in a forward-sitting or supine position or endoscopy of the trachea. Treatment consists of division and closure of the fistula. The prognosis is good.

Three patients, a 74-year-old man and 2 women aged 40 and 58 years, were admitted to the hospital on a number of occasions due to respiratory insufficiency as a result of progressive debilitating COPD. Weaning from mechanical ventilation became increasingly difficult. Therefore, in two patients it was eventually decided not to apply mechanical ventilation again; they died after the next COPD exacerbation. The 40-year-old woman was eligible for a lung transplant and was placed on the waiting list for this procedure. The decision to mechanically ventilate patients with severe COPD and respiratory insufficiency is fraught with therapeutical, emotional and ethical dilemma. Objective criteria indicating a poor outcome in mechanically ventilated patients with severe COPD are: a forced expiratory volume in one second lower than 700 ml, being housebound, advanced age, cardiac comorbidity, and a low serum albumin concentration prior to mechanical ventilation. Since subjective criteria such as the patient's own wishes should also be considered, a policy is advocated in which the consultant pulmonologist regularly evaluates the available data and communicates the feasibility of mechanical ventilation.

Clarithromycin is a relatively new antibiotic with many applications. Its frequent use explains why side-effects previously reported seldom now become clear. Two patients, a man aged 74 and a woman aged 56 years, developed delirium after treatment with clarithromycin as part of eradication treatment of Helicobacter pylori, presumably as a result of an ideosyncratic reaction to the clarithromycin. Preclinical and clinical investigations did not reveal side effects on the central nervous system. By now the appearance of a delirium presumably related to the use of clarithromycin has been described in several patients. Furthermore some patients had a positive rechallenge. Finally, 17 reports on psychiatric side effects, of which 7 were delirium, after the use of clarithromycin reached the Netherlands Pharmacovigilance Foundation (Lareb). This combination of facts makes a causal relationship probable.

Three patients, 1 man and 2 women, aged 60, 55 and 72 years, had an insufficient glucose regulation with insulin therapy or with sulfonylurea derivatives. They started metformin therapy, after which HbA1c decreased by 0.8-1.8%. One patient had to discontinue metformin therapy due to excessive diarrhoea. Many studies have shown the beneficial effect of metformin on glucose control. The recent UK Prospective Diabetes Study has proven the effectiveness of metformin for any diabetes related endpoint. Frequent side effects of metformin are nausea, abdominal discomfort and diarrhoea. Most side effects disappear after decreasing the dosage, although in 5% of patients diarrhoea only disappears after discontinuation of metformin. Lactic acidosis is a rare, serious adverse effect of metformin, which can be prevented by carefully observing the contra-indications.

Obesity is a major health issue in Western society. In the Netherlands every fifth person suffers from obesity and every third person is on a weight-reducing diet. The Montignac method is a very popular diet. The diet is claimed to be a nutritional science. The method is based on several hypotheses about the metabolism of carbohydrates and fatty acids: carbohydrates with a low glycaemic index are preferred, carbohydrates are not to be eaten in combination with fatty acids, fruit is propagated but must not be combined with other components. The scientific literature refutes the hypotheses of Montignac regarding the metabolic effects of carbohydrates and fatty acids. As a method to lose weight, the conventional recommendations of caloric restriction, less intake of saturated fatty acids and more physical activity should be preferred to the Montignac diet.