Eline A. Dubois

Rilonacept and canakinumab

Two new orphan medicines, rilonacept [1, 2] (Regeneron®) and canakinumab [3, 4] (Ilaris®), are indicated for the treatment of cryopyrin-associated periodic syndromes (CAPS). CAPS occur in a group of rare, inherited, inflammatory diseases where patients have a mutation in the NLRP3 (nucleotide-binding domain, leucine-rich family, pyrin domain-containing-3) gene encoding for cryopyrin, which is a regulator in the acute immune reaction. Both familial cold auto-inflammatory syndrome and Muckle–Wells syndrome belong to the CAPS group. Additionally, canakinumab may be used to treat other CAPS such as neonatal-onset multisystem inflammatory disease and familial cold urticaria. The indications for both drugs might be extended in future. Currently, these two drugs are being evaluated in more common diseases including rheumatoid arthritis and systemic-onset juvenile idiopathic arthritis [5, 6].

Key steps for integrating a basic science throughout a medical school curriculum using an e-learning approach.

Basic sciences can be integrated into the medical school curriculum via e-learning. The process of integrating a basic science in this manner resembles a curricular change. The change usually begins with an idea for using e-learning to teach a basic science and establishing the need for the innovation. In the planning phase, learning outcomes are formulated and a prototype of the program is developed based on the desired requirements. A realistic concept is formed after considering the limitations of the current institute. Next, a project team is assembled to develop the program and plan its integration. Incorporation of the e-learning program is facilitated by a well-developed and communicated integration plan. Various course coordinators are contacted to determine content of the e-learning program as well as establish assessment. Linking the e-learning program to existing course activities and thereby applying the basic science into the clinical context enhances the degree of integration. The success of the integration is demonstrated by a positive assessment of the program including favourable cost-benefit analysis and improved student performance. Lastly, when the program becomes institutionalised, continuously updating content and technology (when appropriate), and evaluating the integration contribute to the prolonged survival of the e-learning program.

The progress test of medicine: the Dutch experience

Progress testing in the Netherlands has a long history. It was first introduced at one medical school which had a problem-based learning (PBL) curriculum from the start. Later, other schools with and without PBL curricula joined. At present, approximately 10,000 students sit a test every three months. The annual progress exam is not a single test. It consists of a series of 4 tests per annum which are summative in the end. The current situation with emphasis on the formative and summative aspects will be discussed. The reader will get insight into the way progress testing can be used as feedback for students and schools.

Concept‐based learning of personalized prescribing

The variability of drug response in different patients can be caused by various factors including age, change in renal function, co‐medication and genotype. Traditionally, these personal variables are considered by clinicians prior to issuing a prescription. This paper provides an overview of a process to individualize prescribing for a patient with an emphasis on how to train (learning) clinicians in skillful rational prescribing. For this purpose the 6STEP methodology, a concept‐based learning strategy to achieve a structured therapeutic plan, has been introduced. In contrast to older educational approaches which focused primarily on the drugs or the process of prescribing, the 6STEP is a patient‐centred method resulting in individualized therapy. The six interlinked steps provide the (training) prescriber with a structured framework that facilitates a rationalized therapeutic decision by focusing on the individual patient parameters that influence drug response. Educational tools for rational prescribing involve understanding of basic and clinical pharmacological principles, practicing to write 6STEP therapeutic plans, learning from feedback sessions on these plans and actively obtaining up to date information on drugs and therapeutic standards from online resources.

Creating a culture of thoughtful prescribing

Background: In the Netherlands 170,000 patients yearly fall victim to poor communication between health care professionals, with 44% of patients receiving inappropriate therapy as a result. Evidence indicates that this problem may be due to physicians learning to communicate therapeutic content by unstructured means during training. Aim: To introduce a structured format for creating and communicating therapeutic plans; to provide for students opportunities practice and feedback on their abilities. Methods: We developed the Individualized Therapy Evaluation and Plan (ITEP) for therapeutic decision-making and communication based on the subjective objective assessment and plan note. The therapeutic plans from students of the 2003 cohort were assessed with one simple and one complex case using a 15-point criteria form. Over the next 3 years students were given more practice using the ITEP and the average score on the complex case was tracked and compared to the 2003 cohort. Results: In cohort 2003, 82% of the students satisfactorily completed the simple case, while only 32% did so with the complex case. In subsequent years, the average scores on the complex case significantly improved from 3.8 to 6.8 with increasing practice. Conclusions: Students can select a simple drug regimen, but without practice using the ITEP will not help to deal with multiple disease states.

Dabigatran etexilate: New drug mechanisms

Dabigatran etexilate [1, 2] is registered for the prevention of thromboembolic events in patients who have received hip or knee surgery. The indication is limited, but might be extended in the future, for example to prevention of stroke and thromboembolic events in general. Recent studies have compared the effects of warfarin and dabigatran in patients with atrial fibrillation [3] and acute venous thromboembolism [4]. However these results are still under debate [5].

The impact of pre-clinical pharmacology and pharmacotherapy training on students’ abilities and perceptions during clinical rotations

Background: Due to curricular changes at Leiden University Medical School, students have been exposed to different amounts of pharmacology and pharmacotherapy education. Cohort 1999 received little training; whereas cohort 2000 was provided with self-study materials preclinically and extra attention to pharmacotherapy during rotations. This study compares the cohorts by performance in and perception of pharmacotherapeutic abilities during the internal medicine rotation. Results: Preclinically, both cohorts were unable to adequately complete therapeutic plans. While cohort 1999 did not improve during the rotation, cohort 2000 did. For both cohorts the percentage of students feeling confident about various pharmacotherapeutic abilities increased significantly during rotations, but only 25% felt secure about their overall ability. Conclusions: The extra education helped cohort 2000 perform better, but did not improve their confidence in their pharmacotherapeutic ability. Thorough preclinical training and compulsory practice with feedback and assessment are necessary for students to develop competence in pharmacotherapy.