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The Cochrane Collaboration is an international not-for-profit and independent organization, dedicated to making up-to-date, accurate information about the effects of healthcare readily available worldwide. It produces and disseminates systematic reviews of healthcare interventions and promotes the search for evidence in the form of clinical trials and other studies of interventions. The Cochrane Collaboration was founded in 1993 and named after the British epidemiologist, Archie Cochrane. A Cochrane review is a systematic review. Those who prepare the reviews are mostly healthcare professionals who volunteer to work in one of the many Cochrane review groups, with editorial teams overseeing the preparation and maintenance of the reviews, as well as application of the rigorous quality standards for which Cochrane Reviews have become known. Based upon a clearly defined clinical question all steps of a scientific paper with a rigourous design are inside. This will guide the review process including strategies for locating and selecting studies critically appraising their relevance and validity and for analyzing variation among their results. If there are sufficient studies of good quality a meta-analysis can be performed. The major product of the Collaboration is the Cochrane Database of Systematic Reviews which is published quarterly as part of the Cochrane Library. From 2008 there will be also a place for systematic reviews of diagnostic accuracy studies. The Belgian Centre of Evidence-Based medicine, CEBAM, plays an important role as Belgian Branch of the Dutch Cochrane Collaboration in maintaining and promoting Cochrane Systematic Reviews.

The hygiene hypothesis offers an interesting explanation for the recent increase in allergy. However, all the studies that support this hypothesis are observational and cohort studies, which implies that no causal relationships can be assessed with sufficient validity. Exposure to environmental allergens and infections may very well not be determined by chance but by the behaviour of the parents. Therefore, the hygiene hypothesis should not be accepted without critical reflection of the facts presented.

The recently revised version of the practice guideline 'Problematic alcohol consumption' from the Dutch College of General Practitioners offers realistic advice to general practitioners on how to manage problem drinkers. The number of patients with alcohol problems tends to increase among women of middle age. The proportion of patients that report an alcohol problem themselves is larger than is usually assumed. Questionnaires are oflimited value in the detection of an alcohol problem. The general practitioner should look at problem drinking as a chronic disease that demands structured disease management and monitoring. This perspective will lead to less frustration in handling both the problem and the patients.

Objective: To evaluate the prevalence of urinary, faecal and double incontinence in community-dwelling elderly patients., Design: Cross-sectional population-based survey., Method: By means of a postal questionnaire, data were collected in the period January 1999-July 2001 from patients aged 60 and over from 9 general practices associated with the academic general practitioner registration network of the St Radboud University Medical Centre (the Nijmegen Monitoring Project). Excluded were patients living in a home for the elderly, as well as patients with dementia, patients who were too ill to participate and patients with a catheter., Results: Of the 5278 patients who received a questionnaire, 4650 (88%) returned it. 885 (19%) respondents had involuntary loss of urine twice a month or more, 299 (6%) had involuntary loss of faeces and 153 (3%) had both. The prevalence of urinary, faecal and double incontinence increased with age in both men and women, in men especially in the age group > 80 years. Urinary incontinence was more prevalent in women (29%) than in men (9%). The prevalence of faecal incontinence showed no sex differences (women: 6%; men: 7%), but the loss of slimy faeces occurred twice as often in men as in women (60% versus 29%). Double incontinence was also more or less equally prevalent in men and women (men: 2%; women: 4%), except in the age group 65-74 years (men: 1%; women: 4%)., Conclusion: Especially urinary, but also faecal incontinence was common in the community-dwelling elderly. The prevalence increased with age. Because of ageing of the population and the increasing life expectancy in the next decennia, the prevalence of incontinence can be expected to increase considerably.

Urinary and faecal incontinence are a growing problem in the Dutch elderly population. Recent figures from general practice suggest an average prevalence in the over-60-year-olds of 19 and 6%, respectively. Due to an accurate system of continuous monitoring and a very high response on a non-validated but clearly-worded and short questionnaire, the reliability of these figures is most probably high. The research article is one in a series on incontinence from the same research group that studied the practical implications of urinary incontinence in the elderly. Topics published so far concerned - among others - a systematic review of the efficacy of available interventions for urinary incontinence and an in-depth study of the barriers felt by GPs regarding their familiarity with and frequency of use of these interventions. The results of these studies can easily be translated for postgraduate education. Sadly, the magnitude and quality of the knowledge base for the treatment of faecal incontinence still lags behind.

Rationale: To assess the success rate of smoking cessation with the "minimal intervention strategy" in general practice, and to determine the influence of spirometry on this success rate., Methods: Training in smoking cessation advice was given to 16 general practitioners (GPs). During 12 weeks, these GPs screened their practice population for smoking habits, the degree of dependence on nicotine, and the motivation to quit smoking. Patients willing to stop were randomised to a group that underwent a single office spirometry, or to a control group. The GPs were asked to support the attempts with the minimal intervention strategy. Success rates were compared after 6, 12 and 24 months., Results: On a population of 5590 patients, 1206 smokers were identified (22%). To the vulnerable group, identified following the Prochaska and Di Clemente scheme, the proposal was made to change smoking behaviour. Two hundred and twenty-one patients undertook an attempt of smoking cessation. Nicotine replacement therapy (NRT) or bupropion was prescribed in 51% of the attempts. Sixty-four sustained quitters were counted after 6 months (29%), 43 after 1 year (19%) and 33 after 2 years (15%). We found a small but statistically non-significant difference in success rate in favour of the group that underwent office spirometry., Conclusion: GPs can motivate almost 20% of their smoking population to quit smoking. The success rate with the minimal intervention strategy was 19% after 1 year and 15% after 2 years. We found no arguments in favour of confronting smokers with their lung function as a tool for enhancing smoking cessation.

Objective: To assess the validity of patient history and physical examination in elderly patients in the diagnosis ofvarious types of urinary incontinence., Design: Literature review., Method: Articles on the diagnosis of urinary incontinence in elderly patients (patient history and/or physical examination versus urodynamic testing) were identified using PubMed, Picarta (a Dutch database) and the reference lists of the articles found. Articles were published between January 1970 and August 2005. The applicability and quality of the articles were assessed using the relevant Cochrane criteria. 'Sufficient diagnostic evidence' was defined as a positive likelihood ratio > 5 and a negative likelihood ratio < 0.02., Results: 5 studies met the eligibility criteria; 4 were performed in the second-line setting and 1 in a general population. All 5 studies involved women aged 55 years or older. None of the 5 studies found a positive or negative likelihood ratio for providing sufficient diagnostic evidence for various types of urinary incontinence. In the study conducted in a general population, the positive and negative likelihood ratios for the presence of stress incontinence according to patient history and physical examination were 3.23 and 0.40, respectively., Conclusion: Few adequate studies have been reported on the validity of clinical evaluation in the diagnosis of urinary incontinence in older women, and no studies have been conducted in men. The validity of clinical evaluation has been demonstrated only in the diagnosis of stress incontinence in older women.

Recently a report entitled 'The appropriate prescribing of antidepressants in general practice' was published. The researchers conclude that depression and anxiety are still more under-diagnosed than over-diagnosed and that antidepressants are frequently prescribed even when they are not indicated. Why this is so remains unclear. Looking for better interventions to improve treatment and increase therapy compliance, this study reports that many types of intervention could help but it is not very specific on how this could be achieved. Improving communication and knowledge about prescribing and how and when to discontinue treatment, are among the suggestions made in the report. Many questions remain: (a) is under-diagnosis a problem in a condition that often resolves spontaneously with watchful waiting?, (b) why are antidepressants so widely prescribed when their effectiveness is controversial and they have major adverse reactions?, (c) why are other treatment options such as talking therapy and a short period psychological intervention, of which the effectiveness has been established, not more frequently applied?

Objective: To gain insight into the trends in the prescription ofrofecoxib, the medication and disease histories of rofecoxib users, and the occurrence of cardiac complications during the follow-up., Design: Longitudinal comparative study in family practice., Method: Based on the data from family practices (17 family physicians) affiliated with the Registration Network Groningen, a network with about 30,000 patients in the northern part of the Netherlands, the incidence and prevalence ofrofecoxib use were determined per 1000 patients at risk for every quarter during the period 2000-2004. Data on duration, dosage and indications were taken from the rofecoxib prescriptions. Differences in morbidity between rofecoxib users and the users of traditional NSAIDs were compared using logistic regression, and differences between the two groups in the occurrence of cardiac complications were assessed by means of Cox regression analysis., Results: During the period investigated, rofecoxib was prescribed with increasing frequency in family practice; there was a total of 1784 prescriptions for 509 patients. The drug was used increasingly for short durations and for a growing number of indications. Rofecoxib was selectively prescribed to former users of traditional NSAIDs. The occurrence of acute myocardial infarction, stroke or 'transient ischaemic attack' in the follow-up period was associated especially with pre-existing cardiovascular disease, but these complications were also seen more often among patients without pre-existing cardiovascular disease who used rofecoxib than among those who used the traditional NSAIDs (the difference was not significant)., Conclusion: The observations indicate that, via a process of channelling, rofecoxib was prescribed to a highly-specific population of patients who, paradoxically, were at a higher risk of developing the same cardiac complications with which rofecoxib had been shown to be associated in randomised clinical trials.

The Dutch College of General Practitioners recently published an update of the practice guideline on urinary-tract infections. This guideline provides a clear overview of the medical history, the diagnostic methods and the treatment options. Sixteen management modalities are presented in relation to specific patient characteristics. However, this revised guideline warrants some minor comments. According to the guideline, the dipstick (nitrite) test and dipslide form the two cornerstones of the diagnosis of urinary-tract infections. The value of the dipslide, however, seems to have been overestimated and that of microscopic examination of the urine by skilled physicians to have been underestimated. New in this guideline compared to that of 1999 is that nitrofurantoin (the treatment of first choice in uncomplicated infections) should be given for five instead of three days. The guideline motivates this change in policy on the basis of the numerous treatment failures seen in practice. The most convincing type of evidence, however, is not available due to the lack of relevant randomised clinical trials. The introduction of the prescription of phosphomycin, which is unusual in the Netherlands, as an alternative treatment for uncomplicated infections requires supportive evidence before it will be accepted by general practitioners. This well-documented guideline provides clear guidance for the general practitioner faced with patients with urinary-tract symptoms that could be caused by infection.

Background: Information on the incidence of serious infections in children in general practice is scarce. However, estimates on the incidence of disease are important for several reasons, for example to assess the burden of disease or as a basis of diagnostic research. We therefore estimated the incidence of serious infections in general practice in Belgium., Methods: Intego is a morbidity registration network, in which 51 general practitioners continuously register all diagnoses and additional data in their electronic medical records. Serious infections were defined as pneumonia, sepsis, meningitis, pyelonephritis and osteomyelitis. Incidences are calculated for the period of 1998 to 2002, per 1000 patients in the yearly contact group, which is the group of patients that consulted their GP at least once that year, and in the practice population, which is the estimated true population of that practice., Results: The incidence of all infectious diseases peaks in children between 0 and 4 years, with 1731 infections per 1000 children per year in the yearly contact group. Incidence drops with increasing age: 972 infections per 1000 children per year in children between 5 and 9 years old, and 732 in children between 10 and 14 years old. The same decline in incidence is observed in the subgroup of serious infections: 21 infections per 1000 children per year in children between 0 and 4 years, 12 in children between 5 and 9 years and 5 in children between 10 and 14 years. The results for the estimated practice population are respectively 17, 9 and 4 serious infections per 1000 children per year., Conclusion: In contrast to the total incidence of acute infections, serious infections are rare, around 1% per year. Children younger than 4 years old have the highest risk for serious infections, and incidences of some infections are different for boys and girls.

Patients with medically unexplained symptoms pose a problem for medical professionals. Doctors usually lack tools to handle these complaints adequately. Over the past decades much research has been done in the areas of classification and intervention both in general practice and in specialist care. If the doctor responds to the patient by offering to prescribe medicinal symptom relief, the first step into the vicious circle is taken. The patient is polite enough to try the medication but when it does not help, returns to the doctor. If the doctor continues to think along somatic lines the phenomenon known as iatrogenically enforced somatic fixation may arise. The main development in intervention stems from cognitive behavioural therapy, which is now considered the gold standard for all patients, regardless of their symptoms. In the Netherlands, a postgraduate course has been developed to implement the fundamentals of this approach into general practice. On this course, the doctor learns not to be deterred by the somatizing patient and to effectively close off their somatic treatment trajectory. He or she teaches the patient to look at the situation from a new perspective and instead of being preoccupied with what is not functioning well to concentrate on training those activities which can be carried out effectively. This shift in emphasis can help to cause the preoccupation of the patient to slowly disappear. Initial results are encouraging: both patients and general practitioners have responded favourably.

In the last week of life, the extent and kind of medical practice differ both in intention and in the degree of orientation on the outcome. Patients tend to put long-term prescriptions aside or ask for symptom-relieving medication and sometimes for palliative sedation, euthanasia or physician-assisted suicide. Competent physicians are able to offer or withhold treatment. In case of unconsciousness or severe cognitive impairment, proxies may ask for medical relief of disturbing symptoms. Medical practice is subject to the Dutch Medical Treatment Act (1995). At the start of the specific Dutch law specifying judicial review of euthanasia and physician-assisted suicide (1993, implemented in 2002) 1.8% of deaths concerned euthanasia. In 2005, standard drugs (choice, dose and route of administration) were highly effective in all cases of euthanasia in which they were used (76%): death within a median of 3-4 min, maximum 90 min. In the absence of medical indications for drug overdose, morphine and other choices are now considered obsolete for euthanasia and physician-assisted suicide. The definition of euthanasia must be based exclusively on a standard method and outcome: death on request by a standard medical method with a standard judicial review.

Unlabelled: Problems with instrumental activities of daily living are important in the caring for elderly people, in general practice as well. Impairment in activities and instrumental activities of daily living may be important indicators for early dementia. This study explored how people aged 65 years and over in general practice are performing on four instrumental activities of daily living., Method: General practitioners screened all people, aged 65 years and over, and meeting the inclusion criteria, they met during a period of one month. Personalia, instrumental activities of daily living and cognitive functioning were registered., Results: Twentytwo general practitioners included 1003 persons, with a mean age of 75 year. The majority of this group (81.6%) was rather autonomous. The main cause of functional impairment were transport problems. Cognitive functioning and functional loss were correlated., Conclusion: Elderly people in general practice function better than is generally assumed. This phenomenon has important consequences for training and functioning of GPs as to the evaluation of activities of daily living. The fundamental role of IADL assessment therefore needs attention in the professional development of GPs.

The practice guideline 'Headache' from the Dutch College of General Practitioners, which replaces the guideline 'Migraine', is an improvement in many respects: tension headache and substance-induced headache are discussed in detail, the headache diary is given due emphasis and the recommended treatment for migraine is well-balanced. The symptom-oriented approach is, however, not applied consistently in this guideline and too little attention is given, in particular, to the exclusion of serious causes that are less commonly encountered. The guidelines for performing physical examination provide insufficient footing. The exclusion of serious diseases should be based on a limited set of specific physical examinations to be carried out in all cases of new headache. Interrogating the patient about possible social or psychological aspects and the possibility of referral in this area deserve increased emphasis.

During the past 30 years, the legal and moral framework for terminal care and hospice provision has changed, both nationally and internationally, but the situation is still not completely clear. The nursing homes in the Netherlands have also developed, described and implemented palliative care. In most regional systems for palliative care, a supportive and sometimes an active therapeutic role is played by medical, nursing, paramedical and pastoral nursing home professionals. In view of the strong relationship between a poor or worsening nutritional state and fluid balance and death, particularly of psychogeriatric nursing-home patients, a multiprofessional guideline has been drawn up for the responsible provision of food and fluids in nursing homes. It is likely, although not certain, that this guideline will contribute to the limitation of the suffering of the dying patient. The guideline will in any case make the compassion of the family and the sympathy of care-givers discussible and almost always manageable. In many nursing homes, meanwhile, it has become accepted practice, soon after admission, to discuss the future suffering of the patient during the process of dying and to record this conversation.

Until 2010, the Dutch ministry of Health, Welfare and Sport will fund a nationwide project to identify the approximately 40,000 patients with familial hypercholesterolaemia (FH) in the Netherlands. The Health Care Insurance Board will coordinate the project and safeguard its quality, while the 'Stichting Opsporing Erfelijke Hypercholesterolemie' [Foundation for the Detection of Hereditary Hypercholesterolaemia], with its national network of genetic fieldworkers, will search systematically within families with assessed FH-mutations. The referral of the first suspected case of FH in a family for DNA diagnosis remains a task for GPs, internists and other clinical professionals; these will also be expected to take the responsibility for treatment. The list of diagnostic criteria of the 'Dutch Lipid Clinic Network' has recently been validated and is recommended as a decision-tool for initiating DNA diagnosis. After confirmation of the DNA diagnosis, the plasma level of LDL-cholesterol remains the main criterion for pharmacotherapy; treatment with hypocholesterolaemic agents is recommended at levels above 2.5 mmol/l.

The practice guideline 'Heart failure' from the Dutch College of General Practitioners will be a source of support for the general practitioner/family physician. Its clear set of diagnostic steps helps the general practitioner to assess heart failure in patients with breathlessness, fatigue, decreased exercise tolerance or ankle swelling. Testing plasma concentrations of natriuretic peptides plays a new and central diagnostic role. This guideline differs from the previous one in another important aspect. Based on many RCT's and reviews the authors have succeeded in developing a detailed but balanced treatment protocol for heart-failure patients in general practice. However, adverse effects from co- and multi-medication in the growing number of frail elderly may reduce the patients' compliance.

Objective: To determine how, with the aid of the database of the Transition Project (www.transitionproject.nl), one can calculate posterior probabilities for general practice that provide insight into the clinical significance of the simultaneous occurrence of two events (a symptom and a diagnosis, or two diseases) in general practice., Design: Descriptive., Method: The use of the 'International classification of primary care' (ICPC) to code both the patient's reason for encounter and the diagnosis of the general practitioner in the Transition Project has resulted in a database for the period 1985-2002 with a total of 201,127 patient-years, in which the posterior probability of a diagnosis in the presence of a complaint or symptom is available in the form of an odds ratio. Also in the case of the simultaneous occurrence of 2 episodes of care (comorbidity) in a patient it is now possible to determine whether the ratio between the prior and the posterior probability indicates a clinically relevant relationship or that it is a chance finding. Such posterior probabilities have been calculated for the conditions otitis media, hypertension in diabetes mellitus, shortness of breath and heart failure. In the calculation ofthe prior and posterior probabilities, only 'certain' diagnoses were used., Results: For the diagnosis 'otitis media' in the age group 0-4 years, otalgia had the highest posterior probability (odds ratio: 15.77), with discharge from the ear taking second place (odds ratio: 8.59). 'Fever' contributed almost nothing. The odds ratio for hypertension in 45-74-year-old women with diabetes mellitus was 3.42. When the symptom was 'shortness of breath', the prior probability of heart failure in the age group 45-64 years was relatively low (2.0) but the posterior probability was relatively high (24.2). In this way, the combination of prior and posterior probabilities can provide support for the clinical work of the general practitioner. As a predictive variable for heart failure in the age group 65-74 years, 'ankle oedema' played an important role while 'fatigue' contributed nothing to the diagnosis. It was apparent from the database that the care for patients with heart failure often coincided with that for chronic diseases such as diabetes mellitus, hypertension, ischaemic heart disease, chronic obstructive pulmonary disease and atrial fibrillation. But the question whether there is a clinically relevant relationship could only be answered on the basis of the posterior probabilities: the highest odds ratio's were found for 'atrial fibrillation/atrial flutter' (32.5), 'chronic obstructive pulmonary disease' (22.5) and 'chronic skin ulcer' (20.2)., Conclusion: The calculation of prior and posterior probabilities on the basis of the database of the Transition Project makes it possible for general practitioners to determine the clinical relevance of their observations.

Since the first Consensus Statement on the treatment of stroke (UK, 1988) and the European Helsingborg Declaration on the treatment of stroke (1995), 69 stroke services have been geographically spread in the Netherlands; these consist of an integrated hospital stroke unit, a nursing home rehabilitation unit, and home care. The Dutch stroke services have improved their outcomes in a cost-effective way in comparison with the usual care. Consensus on patient-oriented outcomes--arranged in order of the International Classification of Functioning, Disability and Health--is recommended.

More and more evidence is becoming available that throws doubt on the value of adenotonsillectomy in children with frequent throat infections or hypertrophic tonsils and adenoids. Tonsillectomy and adenoidectomy have a limited range of indications. Objective symptoms such as the size of the tonsils and subjective symptoms of obstruction and sore throat are not always related to each other. Children with only moderate symptoms should not be operated on.

Objective: To obtain information on the frequency of and the indications for prescription of methylphenidate in general practices in the north-east of The Netherlands., Design: Descriptive., Method: Data were collected from 1998 to 2003 from 6 general practices in the north-east of The Netherlands (17 general practitioners, approximately 30,000 patients) that were affiliated to the Registration Network in Groningen. The number of new and existing patients who were prescribed methylphenidate was calculated by age group per 1000 person-years per calendar year. The indication on which the drug was prescribed was looked at, as was the number of patients who were referred to a specialist on that indication., Results: The number of new users per 1000 person-years more than doubled from 17 in 1999 to 42 in 2003. In all years studied the highest number of new users fell into the age group 5-9 years. The total number of users per 1000 person-years tripled (boys: 1.8 in 1998 and 6.2 in 2003; girls: 0.5 in 1998 and 0.8 in 2003). The prevalence of use in boys was 3 to 8 times as high as that of girls and increasing more quickly. In people under 59 years of age attention deficit hyperactivity disorder (ADHD) was the most frequent indication (55%). In the group aged > or = 60 years methylphenidate was mainly prescribed in the palliative phase of somatic morbidity. Over half of the 140 new patients (57%) were referred nor to a specialist in the year before neither in the year after the first prescription of methylphenidate.

In successive years, three members of the same family (a man and woman aged 46 years and their son, aged 20) constantly developed severe pruritic, erythematous, vesicular and bullous dermatitis in the spring and summer after working in the garden. Although the findings were consistent with a photophytotoxic dermatitis, the causative plant remained unclear. Oral therapy with high doses ofprednisolone was necessary. When the man travelled to the USA and visited a doctor there, he recognised the symptoms as those of contact dermatitis caused by poison ivy (Toxicodendron radicans), a plant that is found sporadically in the wild state in Europe. Their grandparents had brought the plant back from a trip to the USA and planted it in the garden because of the beautiful fall colours. The family identified the plant via a search on Internet and eliminated it from the garden completely. Since then, the family has no longer suffered from contact-allergy dermatitis.

Recent research has shown that the simple pathophysiological concept which explains micturition complaints in elderly men as being caused by benign prostatic hyperplasia needs to be abandoned. It has been shown that there is no clear correlation between prostate volume and voiding problems and also that reductase blocker drugs which specifically decrease prostate volume do not lead to a clinically important reduction in symptoms. The internationally accepted new conceptual umbrella description of these micturition problems is 'lower urinary-tract symptoms', a term that is more suited to research this area where a good understanding of the fundamental underlying mechanisms is lacking. The Dutch general practitioners' guideline for micturition problems in elderly men addresses this paradigm change in a thorough and easily understandable way.

Objective: To determine the mid-long-term outcomes after surgery in patients with lumbosacral radicular syndrome (LRS) and to identify prognostic factors for persisting LRS symptoms., Design: Descriptive retrospective and prospective., Method: A total of 250 consecutive patients operated on by 7 neurosurgeons in four hospitals between May and December 2001 were selected from medical records. They were asked to take part in a telephone questionnaire at 6 and 19 months after operation. They had all undergone discectomy for LRS at L4-L5 or L5-S1 and were aged from 18 to 65., Results: Of the 250 patients, 163 participated in the study: 63% reported that they still had LRS-related symptoms 19 months after surgery. However, severe leg pain had decreased in 83% of the patients. In general the patients were satisfied with their treatment. Female gender and an age of 51-65 were prognostic factors for persistent LRS symptoms., Conclusion: More than half of the patients reported LRS symptoms 19 months after surgery.

The recommendations provided by the revised guideline 'Anxiety disorders' are well suited to every-day practice. The multidisciplinary approach reflects the increasing cooperation between primary and secondary care in the management of mental-health problems. The description of the various anxiety disorders and the questions that can be asked to elicit the symptoms will facilitate recognition. The indications for treatment with medication are clear: a limited number of antidepressants should be used. Although it is agreed that patient education is an important part of treatment, the guidelines could have described in more detail how this should be done. Cognitive-behavioural techniques may be used but this requires extra training; its effectiveness when used by general practitioners needs further study. This guideline will add to existing knowledge and improve the skills of general practitioners in dealing with anxiety.

Although the agenda of the European Union (EU) does not directly provide for it, it seems reasonable to assume that due to the process of European social and economic integration there will be mounting pressure on the presently widely differing systems for primary care to move towards a more uniform orientation. In 2004, during its rotating presidency of the EU, the Dutch government asked its Health Council for advice on the current level of knowledge with regard to the organisation and significance of primary care. The Council formulated a set of key recommendations for the future development of primary care in Europe. The Council defines primary care as: generalist care, consisting of general medical, paramedical and pharmaceutical care, nursing and supportive care and non-specialised mental and social health care together with preventive and health educational activities linked to these forms of care. This care is for all health problems, is aimed at ambulatory patients, and is delivered close to the patients' homes. It is easily accessible to all, and provides emergency care when necessary. The main differences in the provision of primary care between countries in Europe concern the presence or absence of registration with a general practitioner and the gate-keeper role of primary care. International comparative research has identified the presence of precisely these features as predictors of better health outcomes in terms of morbidity and mortality. They therefore form a prominent role in the key recommendations, which state, among other things, that a patient should choose a primary-care team in the context of an integrated care circuit, thereby giving up his or her freedom to select care givers outside that circuit, in the interest of quality continuity and the efficiency of care. Other key recommendations are: close cooperation between primary-care teams, preventive services and public health and occupational health, a transparent provision on information between all providers of care, and the creation of a European Center for primary-care development.

The Nijmegen 'continuous morbidity registration', a prospective cohort study in general practice, was founded by F. J. A. Huygen in the nineteen-seventies. Many theses and papers have been written on the basis of these data. The latest fruit from this tree is a contribution on recurrent urinary tract infections in women, published in this journal. In that article, a mixture of quantitative and qualitative data is presented. It is true of quantitative data that their presentation determines their interpretation. Qualitative data provide the doctor with insight into the patients' attributions.

Objective: To investigate the natural history of recurrent urinary tract infections in women of childbearing age and to gain insight into their consequences and the ideas of the patients., Design: Historical cohort-study and interviews with patients., Method: All non-pregnant women in the age-range 15-49 years who had had > or =2 urinary tract infections in one year in the period 1990-1994 were selected with the aid of the 'Continuous morbidity registration' (CMR) from four general practices in Nijmegen, The Netherlands. The patients' files were used for supplementary information. The risk of recurrence was calculated by the Kaplan-Meier method. Patients between the ages of 15 and 35 who had had > or =2 urinary tract infections in one year in the period 2002-2003 were interviewed., Results: Of the 115 women in the CMR-study group, 70 (61%) were younger than 30 years. The median duration of follow-up was 10.0 years. The risk of a new recurrence within one year was 56%; the chance of remaining free of recurrences for two years was 33%. The 115 patients underwent a total of 630 urinary tract infections during the study period; an antibiotic was prescribed every time. 2 of the 115 patients developed pyelitis/pyelonephritis. An underlying abnormality was found in one of the 12 patients that were referred. Of the 21 women that were interviewed, 8 (38%) stayed away from school or work during the infection, depending on the symptoms. Of the 18 women that were sexually active, 13 (72%) did not want to have sex during the infection. 10 of the 21 women (48%) were concerned about possible complications. A decreased resistance, cold on the bladder, stress, menstruation and improper vaginal hygiene were most frequently mentioned by the women as the cause ofthe urinary tract infections. When women with recurrent urinary tract infections consult a general practitioner, the latter can discuss their unjustified concerns and attributions.

The prevalence of sexually transmitted diseases (STDs) increased in the Netherlands in the years 2000-2003. A recent population-based study showed that Chlamydia infections were a problem in urbanised areas; prevalence in rural areas was low. In 2004, the Dutch Health Council advised against a national screening programme for Chlamydia. However, the newest figures on the distribution of Chlamydia infections suggest that screening in large cities might be cost-effective. Much can be learned from the screening programme in the United Kingdom.

Objective: To investigate the incidence, type and consequences of sexual harassment of medical students at the Radboud University in Nijmegen, the Netherlands, during their period of work placement, as well as the students' need for care thereafter., Design: Questionnaire., Method: During the period from 1 July to 31 December 2003, 5th and 6th year medical students were asked about their experiences with sexual harassment by means of a questionnaire. Sexual harassment was defined as unwelcome, sexually-coloured attention., Results: Of the 183 questionnaires distributed, 113 (62%) were returned. 15 (20%) of the 75 female students and none of the 38 male students had experienced sexual harassment. The offenders included 9 patients and 6 doctors (54 men and 1 woman). In 7 of the 15 cases the harassment consisted of combinations of unwanted behaviour and unwanted sexually-coloured remarks. 9 of the 15 students had discussed their experiences with their peers, 7 with a supervisor and 3 with nobody. The most important reason to discuss it first in their peer group was that, despite the fact that the students were convinced that the offender's behaviour was unacceptable, they still doubted their own judgement. 5 students felt inhibited in their contacts with patients after the incident. 8 of the 15 offenders were not confronted with their behaviour. 6 of the 15 students were not satisfied with the way their case was handled., Conclusion: The problem of sexual harassment of medical students during their period of work placement should not be underestimated. It has a negative impact on the personal and professional conduct of future doctors. This subject should be part of the training of both medical students and their supervisors.

In a comparison of the 1987 and 2001 Dutch national studies of diagnoses and performance in general practice, a decline was observed in referrals to pediatricians. This decline concerned all pediatric subspecialties, but was particularly marked for acute otitis media and visual impairment. This trend is in line with other observations of general practitioners' interventions in the last two decades. General practitioners treated a larger proportion of health problems presented to them in 2000 (96% of the episodes) than in 1987 (91%). A decline in referrals of all age groups and all specialties was also reported for 1971--1994. The decline in referrals took place in an aging population, while the annual number of contacts between patients and their general practitioners did not change substantially. This reflects the fact that since 1970 health care policy has been directed at a strengthening of general practice. The decline in referrals proves the success of this policy.

In terminally-ill patients in the Netherlands deep sedation by means of a continuous subcutaneous infusion with midazolam occurs more frequently than euthanasia and assisted suicide. Deep terminal sedation is applied to relieve symptoms during the phase of dying, but in contrast to euthanasia and assisted suicide, does not hasten death. In three terminally-ill patients, a 65-year-old man suffering from pulmonary carcinoma, a 94-year-old woman with general malaise, nausea and anorexia, and a 79-year-old woman in the final stage of ovarian carcinoma, a general-practitioner advisor was consulted about an end-of-life decision--deep terminal sedation versus euthanasia or assisted suicide. The first two patients were given deep sedation until death, in both cases a day and a half later. The third patient's request for euthanasia was considered to meet the legal criteria for euthanasia. Compliance with the Dutch statutory criteria for due care in euthanasia and assisted suicide might also be helpful when deciding about terminal deep sedation, but the role and responsibility of the attending physician may differ. However, the radical effects of sedation on the terminally-ill patient and the rapid changes in the clinical situation of the patient when the decision to sedate is taken, both emphasize the need for consultation with another physician.

A transient ischaemic attack (TIA) can be seen as an attack of angina of the brain. In the first weeks following a TIA there is a sizeable risk of subsequent stroke. After this period, this increased risk tapers off and an elevated risk of cardiovascular disorders remains, with the emphasis on its cardiac component. The management of a patient with a TIA in general practice focuses on these two risk periods. The long-term cardiovascular risk can easily be reduced by prescribing aspirin, an established procedure in general practice. The immediate threat of obstruction of the carotid artery may, as was only recently firmly established, be averted by a timely referral for additional diagnostics and, when needed, carotid desobstruction. This part of TIA management in general practice, however, is hampered by the current waiting periods for these procedures.

The practice guideline 'Miscarriage' has been reviewed for the second time in fifteen years. It provides the practitioner with distinct diagnostic tools for vaginal bleeding in the first sixteen weeks of pregnancy and a clear management algorithm. The management of miscarriage is based on a joint decision between the general practitioner and the woman concerned. A more reserved attitude towards the surgical termination of pregnancy is advised. The guideline sufficiently addresses the issue of informing the woman as to the expected amount of bleeding during a miscarriage and the relationship with fertility. However, the risk factors for heavy blood loss are not mentioned in the guideline. The psychological impact of early miscarriage on women is given adequate attention and is part of the counselling during the follow-up period. Finally, the medical treatment of threatened miscarriage seems to result in an earlier miscarriage with less loss of blood compared to expectant management. The guideline pays also attention to medical treatment. Future research will clarify whether medical treatment is feasible in general practice.

The Dutch Society of Nursing Home Specialists has formulated a guideline for the prevention of influenza in nursing homes and care homes in The Netherlands. The guideline recommends the realisation of the highest possible degree of vaccination of both patients and health care workers. At the start of the flu season, the manager of the chronic care institute should organize a scheme for vaccination against influenza and a plan in case of an outbreak of influenza. The division of tasks between the nursing home specialist, the general practitioner and the company doctor should be recorded in both the vaccination scheme and the outbreak plan. In order to decrease the incidence of non-response to the vaccine a double dose of influenza vaccine for nursing home patients should be considered. The outbreak plan should raise the state of alertness for influenza and ensure that virological confirmation of clinical influenza is obtained quickly. Immediately after virological confirmation of clinical influenza, patients with influenza should be treated with oseltamivir and both patients and health care workers in the unit should receive prophylaxis with oseltamivir. Non-vaccinated patients should also be offered vaccination to restrict re-introduction of the virus. During an influenza outbreak, only patients with influenza or those who have had prophylactic treatment may be admitted to the facility. In the case of an influenza pandemic, national guidelines should be followed.

The interdisciplinary guideline 'Treatment of tobacco dependence' discusses the approach to smoking patients. The point of departure is the concept that smoking is an addiction and that its treatment should be based on this fact. The effectiveness of treatment depends on the patient's motivation to stop smoking and on the intensity of the intervention. Pharmacotherapy may be of added value here, particularly for persistent smokers. The guideline aims at reaching as many smoking patients as possible, regardless of whether there is a relationship between their symptoms or ill health and smoking. Practitioners should ask about smoking habits regularly and smokers should be advised at least once to stop. Further treatment and guidance aims in particular to increase the motivation to quit and at those who are prepared to stop on the basis of the stages-of-change model. More intensive possibilities for treatment, by both general practitioners and specialists, are needed for persistent smokers. Such facilities are hardly available at all in The Netherlands at present, but will have to be developed to make the cost-effective treatment of tobacco addiction possible on a large scale.

Intimate partner abuse is world-wide much more prevalent than often suspected. Three female patients consulted their family doctor with a variety of complaints. A 53-year-old woman, mother of three grown-up children, and divorced a year ago, sought help after four days, for a large infected wound of her right hand. A 32-year-old single mother of a 2-year-old girl asked the practice assistant for an iteration of a tranquillizer because of tension headache. A 36-year-old divorced mother of three sons was sent by her company doctor to ask for a referral to a psychiatrist because of chronic fatigue. All three women appeared to have been severely abused by their partners, recently or in the past, and were reluctant to disclose the abuse. Two women were regular visitors of doctor's offices with diverse unspecific complaints. The third woman was a victim of sexual abuse as a child and was severely depressed. Active asking about experiences of intimate partner abuse helped these women to disclose the real nature of their problem. Important effect is that abused women can accept help and experience support to improve their situation. Doctors should suspect intimate partner abuse more often in patients who are heavy medical consumers, depressed or victims of sexual abuse in childhood. Single and divorced mothers can hide a history of abuse. Doctors should ask clear and specific questions about relationships and listen without passing judgement so as to help women to disclose abuse.

Objective: Determine the prevalence of microalbuminuria in patients with type 2 diabetes mellitus (DM) in general practice, as an independent risk factor for cardiovascular diseases., Design: Prospective, descriptive., Method: Data were collected on patients with type 2 DM in the Zwolle region of the Netherlands, all of whom were being treated by their general practitioner. The inclusion period was 1 February 2000-31 January 2001. The study formed part of a larger investigation, in which the albumin concentration in a urine sample and the albumin-creatinin ratio were determined once per year. A total of 32 general practitioners took part in the study., Results: In the general practices studied, 2094 patients were known with type 2 DM and 1653 (79%) were treated exclusively by the general practitioner. Of these 1653 patients, 67 (4%) were excluded and of the 1586 invited patients remaining, 1441 (91%) participated. Microalbuminuria was present in 33% of the patients and macroalbuminuria in 7% of the patients, and the prevalences increased with age: < 50, 50-70 and > 70 years. 18% (6/33) of the patients aged < 50 years with microalbuminuria were treated with an ACE inhibitor or angiotensin II antagonist compared to 33% (183/548) of patients > or = 50 years. 91% (488/539) of the patients > or = 50 years with microalbuminuria had hypertension and/or lipid profile abnormalities and 82% (402/488) of them were not treated or did not receive adequate treatment for this condition., Conclusion: Microalbuminuria and macroalbuminuria were present in respectively 33% and 7% of the patients with type 2 DM in primary care. The treatment of hypertension and lipid profile abnormalities was often inadequate. Therefore, screening patients aged 50 years and older with type 2 DM for albuminuria is justified.

Implanon is a contraceptive device with a high reliability in the prevention of pregnancy. The insertion is a simple procedure but the physician must master this skill. A number of cases have been recorded in which the rod appeared to have disappeared, which sometimes led to an unwanted pregnancy and sometimes ended in claims for compensation. There are a number of tips the physician can use to make sure that the insertion is done properly. At present, training in the insertion of this device is only offered by the company that sells Implanon. The question arises whether the professional group of GP's or gynaecologists should take over this responsibility.

The practice guideline 'Peripheral vascular disease' (PVD) from the Dutch College of General Practitioners will certainly be of benefit to the Dutch general practitioner. Its limited set of simple diagnostic steps can help the general practitioner to assess or exclude PVD in patients with intermittent claudication. The inclusion of a pretest-posttest probability scheme enhances a clear diagnostic process. This guideline differs from the previous one in one important aspect. This guideline deals not only with the specific management of peripheral arterial disease but also with the management of cardiovascular risk in general. In this way the guideline follows the recently changed international attitude reflected in the European Guidelines on cardiovascular disease prevention. Smoking cessation and exercise therapy continues to be the cornerstone as well as the stumbling block of management of most cases of PVD in general practice; a challenge for every general practitioner.

Objective: To obtain insight into the treatment and course of genital prolapse in four general practices., Design: Historical cohort study., Method: The files of patients in whom a prolapse was first diagnosed in the period 1976-2000 and who belonged to the four general practices associated with the General Practice Department of the UMC St Radboud in Nijmegen, the Netherlands, were studied. Data were collected concerning the management, course and symptoms arising from the use of pessaries and complications after operations., Results: 324 patients were included with a median follow-up of 9 years; 15 of them had been treated by a gynaecologist. The initial treatment prescribed by the general practitioner (n = 309) was a wait-and-see policy in 29% of the cases, a pessary (40%), exercises of the muscles of the pelvic floor (15%) or medication (5%). A total of 192 of the 324 patients (59%) received a pessary in the course of time; 47% of them had no problems during the use of a pessary, 17% had increased vaginal discharge and 17% had a pressure ulcer. In 15% of the cases the pessary was ultimately lost because of insufficient support from the pelvic floor muscles. The pessary remained in situ for an average of 5.4 years (SD: 5.4). In 107 (56%) cases it was removed after a period of time; the most important reasons for this were complaints arising from the use of the pessary (54%) and ineffectiveness (24%). In case of a conservative approach (n = 299), the prolapse became worse in 15% of the cases. A total of 128 patients (40%) were referred to a gynaecologist. Of the 92 patients who were operated, 10% experienced a complication and 24% a recurrence., Conclusion: The pessary was a frequent and justified treatment in women with a genital prolapse. It is important that the complications of the pessary be reduced further.

The practice guideline 'Atrial fibrillation' (AF) from the Dutch College of General Practitioners is a clearly written survey on the diagnosis and treatment of AF in general practice. Rapid cardioversion is no longer an indication for acute referral in AF. As AF, heart failure and COPD often occur simultaneously among elderly people, the exact cause of the symptoms can be unclear. In these complicated cases, with the risk of polypharmacy, a single consultation between general practitioner and cardiologist would be more effective. For control of the rate of ventricular contraction during the treatment of AF, lipophilic beta-blockers are preferable to hydrophilic beta-blockers because the pharmacokinetics in elderly people are substantially different. When there is a high risk of thrombo-embolic complications with AF, treatment with coumarin derivatives is advised. However, little research has been done on this subject among elderly people in a general practice setting. In this age group, the risk of complications due to treatment with coumarin derivatives is sometimes higher than the advantages it offers. This is why the GP should always consider carefully whether or not elderly people with AF should be treated with coumarin derivatives.

The practice guideline 'Acute cough' from the Dutch College of General Practitioners stresses the fact that a cough of less than 3 weeks' duration seldom heralds serious pathology. However, for sound reassurance of patients presenting with a cough of short duration, the general practitioner needs to know much about the signs and symptoms connected to low-prevalence serious pathology in these patients. The practice guideline distinguishes upper and lower respiratory tract infections and defines serious lower respiratory tract infection. The diagnostic value of symptoms and laboratory findings like a sedimentation rate or C-reactive protein in order to make such distinctions, is not explained in detail. Antibiotics are reserved for serious lower respiratory tract infection with the exception of acute bronchitis, croup and bronchiolitis, which can be treated without antibiotics. Recommendations for treatment of acute bronchiolitis with bronchodilators or corticosteroids, and croup with corticosteroids are based on consensus. This practice guideline can be considered as a clear and valuable piece of work for all physicians in primary and secondary care.

Under the auspices of the Dutch Institute for Healthcare Improvement (CBO), a guideline has been developed for the diagnosis and treatment of aspecific low-back pain, based on the recent scientific literature. So-called 'red flags' are used to identify physical disorders. To obtain insight into psychosocial factors, 'yellow flags' are used. Acute low-back pain (0-12 weeks) is treated in a time-contingent manner. Staying active is better than bed rest. If chronicity threatens, exercise therapy can be advised. As part of an activating management, manipulation can be used. For pain relief, paracetamol is the drug of choice. The treatment of chronic low-back pain is aimed at the optimisation of the patients' functionality. Staying active is preferred here as well. Varied exercise therapy is advised. Back training may be considered. Manipulation can be used as part of an activating management. Paracetamol is preferred for pain relief. There is a limited role for percutaneous lumbar facet denervation. Behaviour therapy can be employed and there is a place for multidisciplinary programmes if other methods of treatment have proved insufficiently effective.

A 78-year-old woman felt uncertain 4 days after a stroke, while a 65-year-old man wanted to do too much 6 weeks after a stroke. An 81-year-old man was depressive 6 months after a stroke. By paying attention to the need for information and the burden on the carer, the general practitioner tried to improve the quality of life in both cases. The patient's and carer's ability to cope with post-stroke disability is enhanced by providing adequate information. The three consecutive phases in the post-stroke process have specific characteristics and corresponding needs for information: clinical information in the acute phase, coping information in the rehabilitation phase, and practical information in the chronic phase. In each phase, the information should be tuned to the individual needs of the patient and the carer. Coordination with other professionals is necessary.

During episodes of depression, patients exhibit a low mood and a number of other emotional and/or physical symptoms for a certain period of time. Regarding depression as just the defined episode when patients meet the criteria for diagnosis, ignores the fluctuating character of the illness and the role of the patient. The patient is, after all, the one who decides if and when the symptoms experienced are important enough to seek medical assistance. How a patient with depression should be treated, and whether or not and to whom the patient should be referred, depends on more than just the severity of the depression. This is because severity involves more than just the number of symptoms when the depression was first diagnosed. Ineffective coping behaviour and lack of social support both negatively influence the course of depression and if the initial treatment is not effective enough, the episode will be prolonged. The interest and skills of the general practitioners as well as the expectations and former experiences of the patient play a major role in deciding whether to refer a patient to secondary care.

The practice guideline 'Anaemia' from the Dutch College of General Practitioners will certainly be a support for the Dutch general practitioner. The inclusion of an algorithm to make a more precise diagnosis is an experiment that needs to be evaluated in the near future. However, many general practitioners will regard it as too complex for use in daily practice and specialists will find it to be of limited use, as it does not cover all cases. Consultation between the general practitioner and the specialist will give the best answer in complicated cases. Patients who complain about tiredness or dizziness will expect their general practitioner to take a blood sample for a haemoglobin test. The general practitioner will consider the risk of false-positive test results in interpreting the patient's haemoglobin level. A few concrete remarks: the guideline does not mention that vegetarianism and a low meat intake can increase the risk of vitamin B12 deficiency, and iron suppletion is advised in premenopausal women with profuse vaginal blood loss, whereas there are several treatable disorders that may cause menorrhagia.

Objective: To investigate which reservations to autopsy general practitioners (GPs) experience in themselves and in relatives of the deceased., Design: Focus-group discussions., Method: Three focus-group discussions were organised (24 GPs in total), comprising the following three types of GP: those involved in the training of new GPs, those who were able to request autopsies without encountering practical obstacles, and those who did have to overcome these obstacles when requesting an autopsy., Results: Neither training nor day-to-day functioning as a GP equips Dutch physicians in regarding autopsy as a research tool. The reservations experienced by the GPs were based on emotional issues, organisational obstacles, and financial considerations.

Two patients with terminal cancer, a 46-year-old man with intestinal obstruction and a 12-year-old boy with a brain tumour, were suffering from vomiting and from headaches and nausea, respectively. Their general practitioners consulted the general-practitioner adviser about palliative treatment. After the recommended changes in medication the symptoms decreased in both patients. They died some weeks later. Nausea and vomiting may be treated when one takes into account which centres in the brain and neurotransmitters are involved, together with the site of action of the medication. The medication may be administered by subcutaneous infusion.