Search

Item does not contain fulltext OBJECTIVES: The aim of this study was to investigate the feasibility of systematic monitoring of patients' quality of life and its relationship to GPs' interventions concerning management of asthma and chronic obstructive pulmonary disease (COPD). METHODS: A cross-sectional study on patients' self-reported quality of life in relation to GPs' subsequent interventions during consultation was performed. Fourteen GPs at six general practices in The Netherlands monitored 175 patients aged 18 years and older with asthma and COPD. Directly before each planned follow-up consultation, patients completed a self-report questionnaire (27 items, five dimensions) about their quality of life; GPs reviewed the monitoring scores during consultation and recorded their diagnostic and therapeutic interventions. The relationship between patients' perceived quality of life and GPs' medication prescription, smoking cessation advice, patient education and counselling was analysed. RESULTS: During 15 months, 175 patients underwent 537 consultations. In 57% of the consultations, patients reported impairments in their quality of life. This information was significantly associated with subsequent GP interventions (chi-square = 0.05), especially with providing patient education and counselling. Multivariate logistic regression analyses showed that reported physical complaints were positively associated with changes in medication prescription [odds ratio (OR) 1.7; 95% confidence interval (CI) 1.0-2.8] and with education about the control regimen (OR 1.9; 95% CI 1.1-3.3). Reported emotional complaints were related to extra follow-up appointments (OR 4.3; 95% CI 1.5-12.8) and to counselling (OR 7.3; 95% CI 2.9-18.3). In general, more advanced age was related to less patient education. Patients' and GPs' opinions about the quality of life monitoring were positive. CONCLUSIONS: Information about quality of life of patients, gathered systematically and routinely directly before consultation, could be integrated into a complex medical decision-making process; scores were related to various therapeutic interventions.

Item does not contain fulltext

Background Traditionally, health and the outcomes of medical treatment have been measured in terms of morbidity, incidence or prevalence of disease, or even mortality. This disease model provides an adequate framework for acute illnesses, but for chronic diseases, severity and their effect on everyday functioning are paramount. For chronic diseases, functional health status, as a vital part of quality of life, is now recognized as an important outcome measure of the GP's care. Objective We aimed to assess the impact of type 2 diabetes mellitus on functional health status in Dutch general practice. Method We conducted a cross-sectional study of the functional health status of all patients with type 2 diabetes mellitus under 85 in two general practices, using the Sickness Impact Profile (SIP) and the COOP/WONCA charts. A control group of non-diabetic patients was selected, matched for practice, sex and age. Results In total, 127 type 2 diabetes mellitus patients and 127 controls participated in the study, the responses being 78 and 70%, respectively. Between these groups the following were significantly different: the SIP subscore Physical, the SIP sum score and the COOP/WONCA scores for physical fitness and overall health. Type 2 diabetes mellitus patients were 2.46 (95% CI 1.5-4.1) times more likely to experience functional impairment. Cardiovascular morbidity (odds ratio 2.5, 95% CI 1.3-4.7), locomotory morbidity (odds ratio 2.6, 95% CI 1.4-5.1) and diabetes itself (odds ratio 1.4, 95% CI 1.1-1.9) were significantly associated with the presence of functional impairment. Conclusion This study demonstrates the impact of type 2 diabetes mellitus on functional status, particularly in relation to cardiovascular morbidity.

OBJECTIVE A history of gastrointestinal disease is a risk factor for organic gastrointestinal disorders overall. We conducted a retrospective case-control study to explore whether a history of gastrointestinal disease is of prognostic value for gastric cancer. METHODS Forty-six patients with gastric cancer were identified from a dynamic population of approximately 12,000 patients followed since 1971 in four general practices. The control subjects without gastric cancer were matched one-on-one according to age, general practice, sex and observation period. Data on gastrointestinal morbidity in the period before gastric cancer was diagnosed were obtained from the Continuous Morbidity Registration. RESULTS The mean observation period between the date of enrolment in the registration and the first diagnosis of gastric carcinoma was 12 years. Although every patient with gastric cancer ultimately will develop gastrointestinal complaints, 28 of these patients had no previous gastrointestinal morbidity, in comparison with 26 control subjects. Furthermore, patients who developed gastric cancer did not have more frequent gastrointestinal morbidity in their past than the control subjects (odds ratio 0.80, 95% CI 0.32-2.03). CONCLUSIONS Our results suggest that a history of gastrointestinal morbidity is not of prognostic value for gastric cancer. Focusing attention on patients with a past history of gastrointestinal symptoms to detect gastric cancer may be of little value.

1 Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission of Human Immunodefi ciency Virus Type 1. N Engl J Med 2000; 342: 921–29. 2 Matovu JKB, Gray RH, Makumbi F, et al. Voluntary HIV counseling and testing acceptance, sexual risk behavior and HIV incidence in Rakai, Uganda. AIDS 2005; 19: 503–11. 3 Allen S, Serufi liraA, Bogaerts J, et al. Confi dential HIV Testing and Condom Promotion in Africa. JAMA 1992; 268: 3338–43. 4 Guthrie B, de Bruyn G, Farquhar C. HIV-1 discordant couples in sub-Saharan Africa: explanations and implications for high rates of discordancy. Curr HIV Res 2007; 5: 416–29. 5 Roth DL, Stewart KE, Clay OJ, van der Straten A, Karita E, Allen S. Sexual practices of HIV discordant and concordant couples in Rwanda: eff ects of a testing and counseling programme for men. Int J STD AIDS 2001; 12: 181–88.

Background: Fructooligosaccharides have been claimed to lower fasting glycemia and serum total cholesterol concentrations, possibly via effects of short-chain fatty acids produced during fermentation. Objective: We studied the effects of fructooligosaccharides on blood glucose, serum lipids, and serum acetate in 20 patients with type 2 diabetes. Design: In a randomized, single-blind, crossover design, patients consumed either glucose as a placebo (4 g/d) or fructooligosaccharides (15 g/d) for 20 d each. Average daily intakes of energy, macronutrients, and dietary fiber were similar with both treatments. Results: Compliance, expressed as the proportion of supplements not returned, was near 100% during both treatments. Fructooligosaccharides did not significantly affect fasting concentrations (mmol/L) of serum total cholesterol (95% CI: 20.07, 0.48), HDL cholesterol (20.04, 0.04), LDL cholesterol (20.06, 0.34), serum triacylglycerols ( 20.21, 0.44), serum free fatty acids (20.08, 0.04), serum acetate (20.01, 0.01), or blood glucose (20.37, 0.40). Conclusions: We conclude that 20 d of dietary supplementation with fructooligosaccharides had no major effect on blood glucose, serum lipids, or serum acetate in patients with type 2 diabetes. This lack of effect was not due to changes in dietary intake, insufficient statistical power, or noncompliance of the patients. Am J Clin Nutr 1999;69:64‐9.

To determine whether an empirical drug treatment strategy (empirical group) instead of upper gastrointestinal endoscopy followed by treatment (conventional group) in patients with persistent dyspepsia increases appropriate use of endoscopy facilities, we did a decision analysis based on data found in the literature. We estimated the percentage of patients having an upper gastrointestinal endoscopy in 1 year, the percentage of patients with symptom relief, and the average medical costs per patient for both groups. In the empirical group, fewer patients (38%) had upper gastrointestinal endoscopies compared with the conventional group. Furthermore, an additional 5% of patients in the empirical group experienced symptom relief, and the average medical costs per patient were estimated to be 8% less in this group when compared with the patients in the conventional treatment group. The proposed empirical drug treatment strategy for patients with persistent dyspepsia results in the performance of fewer diagnostic upper gastrointestinal endoscopies per year with greater effectiveness compared with upper gastrointestinal endoscopy followed by treatment.

Background The mortality rate associated with ruptured abdominal aortic aneurysm (AAA) remains high. The objective of this study was to assess the feasibility of population screening for AAA. Methods In an area with a mixed rural and industrialized population of 60 000 inhabitants, all 23 general practitioners (GPs) participated. The GPs selected from their patient lists men aged 60–80 years. Men whose condition was suitable for aortic surgery were invited for screening by a single postal letter. All men responding had aortic ultrasonography in or close to the GP surgery. Diagnosis of AAA was established when the aortic diameter was 30 mm or greater. Referral for surgery was advised for an aortic diameter of 50 mm or greater. Results Of 2914 invitations, 2419 men had ultrasonography, resulting in an attendance rate of 83·0 per cent. A total of 2416 aortic measurements were made; 196 aortic aneurysms were diagnosed (prevalence 8·1 per cent). In 40 men the aortic diameter was over 50 mm. Conclusion Ultrasonographic screening for AAA is feasible in a primary care setting.

SummaryAbouttwo-thirds of long-term users of benzodiazepines in the population are able to discontinue this drug with the aid of supervised programmes for tapering off. Little is known about the long-term outcome of such programmes, and they have never been compared with usual care. After a 15-month follow-up of a randomised controlled trial comparing such a programme with and without psychotherapy with usual care, we found significantly higher longitudinal abstinence rates in long-term benzodiazepine users who received a benzodiazepine tapering-off programme without psychotherapy (25 out of 69, 36%) compared with those who received usual care (5 out of 33, 15%; P=0.03).

Background Monoarthritis is the most common form of arthritis in the general practice. In primary care an arthritis of the first metatarsophalangeal (MTP) joint is almost always considered as gout. Gout is the most frequent cause of a monoarthritis that affects the first MTP joint, but it is unknown which other forms of arthritis occur in the first MTP joint. 1-2-3 Objectives The aims of this study are firstly to determine which other forms of monoarthritis occur in the first MTP joint, and secondly to identify the clinical differences between patients with an arthritis of the first MTP joint caused by gout and those not caused by gout. Methods In this observational follow-up study 159 patients with a monoarthritis of the first MTP joint have been included. These patients were referred by their general practitioner (GP) to the Department of Rheumatology of Rijnstate Hospital, The Netherlands, because of a clinical trial regarding the treatment of an acute gout attack. 4 Within 24 hours of presentation to the GP, the patients were examined by a rheumatologist. Clinical variables were collected. The synovial fluid of the affected MTP-1 joints was obtained and analyzed for the presence of MSU crystals. Thereafter, patients with undifferentiated monoarthritis (n=24) were followed-up by their GPs. 7 years later, in 2012, the GPs were asked for additional information about the course of the disease. In addition, the medical hospital records have been researched whether there eventually was established a definite diagnosis. Results After a mean follow-up period of 7 years 36 of the 159 patients (23%) with MTP-1 arthritis did not have gout. 24 of them had no diagnosis and 12 patients had a different diagnosis than gout, namely rheumatoid arthritis, osteoarthritis, psoriatic arthritis, pseudogout, arthritis with an inflammatory bowel disease, bunion, palindromic rheumatism, IgM rheumatoid factor (RF) positive arthritis, and IgM RF and ACPA negative, ANA positive arthritis. The characteristics which are statistically significant more present in patients with gout are male sex, a previous arthritis, the use of diuretics, the use of cardiovascular or antihypertensive drugs, hypertension or cardiovascular disease, beer consumption, BMI >25 kg/m 2 , serum uric acid >0.35 mmol/L, serum creatinine >105 mcmol/L, glomerular filtration rate 10mg/L (p Conclusions Gout is a prominent but certainly not an exclusive cause of MTP-1 arthritis. In almost a quarter of the patients with a MTP-1 arthritis the cause is different than gout. In these patients the arthritis is mostly an expression of a transient undifferentiated arthritis or a different persistent rheumatic disease. We advocate aspiration of MTP-1 arthritis in order to differentiate gout from other forms of MTP-1 arthritis, in particular when a valid diagnosis has therapeutic or prognostic consequences. References Huskisson, E. C., et al. (1972). “Pseudopodagra. Differential diagnosis of gout.” Lancet 2(7771): 269-71. Ma, L., A. Cranney, et al. (2009). “Acute monoarthritis: what is the cause of my patient’s painful swollen joint?” Cmaj 180(1): 59-65. Velilla-Moliner, J., et al. (2004). “Podagra, is it always gout?” Am J Emerg Med 22(4): 320-1. Janssens, H. J., et al. (2008). “Use of oral prednisolone or naproxen for the treatment of gout arthritis: a double-blind, randomised equivalence trial.” Lancet 371(9627): 1854-60. Disclosure of Interest None Declared

and colleagues [2, 3], which indicated that uncomplicated acute otitis media in children over 2 years of age can be treated as effectively with acetaminophen as with antibiotics, national consensus was reached that antibiotics are unnecessary in most cases of otitis media [4, 5]. Routine tympanocentesis for obtaining culture specimens is also considered unnecessary. Only patients with an irregular clinical course and those under 2 years of age will receive antibiotic treatment.

With the increasing number of elderly people in The Netherlands the prevalence of chronic diseases will rise in the next decades. It is recognized in general practice that many older patients suffer from more than one chronic disease (comorbidity). The aim of this study is to describe the extent of comorbidity for the following diseases: hypertension, chronic ischemic heart disease, diabetes mellitus, chronic nonspecific lung disease, osteoarthritis. In a general practice population of 23,534 persons, 1989 patients have been identified with one or more chronic diseases. Only diseases in agreement with diagnostic criteria were included. In persons of 65 and older 23% suffer from one or more of the chronic diseases under study. Within this group 15% suffer from more than one of the chronic diseases. Osteoarthritis and diabetes mellitus are the diseases with the highest rate of comorbidity. Comorbidity restricts the external validity of results from single-disease intervention studies and complicates the organization of care.

Inleiding Onderdiagnostiek en onderbehandeling van depressie en angststoornissen door de huisarts is onderwerp van uitgebreid wetenschappelijk debat. Verschillende factoren dragen bij aan het gesignaleerde probleem. Meerdere onderzoeken met als doel de kennis en vaardigheden van huisartsen op gebied van diagnostiek en behandeling te verbeteren laten bescheiden langetermijnresultaten zien. Ook de uitvoerbaarheid in de dagelijkse praktijk wordt betwijfeld.

Item does not contain fulltext 2 p.

Background Cost-effectiveness analysis, Helicobacter pylori research and the development of proton pump inhibitors are having an increasing impact on the management of dyspepsia. However, clinical trials have not always included both H. pylori diagnosis and proton pump inhibitors in their protocols. Methods Patients who were referred for upper gastrointestinal endoscopy by their general practitioner were randomized to either prompt endoscopy followed by directed medical treatment (conventional group, n = 38), or to empirical treatment with omeprazole and, in the case of symptom relapse, serological screening for H. pylori infection followed by eradication therapy in seropositive patients (empirical group, n = 42). The study lasted for up to 1 year. Results In the empirical group, only 13 patients (31%) underwent endoscopy. The average number of days for which the patients kept records of their dyspeptic symptoms was 266 (95% CI: 226–307) in the empirical group, of which 166 (95% CI: 128–204) were symptom-free. In the conventional group, 159 (95% CI: 119–198) out of 255 days (95% CI: 209–302) were recorded as symptom-free. The average medical cost in the empirical group was 284 (95% CI: 218–350) and in the conventional group 491 (95% CI: 383–600). In the empirical group, two malignancies were found, whereas in the conventional group one malignancy was found. Conclusions The empirical drug treatment strategy in patients with persistent dyspeptic symptoms resulted in 69% fewer diagnostic endoscopies with lower medical costs and equal effectiveness in the first year, compared to prompt endoscopy followed by directed medical treatment.

Contains fulltext : 89908.pdf (Publisher’s version ) (Closed access) Clinically, gout is generally considered as a preferential male disease. However, it definitely does not occur exclusively in males. Our aim was to assess differences in the clinical features of gout arthritis between female and male patients. Five electronic databases were searched to identify relevant original studies published between 1977 and 2007. The included studies had to focus on adult patients with primary gout arthritis and on sex differences in clinical features. Two reviewers independently assessed eligibility and quality of the studies. Out of 355 articles, 14 were selected. Nine fulfilled the quality and score criteria. We identified the following sex differences in the clinical features of gout in women compared to men: the onset of gout occurs at a higher age, more comorbidity with hypertension or renal insufficiency, more often use of diuretics, less likely to drink alcohol, less often podagra but more often involvement of other joints, less frequent recurrent attacks. We found interesting sex differences regarding the clinical features of patients with gout arthritis. To diagnose gout in women, knowledge of these differences is essential, and more research is needed to understand and explain the differences , especially in the general population. 01 juni 2010

A historical cohort study was performed to assess cardiovascular morbidity and mortality in Type 2 (non-insulin-dependent) diabetic patients. The data were collected from 1967 to 1989 in four Dutch general practices performing the Continuous Morbidity Registration Nijmegen. Each newly diagnosed Type 2 diabetic patient fulfilling the WHO criteria (n = 265) was matched to a control patient for practice, sex, age, and social class. Inclusion started in 1967, the first year of the still ongoing, Continuous Morbidity Registration Nijmegen. On average, a follow-up of 6.8 years (range 1 month-22 years) was realized. Compared to the non-diabetic control patients, the Type 2 diabetic patients showed higher cardiovascular morbidity (risk ratio 1.76, 95% CI 1.34-2.30) and a higher mortality rate (risk ratio 1.54, 95% CI 1.07-2.23). Mortality after 10 years was 36% vs 20% (p < 0.01), the median survival time 16 years vs 19 years. The cumulative survival rates were significantly different (p < 0.01) between patients and controls in the age group 65-74 years. The higher mortality in Type 2 diabetic patients was completely due to an excess of cardiovascular death (risk ratio 2.05, 95% CI 1.24-3.37).