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Contains fulltext : 71366.pdf (Publisher’s version ) (Closed access) BACKGROUND: Disease management of dementia in general practice (GP) is hampered by a lack of data on the prognosis of dementia. AIM: To gain more insight into the life expectancy of and the effects of cardiovascular and cerebrovascular co-morbidity in dementia patients in GP. DESIGN OF STUDY: Historical cohort. SETTING: 4 general practices in Nijmegen, The Netherlands. POPULATION: All patients in these practices participating in the Continuous Morbidity Registration (CMR). METHODS: The patient cohort was diagnosed with dementia between January 1st 1985 and December 31st 2002. The control cohort consisted of patients matched one-to-one with demented patients on age, sex, and socio-economic status. Cardiovascular and cerebrovascular co-morbidity was studied from 5 years before the diagnosis of dementia till the endpoints of data collection. RESULTS: 251 couples of patients and controls were formed (79 men, 172 women, mean age 81.4+/-7.0 years). The median life expectancy after diagnosis was 2.3 years for the dementia patients, and 3.7 years for the controls. Median time from diagnosis till nursing home placement was 1.4 years. Cerebrovascular and cardiovascular morbidity preceding dementia diagnosis decreased survival of cases with dementia with a relative risk of 1.54 (95%CI: 1.13-2.09) and in controls with a relative risk of 1.91 (95%CI: 1.48-2.46). Obesity was associated with a lower risk of dementia (RR=0.77 (95%-CI 0.63-0.94)). Hypertension and obesity diagnosed after the dementia diagnosis were significantly associated with an increase in survival. CONCLUSION: In general practice, the diagnosis of dementia is made at a late stage, when patients will continue to live at home only for a short time. Moreover, life expectancy at diagnosis is very limited and prognosis is furthermore negatively influenced by preceding cardio- and cerebrovascular co-morbidity.

Ziekten van het bewegingsapparaat betreffen spieren, pezen, bindweefsel, kraakbeen, gewrichten, gewrichtskapsel, bursae en bot. Aandoeningen van deze structuren gaan gepaard met pijn en belemmering van de normale bewegingsmogelijkheden. De incidentie en prevalentie van de aandoeningen van het bewegingsapparaat zoals deze in de CMR worden vastgelegd, zijn vermeld in tabel 13.1.1.

Er bestaat een grote diversiteit aan ziekten en functiestoornissen van de tractus digestivus. Tabel 9.1.1 laat een overzicht zien van de incidentie en, waar verschillend van de incidentie, de prevalentie van een aantal ziekten van de tractus digestivus.

De aandoeningen van de luchtwegen worden onderscheiden naar lokalisatie. Als grens tussen bovenste en onderste luchtwegen wordt het strottenhoofd aangehouden: tot en met de larynx worden ziekten en klachten toegerekend aan de bovenste luchtwegen. Het aandeel van ziekten van de luchtwegen in de totale incidentie bedraagt rond de 30%. Deze komen daarmee in de rangorde van frequentie van voorkomen op de eerste plaats. Veel van de aandoeningen van de bovenste luchtwegen vormen dan ook dagelijkse kost voor de huisarts.

Hart- en vaatziekten hebben een relatief groot aandeel in de morbiditeit en de mortaliteit. Aandoeningen van het hart en de arteriele bloedvaten beinvloeden in het algemeen de validiteit en de levensverwachting van patienten sterk, die van de veneuze bloedvaten veel minder.

De nomenclatuur en classificatie van huidziekten varieren in de loop van de tijd en naar ‘school’. Enige toelichting over de gebruiken in de CMR is op zijn plaats. Daartoe wordt als eerste een globaal onderscheid aangebracht, namelijk tussen infectieuze en niet-infectieuze huidziekten.

Dit hoofdstuk is niet lang, maar er worden enkele voor de huisarts erg belangrijke aandoeningen besproken. Het kwantitatieve belang ligt niet zozeer in de incidentiecijfers (zie de tabellen 4.1.1 en 4.1.2), maar in de prevalentiecijfers: in de rangorde van rubrieken naar frequentie van voorkomen bezetten de aandoeningen uit dit hoofdstuk een tweede plaats, na de aandoeningen van de tractus circulatorius. Het gaat in dit hoofdstuk onder andere om adipositas, vetstofwisselingsstoornissen en diabetes. Vooral het aantal bekende gevallen is aanzienlijk en de behandeling en controle van deze patienten vragen veel aandacht in de huisartspraktijk. Voor de huisarts zijn vooral zorginhoudelijke aspecten van belang: adipositas, vetstofwisselingsstoornissen en diabetes mellitus (en dat geldt ook voor hypertensie) komen vaak in combinatie voor; het zijn belangrijke risicofactoren voor het optreden van met name hart- en vaatziekten; zoals comorbiditeit bij allerlei aandoeningen compliceren zij de behandeling en beinvloeden de prognose daarvan in ongunstige zin. De huisarts ziet deze drie, samen met hypertensie, dan ook meer als risico- indicatoren dan als ‘ziekten’; het noteren ervan in de probleemlijsten van patienten is essentieel.

In 1971 werd de eerste continue morbiditeitregistratie in Nederland gestart, de CMR-Nijmegen. Sindsdien leggen de huisartsen uit de vier deelnemende praktijken alle gezondheidsstoornissen vast die de patienten uit deze praktijken doormaken en die bij hen zijn vastgesteld door de eigen huisarts, waarnemend huisartsen, praktijkassistenten en medisch specialisten. Uitgaande van dit inmiddels zeer grote en rijke databestand beschrijven de CMRartsen in dit boek meer dan 150 ziekten en aandoeningen. Zij bespreken klinisch beeld, beloop, prognose en behandeling in relatie tot de epidemiologische kenmerken van deze ziekten en aandoeningen. Centraal staan de veranderingen in de frequentie van voorkomen in de loop van de registratieperiode en de incidentie- en prevalentiecijfers naar leeftijd en geslacht. Deze worden, waar relevant, aangevuld met gegevens over het voorkomen naar jaargetijde en sociaal-economische klasse. In deze vijfde druk van Ziekten in de huisartspraktijk zijn de registratiegegevens van 1985 tot en met 2006 opgenomen en de nieuwste inzichten verwerkt. Bovendien zijn de teksten aangescherpt en gestroomlijnd met de inhoud van de NHGstandaarden.

In de CMR werden in de periode 1985-2006 gemiddeld 50 zwangerschappen per praktijk per jaar geregistreerd (incidentie 31 per 1000 vrouwen per jaar, oplopend van 26 per 1000 vrouwen van 15-24 jaar naar 85 per 1000 vrouwen van 25-44 jaar). In de eerste tien jaar van de registratie werden veel van deze zwangeren tot en met de partus begeleid door de huisarts, de laatste jaren zijn bijna alle bevallingen door een verloskundige of gynaecoloog begeleid. Aangezien niet alle bijzonderheden steeds aan de huisarts worden gemeld, is geen betrouwbaar overzicht te geven van bijvoorbeeld anemieen, urineweginfecties en bloedverlies tijdens de graviditeit.

In dit hoofdstuk worden eerst enkele neurologische aandoeningen besproken en daarna aandoeningen van ogen en oren. Een overzicht van het aantal nieuwe gevallen vindt men in de volgende tabellen: neurologische aandoeningen in tabel 6.1.1, oogaandoeningen in tabel 6.1.2 en ooraandoeningen in tabel 6.1.3.

In deze bijdrage wordt het voorkomen van de belangrijkste klachten en aandoeningen besproken waarvoor adolescenten de huisarts consulteren. Ook is er aandacht voor de chronische aandoeningen in deze leeftijdsgroep, en voor trends in de toekomst. Overgewicht, seksueel overdraagbare aandoeningen en psychische problemen zullen duidelijk toenemen.prevalentie incidentie epidemiologie adolescenten morbiditeit

Contains fulltext : 54696.pdf (Publisher’s version ) (Closed access) Minimal intervention strategies to decrease long-term benzodiazepine use have not yet been evaluated in large primary care based studies with a blinded control condition and a long follow-up period. The purpose of this study was to assess the effects of a letter with a discontinuation advice sent to long-term benzodiazepine users in family practice followed by an evaluation consultation offer. The experimental group consisted of 2425 long-term benzodiazepine users, 1707 of whom were addressed by a discontinuation letter and an evaluation consultation offer. The control group consisted of 1821 long-term users. Primary endpoints were the number of prescribed daily dosages (PDD) and the percentage of subjects without prescription (quitters). At 21 months a reduction in benzodiazepine prescription of 26% was observed in the experimental group, versus 9% in the control group (PDD difference = 12.5; 95%-ci: 8.2–16.8). In the experimental group 13% and in the control group 5% of the study completers were benzodiazepine prescription free through the full follow-up period (RR = 2.6; 95%-ci: 2.0–3.4). The percentage of quitters at short-term (6 months) was 24% in the experimental group versus 12% in the control group (RR = 2.1; 95%-ci: 1.8–2.4). It is concluded that this intervention strategy steadily reduces long-term benzodiazepine use in family practice.

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.

AIM: To assess the scalability, reliability and validity of a newly constructed self-report questionnaire on craving for benzodiazepines (BZs), the Benzodiazepine Craving Questionnaire (BCQ). SETTING AND PARTICIPANTS: The BCQ was administered once to a sample of 113 long-term and 80 former long-term general practice BZ users participating in a large BZ reduction trial in general practice. MEASUREMENTS: (1) Unidimensionality of the BCQ was tested by means of the Rasch model. (2) The Rasch-homogeneous BCQ items were assessed for subject and item discriminability. (3) Discriminative and construct validity were assessed. FINDINGS: The BCQ met the requirements for Rasch homogeneity, i.e. BZ craving as assessed by the scale can be regarded as a unidimensional construct. Subject and item discriminability were good. Construct validity was modest. Highest significant associations were found with POMS depression (Kendall's tau-c = 0.15) and Dutch Shortened MMPI negativism (Kendall's tau-c = 0.14). Discriminative validity was satisfactory. Highest discriminative power was found for a subset of eight items (Mann-Whitney U Z = - 3.6, P = 0.000). The first signs of craving are represented by the acknowledgement of expectations of positive outcome, whereas high craving is characterized by direct intention to use. CONCLUSIONS: The BCQ proved to be a reliable and psychometrically sound self-report instrument to assess BZ craving in a general practice sample of long-term BZ users.

In historische overzichten kan men lezen over de geslaagde wederopstanding van de huisartsgeneeskunde in de jaren vijftig van de vorige eeuw. Ter orientatie op dit thema wijs ik op de zeer toegankelijke serie artikelen die in Huisarts en Wetenschap in 2001 verscheen onder de titel ‘Terug naar Woudschoten, over de kern van de huisartsgeneeskunde’. Het ging en gaat om de identiteit, de professionaliteit, de maatschappelijke verankering en de toekomst van de huisartsgeneeskunde. In alledaagse termen: wie ben ik, wat kan ik, wat ben ik waard en wat wil ik bereiken. De identiteit is beschreven in de bekende Woudschoten-declaratie en ligt vast in rapporten over visie en taakopvatting.

Our aim was to examine the relationship between gout on the one hand and cardiovascular diseases and cardiovascular risk indicators on the other.A case-control study was carried out in an aggregate primary care population of approximately 12 000 patients from four Dutch general practices, with follow-up of the cases free of cardiovascular diseases at the time of the first registered episode of gout. The subjects comprised 261 patients with a first episode of gout, 170 of whom were without prevalent cardiovascular diseases, and two control patients for each case matched for age, sex and practice. In the case-control study, the main outcome measures were the prevalence of cardiovascular morbidity (angina pectoris, myocardial infarction, heart failure, cerebrovascular accident, transient ischaemic attack, peripheral vascular disease), hypertension, diabetes mellitus, obesity and hypercholesterolaemia; in the follow-up study, the main outcome measure was the incidence of cardiovascular morbidity.Thirty-five percent of 261 gout patients and 26% of 522 controls had one or more prevalent cardiovascular diseases. Compared with controls, patients had a higher prevalence of hypertension (43% versus 18%), hypercholesterolaemia (14% versus 6%) and obesity (56% versus 30%). A total of 170 gout patients without prevalent cardiovascular diseases (compared with 340 controls) had a higher prevalence of hypertension (39% versus 14%), hypercholesterolaemia (8% versus 4%), diabetes mellitus (5% versus 1%) and obesity (52% versus 27%). The first occurrence of a cardiovascular disease (real end-point) was seen in 26% of the patients free of cardiovascular morbidity and in 21% of the controls. This difference was not significant. In a Cox proportional hazard model, controlling for the cardiovascular risk indicators, gout did not prove to be an independent determinant for the development of cardiovascular disease.Gout was found to be associated with cardiovascular diseases and with cardiovascular risk indicators, without evidence of it being an independent risk indicator itself. A gout attack should be an incentive to assess the cardiovascular risk profile, when a patient seeks medical help.

AIMS: To assess the course of microalbuminuria in patients with Type 2 diabetes mellitus in general practice and the predictive value of urinary albumin concentration on all-cause mortality, cardiovascular mortality and cardiovascular morbidity. METHODS: Cohort study in Type 2 diabetic patients tested for microalbuminuria in 1992, and re-tested in 1998. During follow-up all cardiovascular morbidity and mortality were recorded. RESULTS: Of the original sample of 317 patients, 163 patients were re-tested. The mean change in urinary albumin concentration was +16.2 mg/l (range -122.0 to +602 mg/l). Seventy-five per cent of the patients without microalbuminuria in 1992 still had no microalbuminuria in 1998 and 40% of those with microalbuminuria in 1992 reverted to normoalbuminuria in 1998. Cox survival analysis, stratified for age, showed that microalbuminuria at baseline resulted in a risk ratio of all-cause mortality of 1.4 (95% confidence interval 0.8-2.7), of cardiovascular mortality of 1.2 (0.5-2.8) and of new cardiovascular events (including cardiovascular mortality) of 1.4 (0.8-2.3). CONCLUSIONS: In the majority of patients the change of urinary albumin excretion was small, but the range was wide. A weak non-significant relationship between microalbuminuria and all-cause mortality and cardiovascular morbidity was observed.

Regelmatig is ‘acute verwardheid’ de diagnose van het psychisch functioneren van ouderen met plotselinge gedragsstoornissen. Dit begrip maakt echter niet duidelijk of er sprake is van stoornissen in bewustzijn, aandacht en concentratie of cognitie, of van combinaties hiervan. In dit artikel wordt aan de hand van twee casus duidelijk gemaakt dat beoordeling en benoeming van aandacht en bewustzijn, samen met het uitvoeren van een volledig lichamelijk onderzoek (corpus), het ABC vormen voor een goede analyse van acute verwardheid bij ouderen. Alleen op deze wijze kan men betrouwbaar de diagnose delier stellen, de belangrijkste oorzaak van acute verwardheid bij ouderen. Vroegtijdig herkenning van het delier is van groot belang, omdat dit snelle behandeling van de altijd aanwezige lichamelijke stoornissen mogelijk maakt en de kans op cognitieve restschade verlaagd. Enkele eenvoudige diagnostische instrumenten kunnen de huisarts goede diensten bewijzen.

Effective interventions are available for general practitioners (GPs) to reduce unwarranted long-term benzodiazepine use [1–3]. A majority of GPs report the intention to critically discuss disconti...

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.

The aim of this article is to determine, by reviewing the literature, whether treatment of Helicobacter pylori infection in patients with non-ulcer dyspepsia affects symptoms. Ten publications were identified through a computerized and manual literature search, and the percentage of patients with symptom improvement after successful or unsuccessful eradication therapy for H. pylori infection was calculated. In the 10 studies, symptom improvement after treatment was found in 73% of the patients that became H. pylori-negative and 45% of the patients that remained H. pylori-positive. Symptom improvement was modified by various clinical features and methodological aspects. If eradication of H. pylori failed, symptoms only improved over a short period. Symptom improvement was more pronounced in dyspeptic patients in whom H. pylori was eradicated than in those in whom H. pylori infection persisted.

Certainty of a diagnosis is not only important for the patient but also for morbidity studies. In the absence of a gold standard, agreement with diagnostic criteria is often the best approach in measuring the certainty of a diagnosis. The agreement with diagnostic criteria has been studied for 5 chronic diseases (hypertension, chronic ischemic heart disease, diabetes mellitus, chronic nonspecific lung disease and osteoar- thritis) in 7 general practices with a total practice population of 23,534 persons. Agreement with diagnostic criteria is operationalized into 3 categories. For each chronic disease a diagnostic quality measure per general practitioner is computed. Retrospective data have been collected in the practices on 2295 diseases in 1989 patients. Two-thirds of the diagnoses were made in general practice. The agreement with the diagnostic criteria for the cases diagnosed in general practice is high, ranging from 96% true positive cases in diabetes mellitus to 58% in chronic nonspecific lung disease. The highest rate of false positive cases is 4%. On the level of general practitioners diagnostic qualities vary from 62 to 96% true positive cases for the different diseases. The variation in diagnostic quality between general practitioners is substantial. The prevalence rates for the 5 chronic diseases are lower after adjustment by only including true positive cases. Diagnoses of the 5 chronic diseases recorded in general practice are generally valid with low numbers of false positive cases.

In order to classify gout without identification of monosodium urate (MSU) crystals, the American College of Rheumatology (ACR) formulated criteria in 1977.1 Of the 11 criteria, ≥6 have to be present to classify patients as having gout. The criteria were not developed with reference to MSU crystals, nor were they tested properly afterwards against this gold standard.1,–,3 However, as they are widely used and cited, testing their validity is critical to our ability to understand and treat gout.4 Many studies of gout include patients with ‘self-reported gout’, provided they fulfil the ACR criteria. Most self-reported diagnoses of gout will originate from a diagnosis made by a family physician as most patients presenting with acute gout are managed by them.2 5 This makes the primary care setting particularly relevant to test the ACR criteria. We designed a prospective study in a Dutch primary care population (∼200 000 subjects) to estimate the validity of the ACR criteria (patient recruitment 2004–6). We used identified MSU …

Van de Laar FA, Van de Lisdonk EH, Lucassen PLBL, Stafleu A, Mulder J, Van den Hoogen HJM, Rutten GEHM, Van Weel C. Eetgedrag in relatie tot calorie- en vetinname bij patienten met diabetes mellitus type 2. Huisarts Wet 2008;51(8):372-7.

Contains fulltext : 55238.pdf (Publisher’s version ) (Closed access) Background. Whether long-term benzodiazepine users who participate in a family practice-based benzodiazepine discontinuation programme substitute benzodiazepines by other psychotropics is not clear. Objective. To evaluate the impact of a benzodiazepine discontinuation programme on non-benzodiazepine psychotropic prescription in family practice. Methods. In family practices in the Netherlands, 2425 long-term benzodiazepine users participated in a two-step benzodiazepine discontinuation programme. The programme started with a discontinuation letter (Step 1). Subjects unable to stop (N = 1707) were offered participation in Step 2, a three-group randomized trial with a taper procedure with group psychotherapy, a taper without psychotherapy and usual care. Only 156 subjects agreed to participate. The comparison group consisted of 1821 long-term users from family practices not participating in the programme. The main outcome was the change in prescription of non-benzodiazepine psychotropic medication from baseline (3 months before the start of the programme) till 21 months after the start of the programme. Four logistic regression models were performed concerning antidepressant prescription in the follow-up. Results. Only antidepressants were prescribed in relevant numbers. The prescription of antidepressants was not related to the programme. (P-value of experimental versus control group varied between 0.18 and 0.85 in the four models). The most important predictor of antidepressant prescription in follow-up was baseline antidepressant prescription [odds ratio (OR): 67.2; 95% confidence interval (95% CI): 49.8–90.7]. Subjects, of whom the prescription of benzodiazepines had been discontinued completely, had been prescribed less antidepressants (OR: 0.8; 95% CI: 0.6–1.0). Conclusion. An effective benzodiazepine reduction programme was not accompanied by a substitute use of other psychotropics. 7 p.

Item does not contain fulltext OBJECTIVE: Real-life data on the treatment of patients with mental health problems are important as a reference to evaluate care and benchmarking. This study describes the treatment of mental health problems in general practice as diagnosed by general practitioners (GP). MATERIAL AND METHODS: Data on mental health problems were available from structured psychiatric interviews in the general population and data on mental health problems diagnosed by general practitioners. Pharmacological and non-pharmacological treatment data were taken from patients records held electronically in general practices. RESULTS: GPs diagnosed a mental health problem in 13.2% of the 1,756 cases examined and 86% of these patients were treated by the GPs themselves. Of the 16% referrals, the majority were referred within primary care. Nearly all patients with a mental health problem received counseling or advice from their GP. Half of the patients with a medication-related disorder, a (single) mood disorder or an (single) anxiety disorder and all patients with a combined anxiety and depressive disorder received a prescription for psychotropic drugs (antidepressants and/or benzodiazepines). Nearly all patients with a sleep disorder received a prescription for benzodiazepine. In patients with psychosocial problems, 20% received benzodiazepines. CONCLUSION: The majority of mental health problems, when professionally treated, are treated in primary care. More than half the patients are treated with antidepressants and/or benzodiazepines. Most patients also receive supportive counseling or advice.

Dit is een lastige vraag met veel onzekerheden. De betrouwbaarheid van telefonische informatie staat ter discussie. Ook wil ik beter zijn geinformeerd over de actuele gezondheid (diarree, braken, koorts), de leeftijd van het kind, de zwangerschap, de geboorte, het gewicht, de voeding en de psychomotore ontwikkeling. Dan komen vragen op als: om welke mate van uitdroging gaat het, hoe nat zijn de luiers, zijn deze gewogen, hoe zijn de natte (en eventueel droge) luiders over het etmaal verdeeld? Kortom, veel is onzeker, ‘automatisch’ handelen is er niet bij.

Contains fulltext : 49395.pdf (Publisher’s version ) (Closed access) AIM: To assess restrained, emotional and external eating behaviour in patients newly diagnosed with Type 2 diabetes compared with the general population, and to assess the relationship of eating behaviour to changes in fat and energy. METHODS: We assessed emotional, external, and restrained eating behaviour and measured fat and energy intake in a cohort of patients with newly diagnosed Type 2 diabetes. Data from a comparable sample of the general population served as reference figures. We calculated correlation coefficients of the three different types of eating behaviour at diagnosis between: (i) energy and fat intake at diagnosis and (ii) changes in energy and fat intake between diagnosis and both 8 weeks and 4 years later. In addition, we used a stepwise multiple regression model with energy and fat intake or changes in energy and fat intake as dependent variables. RESULTS: The distribution of the three types of eating behaviour was similar in patients with Type 2 diabetes and the general population. Emotional and external eating was associated with increased intake of energy and fat. Conversely, restrained eating showed an inverse correlation with energy and fat intake. External eating, but not emotional eating, showed a statistically significant relation with a decrease in energy intake in women. We found no statistically significant correlations between eating behaviour (measured at diagnosis) and changes in energy and fat intake between diagnosis and 4 years. CONCLUSIONS: Patients newly diagnosed with Type 2 diabetes have similar eating behaviour compared with the general population. At diagnosis, external eating behaviour and emotional eating behaviour are associated with high-energy intake and restrained eating behaviour with low-energy intake. Women with high scores for emotional eating behaviour seem to be less able to make initial dietary changes after being diagnosed and having received dietary advice.

Bij een delier is sprake van een acuut ontstane en wisselende verstoring van het bewustzijn en de cognitie, zich uitend, onder andere, in aandachtstoornissen en desorientatie. Men onderscheidt wel een onrustige en een apathische vorm van delier, afhankelijk van het gedrag van de patient.

Koorts is geen ziekte. Het woord ‘koorts’ wordt gebruikt indien de lichaamstemperatuur zich boven een bepaald criterium bevindt, bijvoorbeeld hoger dan 38°C. Koorts is met andere woorden te zien als een testuitslag. Het begrip ‘betrouwbaarheid’ geeft de eigenschap van een test aan die ook wel ‘reproduceerbaarheid’ wordt genoemd. De bedoelde eigenschap geeft aan in hoeverre er bij herhaald meten van (in dit geval) de temperatuur en bij meten hiervan door verschillende onderzoekers bij dezelfde patient, dezelfde uitslagen worden verkregen.

Contains fulltext : 54495.pdf (Publisher’s version ) (Closed access) This study aimed to assess benzodiazepine craving longitudinally and to describe its time course by means of the Benzodiazepine Craving Questionnaire (BCQ). Subjects were long-term benzodiazepine users participating in a two-part treatment intervention aimed to reduce long-term benzodiazepine use in general practice in the Netherlands. Four repeated measurements of benzodiazepine craving were taken over a 21-month follow-up period. Results indicated that (1) benzodiazepine craving severity decreased over time, (2) patients still using benzodiazepines experienced significantly more severe craving than patients who had quit their use after one of the two interventions, and (3) the way in which patients had attempted to quit did not influence the experienced craving severity over time, however, (4) patients who had received additional tapering off, on average, reported significantly more severe craving than patients who had only received a letter as an incentive to quit. Although benzodiazepine craving is prevalent among (former) long-term benzodiazepine users during and after discontinuation, craving severity decreases over time to negligible proportions. Self-reported craving can be longitudinally monitored and quantified by means of the BCQ. 12 p.

Contains fulltext : 56068.pdf (Publisher’s version ) (Closed access) Background. Predictors of benzodiazepine discontinuation after sending a discontinuation letter by the family practitioner have not been established sufficiently. Objective. To identify predictors of short- and long-term discontinuation of benzodiazepine use and relapse in use after a minimal intervention with a discontinuation letter followed by an offer for an evaluation consultation. Methods. Predictors of benzodiazepine discontinuation and relapse in use were studied by logistic regression analysis and survival analysis within a family practice population of long-term benzodiazepine users (n = 1707) addressed by a discontinuation letter and followed for 21 months. Results. A lower baseline prescription, a shorter duration of use, male gender and use of an agent with a half-life time

Op 9 november 2003 verscheen er in The Sunday Times een artikel met als titel ‘With 100 women victims of yet another health scandal, who is to blame?’ De krant vermeldt dat in een praktijk in Schotland werd ontdekt dat gesteriliseerde en niet-gesteriliseerde specula door elkaar werden gebruikt. Daar kun je ongemerkt HIV door oplopen, hepatitis, het kankerverwekkende humane papillomavirus of Chlamydia, weet de krant en voert daarmee de spanning fors op. De kant vermeldt verder een casus waarbij in 12 jaar gebruik wordt gemaakt van niet-gesteriliseerde specula en sommige vrouwen vervolgens positief werden getest op hepatitis B.

De lichaamstemperatuur wordt normaal gesproken constant gehouden door middel van een feedback systeem dat vergelijkbaar is met de thermostaat van de verwarming in een huis.

In deze bijdrage worden overwegingen aangedragen die dienen als bakens voor huisartsen bij het zoeken naar een goed beleid. Een beperking, "de leeftijd": het gaat hier over recidiverende urineweginfecties bij mannen in de geslachtsrijpe leeftijd.

Weefsellijm zit in kleine plastic tubes verpakt. Bij kleine oppervlakkig snijwonden is weefsellijm een goed alternatief voor een hechtdraad. Er is in die gevallen weinig lijm nodig, er blijft veel achter in de tube. Dat nodigt uit voor hergebruik.

In de huisartspraktijk wordt frequent telefonisch advies gegeven, zowel door de huisarts als door de praktijkassistente. De praktijkassistente wordt hiervoor getraind en de telefoonkaarten van het NHG (Nederlands Huisartsen Genootschap) bieden inhoudelijke ondersteuning bij deze functie. Op zich heeft een telefonisch advies geen juridische consequenties. Pas na aangifte (tuchtrecht of civiel recht) kan er sprake zijn van een juridische procedure. Dan is er dus wat mis gegaan. En dat is zeker denkbaar in geval van een melding van ‘symptoomloze uitslag bij een gezonde zuigeling of peuter’.

Prikaccidenten in de huisartspraktijk betreffen vooral naaldverwondingen, het zal niet vaak gaan om mes- of glasverwondingen. De verwonding zelf is meestal minimaal en behoeft geen bijzondere verzorging. De belangrijke vraag is of door de verwonding besmetting kan hebben plaatsgevonden, waarbij de gedachten vooral uitgaan naar hepatitis-B, hepatitis-C en HIV. Deze vraag houdt van tijd tot tijd de gemoederen bezig van alle werkers in de gezondheidszorg, zeker indien zij een verhoogd risico hebben op prikaccidenten, zoals chirurgen, anesthesisten, tandartsen, verpleegkundigen en laboratoriummedewerkers.

Contains fulltext : 50090.pdf (Publisher’s version ) (Closed access) BACKGROUND: It is taken for granted that diuretics may induce gout, but there is a general lack of evidence on this topic. OBJECTIVES: To determine the incidence of gout in patients who use diuretics, taking into account concurrent hypertension and cardiovascular diseases. METHODS: A case-control study was designed. From a primary care population all patients with a first gout registration (59 men, 11 women; mean (SD) age 55.1 (13.5)) were identified as cases. To relate the occurrence of gout to diuretic use a matched reference series of three controls for each case was compiled. Conditional logistic regression analyses were applied to estimate incidence rate ratios (IRRs) of gout, and 95% confidence intervals (CIs), in subjects with and without diuretic treatment, hypertension, and cardiovascular diseases. Additional stratification analyses were made, particularly in the subjects not using diuretics. RESULTS: The IRRs of gout in subjects with v those without diuretic treatment, hypertension, heart failure, and myocardial infarction were 2.8 (95% CI 1.2 to 6.6), 2.6 (95% CI 1.2 to 5.6), 20.9 (95% CI 2.5 to 173.8), and 1.9 (95% CI 0.7 to 4.7), respectively. After adjustment, the IRR of gout for diuretic use dropped to 0.6 (95% CI 0.2 to 2.0), while the IRRs of gout for hypertension, heart failure, and myocardial infarction were still >1. This was also the case for subjects with hypertension or myocardial infarction, who had not used diuretics. CONCLUSION: The results suggest that diuretics do not actually increase the risk of gout. Cardiovascular indications for treatment may have confounded previous inferences.

Contains fulltext : 48650.pdf (Publisher’s version ) (Open Access) BACKGROUND: Alpha-glucosidase inhibitors such as acarbose or miglitol, have the potential to improve glycemic control in type 2 diabetes mellitus. The true value of these agents, especially in relation to diabetes related mortality and morbidity, has never been investigated in a systematic literature review and meta-analysis. OBJECTIVES: To assess the effects of alpha-glucosidase inhibitors s in patients with type 2 diabetes mellitus. SEARCH STRATEGY: We searched The Cochrane Library, MEDLINE, EMBASE, Current Contents, LILACS, databases of ongoing trials, reference lists of reviews on the topic of alpha-glucosidase inhibitors and we contacted experts and manufacturers for additional trials. Date of most recent search: December 2003 (Current Contents) and April 2003 (other databases). SELECTION CRITERIA: Randomised controlled trials of at least 12 weeks duration comparing alpha-glucosidase inhibitor monotherapy in patients with type 2 diabetes with any other intervention and that included at least one of the following outcomes: mortality, morbidity, quality of life, glycemic control, lipids, insulin levels, body weight, adverse events. DATA COLLECTION AND ANALYSIS: Two reviewers read all abstracts, assessed quality and extracted data independently. Discrepancies were resolved by consensus or by the judgement of a third reviewer. A statistician checked all extracted data entrance in the database. We attempted to contact all authors for data clarification. MAIN RESULTS: We included 41 trials (8130 participants), 30 investigated acarbose, seven miglitol, one trial voglibose and three trials compared different alpha-glucosidase inhibitors. Study duration was 24 weeks in most cases and only two studies lasted amply longer than one year. We found only few data on mortality, morbidity and quality of life. Acarbose had a clear effect on glycemic control compared to placebo: glycated haemoglobin -0.8% (95% confidence interval -0.9 to -0.7), fasting blood glucose -1.1 mmol/L (95% confidence interval -1.4 to -0.9), post-load blood glucose -2.3 mmol/L (95% confidence interval -2.7 to -1.9). The effect on glycated haemoglobin by acarbose was not dose-dependent. We found a decreasing effect on post-load insulin and no clinically relevant effects on lipids or body weight. Adverse effects were mostly of gastro-intestinal origin and dose dependent. Compared to sulphonylurea, acarbose decreased fasting and post-load insulin levels by -24.8 pmol/L (95% confidence interval -43.3 to -6.3) and -133.2 pmol/L (95% confidence interval -184.5 to -81.8) respectively and acarbose caused more adverse effects. AUTHORS' CONCLUSIONS: It remains unclear whether alpha-glucosidase inhibitors influence mortality or morbidity in patients with type 2 diabetes. Conversely, they have a significant effect on glycemic control and insulin levels, but no statistically significant effect on lipids and body weight. These effects are less sure when alpha-glucosidase inhibitors are used for a longer duration. Acarbose dosages higher than 50 mg TID offer no additional effect on glycated hemoglobin but more adverse effects instead. Compared to sulphonylurea, alpha-glucosidase inhibitors lower fasting and post-load insulin levels and have an inferior profile regarding glycemic control and adverse effects.

Item does not contain fulltext BACKGROUND: During the past two decades, socio-economic inequalities in health have been a major research theme in Western Europe. Research has shown that there are persistent differences in health between people with a high socio-economic status (SES) compared with people with a low SES. There are also indications for a widening health gap. The present paper aimed to find out whether this widening health gap exists in The Netherlands using morbidity data from a general practice (GP) registry. METHODS: Incidence data from a GP registry were used, involving over 12,000 patients. Morbidity data from 1975 to 2000 were grouped into 25 disease categories. SES was based on household occupational status. Poisson regression was used to determine the relationship between morbidity and SES and its changes over time. Separate analyses were performed for men and women. RESULTS: In most disease categories, a clear SES gradient disadvantageous to the lowest-SES group was identified: 17 out of 22 morbidity categories for men and 17 out of 24 for women. For seven (men) and eight (women) morbidity categories out of 17, the SES gradient increased between 1975 and 2000. CONCLUSIONS: This study provides new evidence for a widening gap in health between higher and lower SES in The Netherlands, using GP-defined disease data and a wide range of morbidity categories.

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Contains fulltext : 58944.pdf (Publisher’s version ) (Closed access) AIMS: To evaluate risk factors for the development of an impaired renal function, defined as a glomerular filtration rate (GFR) by Cockcroft-Gault formula < 50.5 ml/min, in primary care patients with Type 2 diabetes mellitus. METHODS: A case-control study of Type 2 diabetes mellitus patients with impaired renal function and age, sex and practice matched controls with Type 2 diabetes mellitus without impaired renal function in 10 Dutch family practices performing the Nijmegen Monitoring Project. Main outcome measure was the independent risk factors of impaired renal function. RESULTS: Eighty-seven individuals with impaired renal function were identified. The point prevalence of impaired renal function in the sample population on 31 March 2001 was 87/873 (10.0%; 95% confidence interval 7.0-15.1%). Of 87 cases, 23 (26.5%; 17.3-30.9%) were found to have impaired renal function at diagnosis. Conditional multiple logistic regression analysis revealed the following independent risk factors for the development of impaired renal function: duration of diabetes > or = 8 years (adjusted odds ratio 5.6 (2.5-12.5); P < 0.001), glomerular filtration rate by Cockcroft-Gault formula 50.5-80.5 ml/min at diagnosis [3.5 (1.5-8.1); P < 0.01] and existing macrovascular complications at diagnosis [2.6 (1.1-6.3); P < 0.01]. CONCLUSION: Duration of diabetes > or = 8 years, mild renal impairment at the time of diagnosis and existing macrovascular complications at the time of diagnosis are independent risk factors for the development of impaired renal function in white patients with Type 2 diabetes mellitus.

Item does not contain fulltext BACKGROUND: Contrary to short-term use, long-term benzodiazepine use is undesirable. Nevertheless, its prevalence is high. To prevent long-term use, it is important to know which short-term users are at risk of becoming long-term users. OBJECTIVES: The purpose of the present study was to identify patient-related factors of long-term versus short-term use of benzodiazepines. METHODS: A cross-sectional study was carried out in family practices among users of benzodiazepines with regard to DSM-IV diagnosis, coping and psychosocial characteristics,. In a multivariate logistic regression analysis, long-term use of benzodiazepines was the dependent variable. RESULTS: A total of 164 short-term and 158 long-term benzodiazepine users participated in the study. Having a DSM-IV disorder and psychiatric co-morbidity, being older, less educated, lonely and using more avoidance coping behaviour was associated with long-term use of benzodiazepines compared with short-term use. CONCLUSION: The associations found point to possibilities to reduce long-term benzodiazepine use, for example if patients with these characteristics are treated with the alternatives to benzodiazepines or are monitored closely for a short period after being prescribing benzodiazepines.

BackgroundBenzodiazepine withdrawal programmes have never been experimentally compared with a nonintervention control condition.AimsTo evaluate the efficacy and feasibility of tapering off long-term benzodiazepine use in general practice, and to evaluate the value of additional group cognitive–behavioural therapy (CBT).MethodA 3-month randomised, controlled trial was conducted in which 180 people attempting to discontinue long-term benzodiazepine use were assigned to tapering off plus group CBT, tapering off alone or usual care.ResultsTapering off led to a significantly higher proportion of successful discontinuations than usual care (62% v. 21%). Adding group CBT did not increase the success rate (58% v. 62%). Neither successful discontinuation nor intervention type affected psychological functioning. Both tapering strategies showed good feasibility in general practice.ConclusionsTapering off is a feasible and effective way of discontinuing long-term benzodiazepine use in general practice. The addition of group CBT is of limited value.

Item does not contain fulltext BACKGROUND: Different prevalences of benzodiazepine (BZ) use are described in the literature. The present study assessed the effects of employing various definitions of BZ use and various observation periods on the prevalence rate of BZ use in an open population aged 18-74 years. METHOD: In a literature review, prevalence studies were systematically compared. In a second stage, a descriptive cross-sectional multipractice study was analysed using 48,046 prescriptions of BZ in the past year given to a population of 80,315 patients at 31 general practices in the Nijmegen Health Area. From this database, prevalence rates were calculated applying different definitions of BZ use and different observation periods. RESULTS: In the literature, prevalence rates varied between 2.2 and 17.6%. There was wide variation in definitions of BZ use and observation period. In our prescription database, depending on the definitions of BZ use and observation period, prevalence rates ranged from 0.2% to 8.9%. The ratio of female:male (2:1) remained constant irrespective of the prevalence rate. Age distribution varied according to the duration of use: among long-term BZ users, approximately 80% were older than 45 years; among short-term BZ users, approximately 55% were older than 45 years. CONCLUSIONS: The wide variation in prevalence rates of BZ use reported in the literature can largely be explained by differences in definitions of BZ use and observation period. This affected the distribution of some BZ-use-related variables such as age. For reliable comparisons of BZ use, standardisation of the definition of BZ use is required. A proposal for standardising methodology is presented.