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Contains fulltext : 238112.pdf (Publisher’s version ) (Open Access) OBJECTIVES: We investigated the 2-week prevalence and correlates of very frequent physical aggression (PA) and vocalizations in nursing home (NH)-residents with dementia. METHOD/DESIGN: This cross-sectional study used combined data of 2074 NH-residents from four studies, collected from 119 dementia special care units in 26 Dutch NH. Very frequent PA was defined as scoring 6 or 7 on the items 'hitting', pushing', 'biting' and 'kicking' of the Cohen Mansfield Agitation Inventory; very frequent vocalizations as scoring 6 or 7 on 'screaming' and 'making strange noises'. We compared NH-residents with very frequent PA or vocalizations with residents with less frequent PA or vocalizations, assessing correlates using univariate and multivariate multilevel logistic regression analyses. RESULTS: We found a 2-week prevalence of 2.2% (95% confidence interval (CI): 1.63-2.89) of very frequent PA and 11.5% of very frequent vocalizations (95% CI: 10.23-12.98). Very frequent PA was only associated with apathy (odds ratio (OR)=1.93, 95% CI: 1.04-3.61). Correlates of very frequent vocalizations were age (OR = 0.97, 95% CI: 0.951-0.998), dementia severity (overall p-value 0.020), antipsychotic drug use (OR = 1.56, 95% CI: 1.08-2.26), antiepileptic drug use (OR = 2.75, 95% CI: 1.34-5.68) and euphoria (OR = 2.01, 95% CI: 1.22-3.31). CONCLUSION: Characteristics of NH-residents with very frequent PA or very frequent vocalizations differ from those of NH-residents with less frequent PA or vocalizations. Frontal lobe damage, boredom, pain and/or external factors may explain several of the found associations, but further research is necessary. Our findings may contribute to better care for these residents and thereby to improving their quality of life.

BACKGROUND: Lower urinary tract symptom (LUTS) is a common condition in older men. In accordance with the Dutch College of General Practitioners Guideline "Micturition symptoms in men", the diagnosis can be made based on a patient's medical history and a physical examination. GPs lack additional tools in primary care to assess the residual urine volume. A residual volume usually requires a referral to a urologist. We hypothesized that the IPSS screening questionnaire score (measuring the severity of symptoms) might be related to patients' residual urine volume. The research objective was to examine the relation between the IPSS score and the residual urine volume. METHODS: In a cross-sectional study, we analysed patients' IPSS and residual urine volume. Men aged over 50 with LUTS who consulted Dutch primary-care physicians were included. The interventions comprised an IPSS screening and a bladder scan. Data regarding the patients' residual volume, total IPSS score, single IPSS score, IPSS storage score, and IPSS voiding score were recorded and analysed. We used odds ratios to describe the relation between the IPSS categories associated with the presence of a normal or abnormal (above 100 cc and above 200 cc) residual urine volume. RESULTS: A total of 126 patients were included in this study. Patients with higher scores on the overall IPSS, separate IPSS, IPSS storage and IPSS voiding showed no higher odds ratios of having an abnormal residual volume, neither above 100 mL or 200 mL. CONCLUSION: We did not find a relation between the IPSS core to an abnormal residual urine volume in men aged over 50 with LUTS consulting primary-care physicians. TRIAL REGISTRATION: This study has been approved by the Central Committee on Research Involving Human Subjects for the Arnhem-Nijmegen Region and is registered with ToetsingOnline under ID number 29822.091.10.

ObjectivesNeuropsychiatric symptoms (NPSs) in dementia patients in nursing homes are common and often treated with psychotropic drugs. Thus far, studies on psychotropic drug use (PDU) mainly focused on elderly patients with dementia. It is important to know the prevalence and correlates of PDU in patients with young-onset dementia (YOD) to optimize NPS treatment and reduce excess PDU in this group.DesignThe Behavior and Evolution in Young-Onset Dementia (BEYOnD) study is a cross-sectional study in 230 residents with YOD in eight nursing homes providing specialized YOD care. PDU was registered from medical charts. The influence of age, gender, severity, and type of dementia, NPS, and agitation on PDU was analyzed.ResultsEighty-seven percent of the residents used psychotropic drugs, and 47% used two or more psychotropic drugs. No significant associations with age, gender, dementia subtype, and dementia severity were found. Depressive symptoms showed an association with the use of antidepressants, nighttime behavior with use of hypnotics, and verbal agitation with antipsychotics. Apathy was strongly associated with lower PDU.ConclusionsNursing home patients with YOD have a high prevalence of PDU. The association with NPS raises questions of efficacy of these drugs in managing NPS. Patients with apathy had a lower chance of using psychotropics. More research on indications and effects of psychotropic drugs is needed, as well as on (nonpharmacological) alternatives for managing challenging behavior in YOD.

This cross sectional study examines how patient characteristics, doctor characteristics, and doctors’ education and attitudes affect the extent to which doctors link progress notes to clinical problems. The independent effects of patient characteristics on the linking of notes was examined with a mixed model logistic regression. The effects of doctor characteristics and doctors’ education and attitudes on the link ratio was analyzed with univariate analysis of variance. A survey was used to obtain arguments and attitudes on linking notes. For “patient characteristics”, the odds of linking increased with an increase in the number of problems or hospital days, decreased, with an increase in the number of involved doctors, medical specialties or the number of notes. For “doctor characteristics”, the link ratio increased with more work experience. For “doctors’ education and attitudes”, the link ratio increased with more familiarity in linking notes and belief in the added value of problem oriented charting. “Overview” was the most cited reason for linking; “I don’t know how” the most cited reason for not linking. There is a huge variation within and between all disciplines. Important arguments, for and against, are found. Recommendations for policymakers and medical leadership are given to maximize the benefits.

Background: The progression of dementia in people with young-onset dementia (YOD) is relatively unknown. Objective: To investigate the progression of dementia and cognitive decline in the three most common subtypes in YOD and to explore which factors are associated with this course. Methods: The course of dementia was examined in 198 people with YOD. The primary outcomes were cognitive function, as assessed by the Mini-Mental State Examination (MMSE) and dementia severity, as assessed by the Global Deterioration Scale (GDS). Mixed-model analyses were used to explore factors associated with the course of dementia of the diagnostic sub-types. Results: The mean overall two-year progression of dementia severity was 0.9 GDS points, this was a statistically significant change (p = 0.012) and was not significant different for the three dementia subtypes. The mean overall two-year decline in cognitive function was 1.6 points on the MMSE. The differences in cognitive decline were statistically significant (p = 0.046) among the three diagnosis groups, AD participants showed the greatest decline, of 2.3 points. In addition to lower education (p = 0.010), higher scores on the Neuropsychiatric Inventory (NPI) sub-syndromes psychosis (p < 0.001) and hyperactivity (p = 0.002) were associated with higher rates of cognitive decline. In contrast, higher scores on the NPI affect cluster were associated with lower levels of cognitive decline (p < 0.001). Conclusion: Different YOD subtypes show different rates of decline in cognitive functioning, and this decline seems less progressive compared to those observed in studies in late-onset AD. Further research is needed to evaluate whether managing neuropsychiatric symptoms can positively influence the decline of cognitive function.

Background: Paying attention to their patients’ work and recognizing work-related problems is challenging for many general practitioners (GPs). Objectives: To assess the effect of training designed to improve the care for patients with work-related problems in general practice. Methods: A cluster randomized controlled trial among 32 Dutch GPs. GPs in the intervention group received five-hour training. GPs in the control group were not trained. Included patients (age 18–63, working ≥12 h per week) completed baseline questionnaires and follow-up questionnaires planned after one year. Primary outcome at patient level was patients’ expectations about their ability to work, measured using the return-to-work self-efficacy scale (RTW-SE). Primary outcomes on GP level were their use of ICPC-code Z05 (‘work-related problem’) per 1000 working-age patients and percentage of the electronic medical files of working-age patients in which information about occupation had been recorded. Results: A total of 640 patients completed the baseline questionnaire and 281 the follow-up questionnaire. We found no statistically significant differences in patients’ RTW-SE scores: intervention 4.6 (95%CI: 4.2–5.0); control 4.5 (95%CI: 4.1–4.9). Twenty-nine GPs provided data about the GP-level outcomes, which showed no statistically significant differences: use of ICPC code Z05 11.6 (95%CI: 4.7–18.6) versus 6.0 (95%CI: –1.2 to 13.2) per 1000 working-age patients; recording of occupation 28.8% (95%CI: 25.8–31.7) versus 28.6% (95%CI: 25.6–31.6). Conclusion: Training GPs did not improve patients’ work-related self-efficacy or GPs’ registration of work-related problems and occupation.

Objective: Although many nursing home residents with dementia show agitation, hardly any literature is published about very frequent agitation. The WAALBED-III study focuses on the 2-week prevalence and correlates of very frequent agitation in these residents. Design: Cross-sectional study using combined data of four studies. Setting: One hundred nineteen dementia special care units in twenty-six nursing homes in The Netherlands. Participants: Two thousand seventy-four residents with dementia. Measurements: We operationally defined very frequent agitation as having a score of 6 (several times a day) or 7 (several times an hour) on at least five items of the Cohen Mansfield Agitation Inventory (CMAI) combined with a CMAI total score above the 90th percentile. To assess the association of demographic and behavioral characteristics with very frequent agitation, we performed a multivariate multilevel logistic regression analysis. Results: The 2-week prevalence of very frequent agitation was 7.4% (95% CI: 6.374-8.634). Correlates for very frequent agitation were age (OR: 0.967, 95% CI: 0.942-0.992), dementia severity (GDS 6 = OR: 3.636, 95% CI: 1.929-6.875; GDS 7 = OR: 2.951, 95% CI: 1.321-6.588), delusions (OR: 2.480, 95% CI: 1.555-3.956), anxiety (OR: 1.904, 95% CI: 1.259-2.881), euphoria (OR: 3.712, 95% CI: 2.171-6.337) and irritability (OR: 4.411, 95% CI: 2.854-6.816). Conclusions: To our knowledge, this study is the first to report prevalence data and correlates about nursing home residents with very frequent agitation. We found several correlated factors for very frequent agitation. Still, further research is needed for a better understanding of the behavior of this group, and to identify good treatment options.

Inleiding Het voorschrijven van nifedipine bij chronische perniones vindt steun in enkele niet-placebogecontroleerde onderzoeken en een kleine RCT van Rustin et al. uit 1989. Doel van ons onderzoek was het bevestigen van de veronderstelde superioriteit van 60 mg nifedipine per dag in vergelijking met een placebo voor de behandeling van chronische perniones in de eerste lijn. Methode We voerden een gerandomiseerd, placebogecontroleerd, dubbelblind, cross-overonderzoek in een eerstelijnssetting uit. Daarbij volgden we zo veel mogelijk de opzet van de originele RCT door Rustin. De onderzoekspopulatie bestond uit 32 deelnemers met chronische perniones. De interventie was tweemaal daags 30 mg nifedipine met gereguleerde afgifte per os, vergeleken met een placebo. Primaire uitkomst waren de ervaren klachten (VOC). Secondaire uitkomst waren de ervaren beperkingen (VOD). Beide hebben we beoordeeld met behulp van een dagboek van de deelnemers met dagelijkse scores op een 100 mm visueel-analoge schaal. We hebben rekening gehouden met de omgevingstemperatuur, zijn nagegaan of er sprake was van een carry-over-effect en hebben bijwerkingen gemonitord. Resultaten Voor de primaire uitkomst vonden we een verschil in VOC van 1,84 mm (95%-BI -6,67 tot 2,99 mm, p = 0,44) in het voordeel van nifedipine. Voor de secondaire uitkomst bleek het verschil in VOD 0,56 mm (95%-BI -2,97 tot 4,09 mm, p = 0,75) in het voordeel van de placebo. We vonden geen carry-over-effect. De systolische bloeddruk was lager en oedeem kwam vaker voor tijdens nifedipinegebruik Conclusie Nifedipine heeft geen plaats meer bij de behandeling van winterhanden en -voeten.

Background During the course of dementia, most people develop some type of neuropsychiatric symptoms (NPS), which result in lower quality of life, high caregiver burden, psychotropic drug use and a major risk of institutionalization. Studies on NPS in people with dementia have been mainly conducted in clinical centres or psychiatric services. Objectives To investigate the course of NPS in people with dementia in primary care. Methods Analysis of (cumulative) prevalence and incidence, persistence and resolution based on data collected during an assessment at home of a prospective naturalistic cohort study in primary care in a sample of 117 people with dementia and their informal caregivers. Subsyndromes of NPS were assessed with the Neuropsychiatric Inventory (NPI) and Cohen-Mansfield Agitation Inventory. Multivariate analyses were used to detect determinants for the course of NPS. Results The mean age of the people with dementia was 78.6 years, and 52% were female. Mean Mini-Mental State Examination total score was 19.5, mean NPI total score 15.7. The most prevalent clinically relevant subsyndromes of the NPI were hyperactivity and mood/apathy, and the most prevalent individual NPS were aberrant motor behaviour (28%), agitation/aggression (24%) and apathy/indifference (22%). Of the people with dementia, 72.3% had one or more symptoms of the mood/apathy and 75.3% of the hyperactivity subsyndrome. Conclusions GPs should be aware of NPS in people with dementia and should actively identify them when they visit these patients or when informal caregivers consult them. Timely diagnosing facilitates adequate professional care.

Objective: Young-onset dementia (YOD) is defined as dementia that develops before the age of 65. Neuropsychiatric symptoms (NPS) have important clinical consequences for patients and their family members. To date, knowledge about the prevalence and correlates of NPS in YOD is limited, but essential to establish specific tailored care for patients with YOD. The aim of this study was to explore the prevalence and correlates of NPS in nursing home residents with YOD.Design/Setting: Cross-sectional cohort study in Dutch long-term care facilities providing specialized care for YOD.Participants: Participants included 230 institutionalized patients with YOD.Measurements: NPS were assessed using the Cohen-Mansfield Agitation Inventory (CMAI) and the Neuropsychiatric Inventory-Nursing Home version (NPI-NH). The influence of gender, dementia severity, type of dementia, and disease awareness on clusters of relevant NPS was investigated using multivariate logistic regression analysis and subsequently corrected for the possible confounders of age, duration of institutionalization, and psychoactive medication use.Results: Ninety percent of the nursing home residents with YOD showed 1 or more neuropsychiatric symptoms, 88% showed significant agitation, and 56% showed relevant apathy. No gender differences were found. Although physically aggressive behavior, non-physically aggressive behavior, and apathy were more common in patients with (very) severe cognitive decline (Global Deterioration Scale [GDS] stage 6-7), verbally agitated behavior was common in patients in all except the most severe stages of dementia (GDS 2-6). Apathy was more prevalent in alcohol-related dementia. Low levels of awareness were associated with more physically aggressive behavior and aberrant motor behavior.Conclusion: The prevalence of NPS was high and was associated with the severity and type of dementia and disease awareness. Agitation and apathy are the most important symptoms to focus on in YOD. The high prevalence of NPS supports the idea of care delivery in special care units. Further research is needed on potentially influencing environmental correlates of NPS in YOD. (C) 2016 AMDA - The Society for Post-Acute and Long-Term Care Medicine.

Background:Neuropsychiatric symptoms (NPS) have a high prevalence among patients with dementia, up to 80%. NPS can be grouped by type and stage of dementia. However, NPS have not previously been grouped by gender. Our objective was to investigate whether NPS cluster differently in men or women in the nursing home patients.Methods:Factor analysis to assess the clustering of items in the Cohen-Mansfield Agitation Inventory (CMAI) and Neuropsychiatric Inventory-Nursing home version (NPI-NH) into components, for both scales and for gender. Differences in symptom clustering between male and female patients were assessed using a three-step procedure: (1) identifying a gender specific distinctive item, (2) describe the correlation between the distinctive item with any other item in this cluster, (3) testing whether the correlation between a distinctive item and any other item in the cluster (which is present in both sexes) is different for males and females using a general linear model.Results:Our database consisted of 1,609 patients. There were five male and three female clusters for NPI-NH and eight male and seven female clusters for CMAI. There were three distinctive items in the NPI-NH and ten in the CMAI.Conclusions:There are other clusters of NPS in males and females. Our analysis revealed more significant relations in female than male patients. This might have an implication on the clinical course.

Contains fulltext : 171785.pdf (Publisher’s version ) (Open Access) BACKGROUND: Symptoms with a high predictive power for colorectal cancer (CRC) do not exist. OBJECTIVE: To explore the predictive value of patients' reason for encounter (RFE) in the two years prior to the diagnosis of CRC. METHODS: A retrospective nested case-control study using prospectively collected data from electronic records in general practice over 20 years. Matching was done based on age (within two years), gender and practice. The positive likelihood ratios (LR+) and odds ratios (OR) were calculated for RFE between cases and controls in the two years before the index date. RESULTS: We identified 184 CRC cases and matched 366 controls. Six RFEs had significant LR + and ORs for CRC, which may have high predictive power. These RFEs are part of four chapters in the International Classification of Primary Care (ICPC) that include tiredness (significant at 3-6 months prior to the diagnosis; LR+ 2.6 and OR 3.07; and from 0 to 3 months prior to the diagnosis; LR+ 2.0 and OR 2.36), anaemia (significant at three months before diagnosis; LR+ 9.8 and OR 16.54), abdominal pain, rectal bleeding and constipation (significant at 3-6 months before diagnosis; LR+ 3.0 and OR 3.33; 3 months prior to the diagnosis LR+ 8.0 and OR 18.10) and weight loss (significant at three months before diagnosis; LR+ 14.9 and OR 14.53). CONCLUSION: Data capture and organization in ICPC permits study of the predictive value of RFE for CRC in primary care.

Item does not contain fulltext BACKGROUND: Patients repeatedly presenting with medically unexplained symptoms (MUS) to their GPs, suffer from their symptoms. Experts in the field suggest a multicomponent approach for these patients. Brief multimodal psychosomatic therapy (BMPT) is such an intervention. OBJECTIVES: To test the systematic identification of eligible patients, acceptability of BMPT and potential treatment effects of BMPT. METHODS: The participants in this randomized pilot trial, patients consulting their GPs more than once with MUS, were randomized to intervention [usual care (UC) and additional BMPT] or control condition (UC alone).We monitored the number of patients identified and recruited, trial recruitment and retention. Potential treatment effects were measured with perceived symptom severity [Visual Analogue Scale (VAS)]; patients' self-rated symptoms of distress, depression, anxiety and somatization [Four-Dimensional Symptom Questionnaire (4DSQ)]; symptoms of hyperventilation [Nijmegen Hyperventilation List (NHL)]; physical and mental health status and quality of life [Short-Form Health Survey-36 items (SF-36)]; and level of functioning (measure of general functioning). Follow-up was 1 year. RESULTS: A total of 42 patients could be included in the trial. Four patients withdrew after randomization and two patients were lost to follow-up, resulting in 36 patients (86%). During the 12-month follow-up after BMPT, there was an improvement in perceived symptom severity [adjusted mean difference -2.0, 95% confidence interval (CI) -3.6 to -0.3], in somatization (adjusted mean difference -4.4, 95% CI -7.5 to -1.4) and in symptoms of hyperventilation (adjusted mean difference -5.7, 95% CI -10.5 to -0.8). CONCLUSIONS: This randomized pilot study shows that a larger trial studying the effectiveness of BMPT in patients with MUS in primary care is feasible and useful.

Item does not contain fulltext Background: The reason why patients contact a care provider, the reason for encounter (RFE), reflects patients' personal needs and expectations regarding medical care. RFEs can be symptoms or complaints, but can also be requests for diagnostic or therapeutic interventions. Objectives: Over the past 30 years, we aim to analyse the frequency with which patients consult a GP to request an intervention, and to analyse the impact of these requests on the subsequent diagnostic process. Methods: We included all patients with a request for diagnostics, medication prescription or referral from 1985 to 2014. We analysed the number of requests, granted requests and interventions originating from a request. We compared the final diagnosis (symptom or disease diagnosis) between patients with and without a request. Design and Setting: This is a retrospective cohort study with data from Family Medicine Network, a Dutch primary healthcare registration network. Results: Over time, patients more often present to their GP with a request for intervention. GPs are increasingly compliant with these requests. Patients presenting with a request for intervention are more likely to be diagnosed with a symptom rather than a disease. Conclusion: This study provides insight into the changes in patients' and GPs' behaviour and patients' influence on the medical process, and confirms the clinical relevance of the RFE. This study could support GPs in daily practice when deciding whether or not to grant a request.

Objective: To assess the course of quality of life (QoL) in nursing home residents with dementia and to study its predictors. Methods: This longitudinal, multicenter, observational cohort study with a 2-year follow-up looked at 290 residents with dementia, who lived in 14 dementia special care units in nine nursing homes in the Netherlands. QoL was assessed with the Qualidem, providing a total score and QoL profile with nine subscales. Residents were assessed at five assessments: every 6 months during 2 years. A linear mixed model was used for data analysis. Results: No change was found in the Qualidem total score (range: 0-111) over 2 years. However, a significant increase of QoL over time was seen in the subscales "Care relationship," "Negative affect," "Restless tense behavior," "Positive self-image," "Social isolation," and "Feeling at home." A significant decrease of QoL was seen in the subscales "Positive affect," "Social relations," and "Having something to do." Most predictors of the course of Qol were found for the subscales "Positive self-image" (sex, Global Deterioration Scale, Severe Impairment Battery, Activities of Daily Living, and Neuropsychiatric Inventory) and "Having something to do" (Global Deterioration Scale, Severe Impairment Battery, and Activities of Daily Living). Sex and Neuropsychiatric Inventory at baseline were the predictors found most frequently. Conclusion: The total QoL score was stable over a 2-year period. However, QoL subscales showed multidirectional changes. The largest QoL decline in the subscale "Having something to do" suggests that more attention should be given to useful activities in nursing home care.

Objective Breaking bad news (BBN) should be trained, preferably early and following a helical model with multiple sessions over time, including feedback on performance. It’s unclear how medical students evaluate such an approach. Methods We gathered student opinions regarding a helical BBN training programme, the feedback and emotional support they received, and the applicability of the skills training immediately after BBN skills training (Q1) and after finishing their clinical clerkships (Q2). Results Students find a helical curriculum useful, but this declines on follow-up. At Q2 students report less satisfaction with the amount of feedback and emotional support they received and report that the skills training was less applicable in clinical practice compared to what they reported at Q1. Conclusion A helical BBN training programme with early exposure seems to lead to a shift from students being unconsciously incompetent to consciously incompetent. Students would have appreciated more emotional support and feedback. Practice implications We recommend more feedback and emotional support after BBN during clerkships. The gap between classroom and practice can be diminished by emphasizing real life role play and clinical role models should demonstrate continuity and agreement between the skills that are taught and those that are used in clinical practice.

BackgroundA recent Dutch study in general practice showed a clear relationship between the diagnosis of vulvovaginal candidiasis (VVC) and symptoms suggestive of provoked vulvodynia (PVD). PVD accounts for the largest group of vulvar pains, but is often not recognised by GPs.AimTo investigate whether diagnostic uncertainty about VVC in general practice could also point to the diagnosis of PVD, and whether and how this diagnostic uncertainty affects management.Design & settingAn observational study in 2014 in Dutch general practices of the NIVEL Primary Care Database.MethodWomen with an uncertain diagnosis of VVC were distinguished from those with certain VVC based on the occurrence of recurrent episodes and persisting complaints, despite treatment. Factors known to be associated with PVD were hypothesised to be more prevalent in women with uncertain VVC. Data on symptom management by GPs were collected.ResultsIn total 7066 women with VVC or uncertain VVC were included. Uncertain VVC was found to account for 28% of these patients. Compared to VVC, the group uncertain VVC included significantly more women with female genital symptoms, tiredness, irritable bowel syndrome (all PPPP = 0.009), and higher mean numbers of prescriptions per patient (PConclusionThis study's findings indicate that uncertain VVC could be a marker of PVD. GPs might reconsider their diagnostics and management when women present recurrent and persistent vulvovaginal complaints, especially if accompanied by dyspareunia, functional syndromes, micturition symptoms, and psychological conditions.

Contains fulltext : 139247.pdf (Publisher’s version ) (Open Access) Physician gender is associated with differences in the male-to-female ratio between specialities and with preferred working hours. We explored how graduating students' sex or full-time or part-time preference influences their speciality choice, taking work-life issues into account. Graduating medical students at Radboud University Medical Centre, the Netherlands participated in a survey (2008-2012) on career considerations. Logistic regression tested the influence of sex or working hour preference on speciality choice and whether work-life issues mediate. Of the responding students (N = 1,050, response rate 83, 73.3 % women), men preferred full-time work, whereas women equally opted for part time. More men chose surgery, more women family medicine. A full-time preference was associated with a preference for surgery, internal medicine and neurology, a part-time preference with psychiatry and family medicine. Both male and female students anticipated that foremost the career of women will be negatively influenced by family life. A full-time preference was associated with an expectation of equality in career opportunities or with a less ambitious partner whose career would affect family life. This increased the likelihood of a choice for surgery and reduced the preference for family medicine among female students. Gender specifically plays an important role in female graduates' speciality choice making, through considerations on career prospects and family responsibilities.

Objectives: To explore changes in specialty preferences and work-related topics during the theoretical phase of Dutch medical education and the role of gender. Methods: A cohort of medical students at Radboudumc, the Netherlands, was surveyed at start (N=612, 69.1% female) and after three years (N=519, 69.2% female), on specialty preferences, full-time or part-time work, motivational factors, and work-life issues. Chi square tests were performed to analyze gender-differences, and logistic regression to explore the influence of gender on considerations. Results: A total of 214 female and 78 male students completed both surveys. After three years, the male students remained highly interested in surgery, but the female students increasingly preferred gynecology. These initial preferences were predictive. Four out of five male students versus three out of five female students continued to show a full-time preference. Women increasingly preferred part-time work. After three years, the combination of work, care, and patient contact motivated female students more, whereas salary remained more important to male students. Female students indicated that their future careers would influence their family life; male students assumed having a family would only affect their partners' careers. Conclusions: Against an international background of the feminization of medicine, our study shows that career considerations are reinforced early in medical studies. Women prefer to work fewer hours and anticipate care tasks more often. Students' preferences reflect Dutch cultural norms about working men and women. Therefore, guidance in choice-making much earlier in medical education can create opportunities. Gender Challenges in Medical Education

Background Depression is assumed to be common in chronically ill patients during their last phase of life and is associated with poorer outcomes. The prevalence of depression is widely varying in previous studies due to the use of different terminology, classification, and assessment methods. Aim To explore the reported incidence of depressive disorder, as registered in the last phase of life of patients who died from cardiovascular disease, cancer or COPD, in a sample of primary care patients. Design and setting A historic cohort study, using a 20-year period registration database of medical records in four Dutch general practices (a dynamic population based on the Continuous Morbidity Registration database). Method Medical history of the sample cohort was analysed for the diagnosis of a new episode of depressive disorder and descriptive statistics were used. Results In total 982 patients were included, and 19 patients (1.9%) were diagnosed with a new depressive disorder in the last year of their life. The lifetime prevalence of depressive disorder in this sample was 8.2%. Conclusion The incidence of depressive disorder in the last phase of life is remarkably low in this study. These data were derived from actual patient care in general practice. Psychiatric diagnoses were made by GPs in the context of both patient needs and delivered care. A broader concept of depression in general practice is recommended to improve the diagnosis and treatment of mood disorders in patients in the last phase of life.

Background: Patients with medically unexplained symptoms make heavy demands on the health care system. An offer for psychological treatment is often declined. There is a need for acceptable and effective treatments. We assessed the acceptability and effectiveness of mindfulness-based cognitive therapy (MBCT) for patients with persistent medically unexplained symptoms. Method: A randomized controlled trial comparing MBCT (n = 64) to enhanced usual care (EUC; n = 61). Participants were the 10% most frequently attending patients in primary care. The primary outcome measure was general health status at the end of treatment. Secondary outcome measures were mental and physical functioning. Assessments took place at the end of treatment and at the 9-month follow-up. Results: Health status and physical functioning did not significantly differ between groups. However, participants in the MBCT group reported a significantly greater improvement in mental functioning at the end of treatment (adjusted mean difference, 3.9; 95% CI, 0.24-7.6), in particular with regard to vitality and social functioning. In addition, at 9 months of follow-up, the mindfulness skills ‘observing' and ‘describing' were significantly higher in the MBCT group. Within the MBCT group, almost half of the outcome measures had significantly improved at the end of treatment, whereas in the EUC group none had. Conclusions: MBCT was feasible for frequently attending patients with persistent medically unexplained symptoms in primary care. Although MBCT did not lead to a significant difference in general health status between the two groups, it did result in a significant improvement in mental functioning.

Item does not contain fulltext Abstract Background: Chronic diseases are considered major threats to self-rated health (SRH). In many elderly people multimorbidity is present, in elderly women more than in elderly men. This study aims at establishing the impact of multimorbidity and specific disease combinations on SRH in elderly women. Objectives: To study the relationship between the number of chronic diseases and SRH and explore possible effects of combinations of chronic conditions on SRH in elderly women. Methods: Health interview data used for this study originated from the second Dutch National Survey of General Practice, a study with a response rate of 64.5%. From the 12 699 respondents, 315 were females between 70 and 74 years old. Results: Of the women, 87% reported one or more chronic condition. Women without any chronic condition rated their health significantly better than those with one or more chronic conditions. Either severe back pain or severe headache was included in return the most prevalent combinations of two chronic conditions with a significantly higher negative impact on SRH than expected. Conclusion: All combinations including severe headache and some combinations including severe back pain and another chronic condition had a significantly more negative impact on SRH than expected in women aged 70-74 years. General practitioners should be alert on severe headache and severe back pain in elderly women to improve proactive the quality of care and thus add to the quality of later years of life. 6 p.

Item does not contain fulltext OBJECTIVE: Our aim was to assess cost-effectiveness of mindfulness-based cognitive therapy (MBCT) compared with enhanced usual care (EUC) in treating patients with persistent medically unexplained symptoms(MUS). METHODS: A full economic evaluation with a one year time horizon was performed from a societal perspective. Costs were assessed by prospective cost diaries. Health-related Quality of Life was measured using SF-6D. Outcomes were costs per Quality-Adjusted Life Year (QALY). Bootstrap simulations were performed to obtain mean costs, QALY scores and incremental cost-effectiveness ratios (ICERs). RESULTS: MBCT participants (n=55) had lower hospital costs and higher mental health care costs than patients who received EUC (n=41). Mean bootstrapped costs for MBCT were euro6269, and euro5617 for EUC (95% uncertainty interval for difference: -euro1576; euro2955). QALYs were 0.674 for MBCT and 0.663 for EUC. MBCT was on average more effective and more costly than EUC, resulting in an ICER of euro56,637 per QALY gained. At a willingness to pay of euro80,000 per QALY, the probability that MBCT is cost-effective is 57%. CONCLUSION: Total costs were not statistically significantly different between MBCT and EUC. However, MBCT seemed to cause a shift in the use of health care resources as mental health care costs were higher and hospital care costs lower in the MBCT condition. Due to the higher drop-out in the EUC condition the cost-effectiveness of MBCT might have been underestimated. The shift in health care use might lead to more effective care for patients with persistent MUS. The longer-term impact of MBCT for patients with persistent MUS needs to be further studied.

BACKGROUND: The course of psychological distress in informal caregivers of patients with dementia has been investigated in longitudinal studies with conflicting outcomes.OBJECTIVES: We investigated the course and determinants of psychological distress in informal caregivers of patients with dementia in primary care.METHODS: In this prospective observational cohort study, data were collected at baseline, after 9 and 18 months. We assessed cognition and neuropsychiatric symptoms (NPS) of the patient (Mini-Mental State Examination and Neuropsychiatric Inventory) and psychological distress (Sense of Competence Questionnaire, Center for Epidemiological Studies Depression scale and General Health Questionnaire 12-tem version) of the informal caregivers. Determinants for the course of psychological distress were caregivers' age, gender and relationship with the patient, patients' cognition and NPS, participation in a care program and admission to long-term care facilities (LTCF). With linear mixed models, the course over time for psychological distress and its determinants were explored.RESULTS: We included 117 informal caregivers, of whom 23.1% had a high risk for depression and 41.0% were identified to be likely to have mental problems at baseline. We found a stable pattern of psychological distress over time. Higher frequency of NPS, informal caregivers' age between 50 and 70 years and being female or spouse were associated with higher psychological distress. For patients who were admitted to a LTCF during the study psychological distress of the informal caregivers improved.CONCLUSIONS: GPs should focus on NPS in patients with dementia and on caregivers' psychological distress and be aware of their risk for depression and mental problems, specifically to those who are spouse, female or between 50 and 70 years of age.

Item does not contain fulltext BACKGROUND: New care modes in primary care may affect patients' experienced continuity of care. AIM: To analyse whether experienced continuity for patients with chronic obstructive pulmonary disease (COPD) changes after different care modes are introduced, and to analyse the relationship between continuity of care and patients' quality of life. DESIGN AND SETTING: Randomised controlled trial with 2-year follow-up in general practice in the Netherlands. METHOD: A total of 180 patients with COPD were randomly assigned to three different care modes: self-management, regular monitoring by a practice nurse, and care provided by the GP at the patient's own initiative (usual care). Experienced continuity of care as personal continuity (proportion of visits with patient's own GP) and team continuity (continuity by the primary healthcare team) was measured using a self-administered patient questionnaire. Quality of life was measured using the Chronic Respiratory Questionnaire. RESULTS: Of the final sample (n = 148), those patients receiving usual care experienced the highest personal continuity, although the chance of not contacting any care provider was also highest in this group (29% versus 2% receiving self-management, and 5% receiving regular monitoring). There were no differences in experienced team continuity in the three care modes. No relationship was found between continuity and changes in quality of life. CONCLUSION: Although personal continuity decreases when new care modes are introduced, no evidence that this affects patients' experienced team continuity or patients' quality of life was found. Patients still experienced smooth, ongoing care, and considered care to be connected. Overall, no evidence was found indicating that the introduction of new care modes in primary care for patients with COPD should be discouraged. 01 juni 2012

Item does not contain fulltext BACKGROUND: In The Netherlands, 1168 Q-fever patients were notified in 2007 and 2008. Patients and general practitioners (GPs) regularly reported persisting symptoms after acute Q-fever, especially fatigue and long periods of sick leave, to the public health authorities. International studies on smaller Q-fever outbreaks demonstrate that symptoms may persist years after acute illness. Data for the Dutch outbreaks were unavailable. The aim of this study is to quantify sick leave after acute Q-fever and long-term symptoms. METHODS: Our study targeted 898 acute Q-fever patients, notified in 2007 and 2008 residing in the Province Noord-Brabant. Patients from the 2008 cohort were mailed a questionnaire at 12 months and those of the 2007 cohort at 12-26 months after onset of illness. Patients reported underlying illness, Q-fever-related symptoms and sick leave. RESULTS: The response rate was 64%. Forty percent of the working patients reported long-term (>1 month) sick leave. Pre-existent heart disease odds ratio (OR) 4.50; confidence interval (CI) 1.27-16.09), hospitalization in the acute phase (OR 3.99; 95% CI 2.15-7.43) and smoking (OR 1.69; 95% CI 1.01-2.84) were significant predictors for long-term absence. Of the patients who resumed work, 9% were-at the time of completing the questionnaire-still unable to function at pre-infection levels due to fatigue or concentration problems. Of the respondents, 40% reported persisting physical symptoms at the time of follow-up. Fatigue (20%) was most frequently reported. Daily activities were affected in 30% of cases. CONCLUSIONS: Q-fever poses a serious persisting long-term burden on patients and society.

Item does not contain fulltext It takes considerable time before Autism Spectrum Disorders are diagnosed. Validated diagnostic instruments are available, but not applicable to primary healthcare. By means of a case-control study we investigated whether there were differences in presented complaints and referral patterns between children with ASD (n = 49) and a control group of children without ASD (n = 81). Children with ASD were often presented as crybabies and often showed feeding problems. They visited the GP's surgery more often with anxiety disorders, enuresis, and sleeping disorders. They were referred more often to physiotherapists and speech-therapists and had tympanostomy tubes and tonsillectomies more often. Depression in the parents of children with ASD was remarkably prevalent. 01 augustus 2012

To cite this article: van den Nieuwenhof L, Schermer T, Bosch Y, Bousquet J, Heijdra Y, Bor H, van den Bosch W, van Weel C. Is physician-diagnosed allergic rhinitis a risk factor for the development of asthma? Allergy 2010; 65: 1049–1055. Abstract Background: There is strong evidence that there is a relationship between allergic rhinitis (AR) and asthma, but it is unclear whether there is a causal relation between AR and asthma. The aim of this study was to assess prospectively whether AR is a risk factor for the diagnosis of asthma in a large primary care population. Methods: We performed a historic cohort study of life-time morbidity that had been recorded prospectively since 1967 in four general practices. Two groups of subjects were selected: (i) patients with diagnosis of AR, (ii) a control group matched using propensity scores. We assessed the risk of physician-diagnosed asthma in patients with physician-diagnosed AR compared to subjects without a diagnosis of AR (controls). Results: The study population consisted of 6491 subjects (n = 2081 patients with AR). Average study follow-up was 8.4 years. In patients with AR, the frequency of newly diagnosed asthma was 7.6% (n = 158) compared to 1.6% (n = 70) in controls (P

Changes in the burden of chronic obstructive pulmonary disease (COPD) and its exacerbations on primary health care are not well studied.To identify trends in the prevalence of physician-diagnosed COPD and exacerbation rates by age, sex, and socioeconomic status in a general practice population.Trend analysis of COPD data from a 27-year prospective cohort of a dynamic general practice population.Data were taken from the Continuous Morbidity Registration Nijmegen.For the period 1980-2006, COPD and COPD exacerbation data were extracted for patients aged ≥40 years. Data were standardised for the composition of the Continuous Morbidity Registration population in the year 2000. Regression coefficients for trends were estimated by sex, age, and socioeconomic status. Rate ratios were calculated for prevalence differences in different demographic subgroups.During the study period, the overall COPD prevalence decreased from 72.7 to 54.5 per 1000 patients per year. The exacerbation rate decreased from 44.1 to 31.5 per 100 patients, and the percentage of patients with COPD who had exacerbations declined from 27.6% to 21.0%. The prevalence of COPD increased significantly in women, in particular those aged ≥65 years with low socioeconomic status. Decreases in exacerbation rates and percentages of patients with exacerbations were independent of sex, age, and socioeconomic status.The decline in COPD prevalence and exacerbation rates suggests a reduction of the burden on Dutch primary care. The increase of the prevalence in women indicates a need to focus on this particular subgroup in COPD management and research.

Contains fulltext : 167641.pdf (Publisher’s version ) (Closed access) BACKGROUND: The aim of prescribing medication in palliative end-of-life care should be symptom control. Data are lacking regarding the prescription of medication at the end of life. AIM: To investigate the prescription of medication in patients at the end of life in palliative care facilities. DESIGN, SETTING, AND PARTICIPANTS: An observational multicenter study in 7 inpatient palliative care facilities. Participants were adults with an estimated life expectancy of less than 3 months. The study was conducted from February 1, 2012, to January 1, 2013. RESULTS: A total of 155 patients were enrolled. On average, patients were prescribed 6.1 drugs at the moment of admission and 4.6 drugs on the day of death. The prescription of analgesics, psycholeptics, and drugs for functional gastrointestinal disorders increased from admission until death. In general, these are drug classes prescribed for symptom control. All other drug classes decreased between admission and the day of death, including different drug classes for the treatment of comorbid disease, such as anticoagulants, beta-blocking agents, drugs used in diabetes, and lipid-modifying agents. CONCLUSIONS AND RELEVANCE: A reduction in the total amount of medication is seen between admission and death in the palliative care facilities. Although there is an increase in prescribed symptom-specific medication and a reduction in medication prescribed for comorbid disease, there are still patients dying with medication not used for symptom control. This increases pill burden and indicates that physicians need to develop guidelines and educational programs for decreasing medication for comorbidities at the end of life.

Contains fulltext : 153892.pdf (Publisher’s version ) (Open Access) BACKGROUND: There is only limited accurate data on the epidemiology of rhinosinusitis in primary care. This study was conducted to assess the incidence of acute and chronic rhinosinusitis by analysing data from two Dutch general practice registration projects. Several patient characteristics and diseases are related to the diagnosis rhinosinusitis. METHODS: The Continuous Morbidity Registration (CMR) and the Transitionproject (TP) are used to analyse the data on rhinosinusitis in primary practice. Both registries use codes to register diagnoses. RESULTS: In the CMR 3244 patients are registered with rhinosinusitis and in the TP 5424 CMR: The absolute incidence of (acute) rhinosinusitis is 5191 (18.8 per 1000 patient years). Regarding an odds ratio of 5.58, having nasal polyps is strongest related to rhinosinusitis compared to the other evaluated comorbidities. A separate code for chronic rhinosinusitis exists, but is not in use. TP: Acute and chronic rhinosinusitis are coded as one diagnosis. The incidence of rhinosinusitis is 5574 or 28.7 per 1000 patient years. Patients who visit their general practitioner with "symptoms/complaints of sinus", allergic rhinitis and "other diseases of the respiratory system" have the highest chances to be diagnosed with rhinosinusitis. Medication is prescribed in 90.6 % of the cases. CONCLUSIONS: Rhinosinusitis is a common diagnosis in primary practice. In the used registries no difference could be made between acute and chronic rhinosinusitis, but they give insight in comorbidity and interventions taken by the GP in case of rhinosinusitis.

Background Indonesia has a major problem with iron deficiency anemia among pregnant women. A new model named the Four Pillars Approach was designed to improve antenatal care for these women. This study aimed to measure the effectiveness of the model in managing pregnant women with iron deficiency anemia. Method We used a nonrandomized controlled intervention study. The study, with the Four Pillars Approach as intervention versus usual care as its control, was conducted in two provinces in Java (Indonesia) during the period from March 2012 until May 2013. Main outcome measures were a difference of Hb level ≥ 0.5 g/dL, the number of women who attended five or more antenatal care visits, and birthing with a skilled birth attendant. Results Three hundred fifty-four participants were enrolled in the study. Participants in the intervention group had an adjusted odds ratio of 25.0 (95% CI 12.03–52.03, p = 0.001) for increased hemoglobin of ≥ 0.5 g/dL at 35–37 weeks of gestation, compared with the control group. In the intervention group, 95.0 percent of women had five or more antenatal care visits, compared with 57.2 percent (p = 0.001) in the control group. All births in both groups were assisted by skilled birth attendants. Conclusion The Four Pillars Approach is effective in increasing the hemoglobin level and the frequency of antenatal care visits of participants when compared with the usual care for pregnant women with anemia.

Het belangrijke historische eerstelijns registratienetwerk CMR (Continue Morbiditeits Registratie) heeft een aantal ingrijpende veranderingen doorgemaakt waarbij na het samengaan met het Transitieproject onder andere de naam is veranderd naar FaMe-Net (Family Medicine Network).

Contains fulltext : 154329.pdf (Publisher’s version ) (Open Access) BACKGROUND: Most patients with advanced cancer, debilitating COPD or chronic heart failure (CHF) live at home. General practitioners (GPs) asked for guidance in how to recognize patients in need of palliative care in a timely way and to structure anticipatory care. For that reason, we developed a training for GPs in identifying patients in need of palliative care and in structuring anticipatory palliative care planning and studied its effect on out-of-hours contacts, contacts with their own GP, hospitalizations and place of death. METHODS: We performed a cluster randomised controlled trial. GPs in the intervention group were trained in identifying patients in need of palliative care and anticipatory care planning. Next, for each identified patient, they were offered a coaching session with a specialist in palliative care to fine-tune a structured care plan. The GPs in the control group did not receive training or coaching, and were asked to provide care as usual. After one year, characteristics of patients deceased of cancer, COPD or CHF in both study groups were compared with mixed effects models for out-of-hours contacts (primary outcome), contacts with their own GP, place of death and hospitalizations in the last months of their life (secondary outcomes). As a post-hoc analysis, of identified patients (of the intervention GPs) these figures were compared to all other deceased patients, who had not been identified as in need of palliative care. RESULTS: We did not find any differences between the intervention and control group. Yet, only half of the trained GPs (28) identified patients (52), which was only 24 % of the deceased patients. Those identified patients had significantly more contacts with their own GP (B 4.5218; p

Contains fulltext : 152800.PDF (Publisher’s version ) (Open Access) AIMS: To explore the longitudinal effect of chronic comorbid diseases on glycemic control (HbA1C) and systolic blood pressure (SBP) in type 2 diabetes patients. METHODS: In a representative primary care cohort of patients with newly diagnosed type 2 diabetes in The Netherlands (n = 610), we tested differences in the five year trend of HbA1C and SBP according to comorbidity profiles. In a mixed model analysis technique we corrected for relevant covariates. Influence of comorbidity (a chronic disease already present when diabetes was diagnosed) was tested as total number of comorbid diseases, and as presence of specific disease groups, i.e. cardiovascular, mental, and musculoskeletal disease, malignancies, and COPD. In subgroup effect analyses we tested if potential differences were modified by age, sex, socioeconomic status, and BMI. RESULTS: The number of comorbid diseases significantly influenced the SBP trend, with highest values after five years for diabetes patients without comorbidity (p = 0.005). The number of diseases did not influence the HbA1C trend (p = 0.075). Comorbid musculoskeletal disease resulted in lower HbA1C at the time of diabetes diagnosis, but in higher values after five years (p = 0.044). Patients with cardiovascular diseases had sustained elevated levels of SBP (p = 0.014). Effect modification by socioeconomic status was observed in some comorbidity subgroups. CONCLUSIONS: Presence of comorbidity in type 2 diabetes patients affected the long-term course of HbA1C and SBP in this primary care cohort. Numbers and types of comorbidity showed differential effects: not the simple sum of diseases, but specific types of comorbid disease had a negative influence on long-term diabetes control parameters. The complex interactions between comorbidity, diabetes control and effect modifiers require further investigation and may help to personalize treatment goals.

Early and correct diagnosis of asthma in wheezing children is essential for early treatment and prevention of under- or over-treatment. The aim was to study whether combining frequency and age of onset of wheezing illness with respiratory and atopic morbidity at age 0-6 years and sociodemographic parameters for asthma might be helpful for the general practitioner to diagnose asthma early and accurately.Birth cohort, mean follow-up 20 years (SD 4.8) in general practice. The outcome, adolescent asthma, was analysed in relation to wheezing and non-wheezing respiratory and personal and familial atopic morbidity. All diagnoses were from the Continuous Morbidity Registration of the Department of General Practice of the University of Nijmegen, the Netherlands.1586 (64%) of the children could be followed. Adolescent asthma occurred in 6.4%. There were indications for under- and over-diagnosis of asthma at age 0-6 years. Non-recurrent wheezing (only one episode) and recurrent wheezing (or =2 episodes) in the first three years of life, and recurrent wheezing at age 4-6 increased the risk with odds ratios (95% confidence interval) of 3.3 (1.9-5.6), 4.7 (2.8-8.2) and 15.4 (7.1-33.7), respectively. The risk additionally increased independently with a family history for asthma, (2.0 [1.1-3.6]), atopic dermatitis (1.7 [1.1-2.7]) and sinusitis (2.9 [1.3-6.4]) and decreased foror =2nd born children (0.38 [0.19-0.47]) and those with a low social-economic status (0.61 [0.39-0.94]).Easily available history and clinical data may facilitate the early diagnosis of asthma in children with wheezing illness.

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.

Background:Young-onset dementia (YOD) is defined as dementia that develops before the age of 65 years. The prevalence and type of neuropsychiatric symptoms (NPS) in YOD differ from patients with late onset dementia. NPS in dementia patients are often treated with psychotropic drugs. The aim of this study was to investigate psychotropic drug use (PDU) in Dutch community-dwelling YOD patients and the association between age, gender, dementia etiology and severity, symptoms of depression, disease awareness, unmet needs, and type of NPS.Methods:Psychotropic drug use in 196 YOD patients was registered. Drugs were categorized according to the Anatomical Therapeutical Chemical classification. The association between age, gender, dementia type, dementia stage, type of NPS, depressive symptoms, disease awareness, and amount of unmet needs on total PDU was analyzed using binomial logistic regression analysis.Results:Fifty-two percent of the patients were prescribed at least one psychotropic drug; 36.2% of patients used one drug, and 12.2% used two different drugs. Antidepressants (36.2%) and antipsychotic drugs (17.3%) were the most frequently prescribed psychotropic drugs. Anti-dementia drugs were prescribed in 51.5% of the patients. Increasing age and moderate to severe depressive symptoms were positively associated with the total use of psychotropic drugs.Conclusions:Community-dwelling YOD patients have a high prevalence of PDU. More research is needed to study the association between unmet needs, NPS, and PDU, and psychosocial interventions have to be developed to limit the use of psychotropic drugs in YOD.

Item does not contain fulltext OBJECTIVES: Geriatric patients' physical disabilities, dependency on care, and possible psychological ill-being may negatively affect both the patient's quality of life and the informal caregiver burden. Focusing on this interrelationship which can be particularly prominent in geriatric patients with stroke, the objective of this study was to identify determinants of patients' quality of life and informal caregiver burden. METHOD: This is a prospective, multicentre, cohort study. Data were collected in 84 geriatric home-dwelling patients with stroke three months after their rehabilitation period in skilled nursing facilities (SNFs). We assessed patients' quality of life, depressive complaints, neuropsychiatric symptoms, balance, (instrumental) activities of daily living, and informal caregiver burden. Linear regression models were constructed to study the association between the variables. RESULTS: For several domains, high quality of life of these geriatric patients was associated with high functional independence, less neuropsychiatric symptoms, and less depressive complaints. Informal caregiver burden was not associated with patients' quality of life, but patients' neuropsychiatric symptoms were a significant determinant of high informal caregiver burden. CONCLUSION: The presence of neuropsychiatric symptoms (more specifically depressive complaints) negatively affects the quality of life of geriatric patients. Their neuropsychiatric symptoms also affect caregiver burden. Health care professionals in SNFs can play an important role in providing the necessary psychosocial support and aftercare.

Item does not contain fulltext BACKGROUND: Timely diagnosis of Parkinson's disease (PD), facilitating early intervention, depends largely on the GP's awareness of early symptomatology. For general practice, it is unknown which prodromal symptoms (symptoms preceding the typical motor symptoms of PD) demand the GP's alertness. OBJECTIVE: To assess prodromal symptoms that should alert the GP to the possibility of PD in primary care patients. METHODS: A nested case-control study was carried out in a population of approximately 12000 patients registered in the Continuous Morbidity Registration database affiliated with the University of Nijmegen in the Netherlands. The database pools subject data from four primary care practices. The subjects comprised all 86 patients diagnosed with PD between 1972 and 2007, and 78 controls, matched by sex, age, socioeconomic status and primary care practice. The primary measures of outcome were the prodromal symptoms presenting in the two years prior to the diagnosis of PD. The number (and type) of referrals and diagnostic tests were also assessed. RESULTS: In the two-year period prior to diagnosis, PD patients more often presented with functional somatic symptoms, constipation, hyperhidrosis and sleep disorders than controls. Patients also more frequently experienced more than one prodromal symptom and were more often referred within the primary care team or to a medical specialist. CONCLUSIONS: Prodromal symptoms of PD are encountered in general practice. GPs should be alert when patients present with multiple prodromal symptoms in a two-year period, especially considering the benefits of early intervention, and the future possibilities for disease-modifying therapy.

OBJECTIVE: To explore the prevalence of rare diseases in the Continuous Morbidity Registration (CMR) Nijmegen, and to discuss methodological difficulties in the study of rare diseases in general practice. METHODS: We selected all diseases with a prevalence

Contains fulltext : 69665.pdf (Publisher’s version ) (Open Access) BACKGROUND: General practitioners are familiar with the fact that individual use of care is determined by the family. This paper describes to what extent patterns found in the 1970s can still be replicated in the early 21(st) century, analyzing the impact of the family on frequency of presenting minor illnesses in general practice. METHODS: We used the data of the families in the CMR database during two five-year periods: 1971-1975 and 2001-2005. All episodes of minor illness were registered using the same classification criteria in both studies. The population under study was divided in low and medium/high social class. Pearson correlation coefficients and a hierarchical linear model were used to analyse the impact of family on the frequency of presenting minor illnesses. RESULTS: Correlations between parents (M/F) were stronger in 1971-1975 than in the 2001-2005 period. The influence of the family on presenting minor illness in general practice has decreased from 27.7 to 20.3%. CONCLUSION: Though the influence of the family on presenting minor illness in general practice has decreased, nowadays (2001-2005) still we found strong correlations between family members in presenting morbidity to the GP.

Objectives: We determine how gender or culture influence new medical students' specialty preferences and work-life issues and explore the relation between work-life issues and each specialty preference. Methods: In a cross-sectional study, we surveyed first year Dutch and Swedish medical students (N=1173, cohorts from 2006-2009) on their preferences for specialties, full-time or part-time work, and agreement to eleven work-life issues. We tested differences by gender or culture using chi square and logistic regression. Results: Over 93% of all students responded (N=1095). Almost no male first year student preferred gynecology as a specialty. Dutch male students were more often interested in surgery, Dutch female students in paediatrics. In the Netherlands, male students in particular preferred full-time work. In Sweden gender did not influence working hour preferences. Women in both countries expected equality in career-opportunities and care-tasks more than men, and agreed more often that their career would influence their family life. Women with a preference for surgery most often emphasized equality in career opportunities and care tasks. In most preferred specialties female gender related to a lower degree to full-time work. A gender gap in preferred working hours was larger for Dutch students preferring surgery or paediatrics than for Swedish students. For most of the specialty preferences studied, Swedish students anticipated childcare by day cares and Dutch students' informal day care. Conclusions: Early in training, medical students have gendered specialty preferences and work-life preferences which relate to each other. Gender differences are signifi-cantly more pronounced in the Netherlands than in Sweden. Gender challenges in medical education

Objective We hypothesised that frailty assessment is of additional value to predict delirium and mortality after transcatheter aortic valve implantation (TAVI). Methods Observational study in 89 consecutive patients who underwent TAVI. Inclusion from November 2012 to February 2014, follow-up until April 2014. Measurement of the association of variables from frailty assessment and cardiological assessment with delirium and mortality after TAVI, respectively. Results Incidence of delirium after TAVI: 25/89 (28%). Variables from frailty assessment protectively associated with delirium were: Mini Mental State Examination, (OR 0.79; 95% CI 0.65 to 0.96; p=0.02), Instrumental Activities of Daily Living (OR 0.79; 95% CI 0.63 to 0.99; p=0.04) and gait speed (OR 0.05; 95% CI 0.01 to 0.50; p=0.01). Timed Up and Go was predictively associated with delirium (OR 1.14; 95% CI 1.03 to 1.26; p=0.01). From cardiological assessment, pulmonary hypertension was protectively associated with delirium (OR 0.34; 95% CI 0.12 to 0.98; p=0.05). Multivariate logistic analysis: Nagelkerke R2=0.359, Mini Mental State Examination was independently associated with delirium. Incidence of mortality: 11/89 (12%). Variables predictively associated with mortality were: the summary score Frailty Index (HR 1.66, 95% CI 1.06 to 2.60; p=0.03), European System for Cardiac Operative Risk Evaluation (EuroSCORE) II (HR 1.14, 95% CI 1.06 to 1.22; p

This study aimed to establish whether antipsychotic (AP) use in patients with dementia negatively affects quality of life (QoL) independent of neuropsychiatric symptoms (NPS).We tested 290 patients with dementia living in nine nursing homes throughout the Netherlands in a longitudinal study. The measurements were repeated every 6 months over 2 years. We studied the change in NPS and AP use and their effect on QoL over time in two separate generalized estimating equations. We assessed QoL and NPS using the Qualidem questionnaire and the Neuropsychiatric Inventory-Nursing Home Version (NPI-NH), respectively.Antipsychotic prescriptions did not significantly change participant QoL, whereas NPI-NH total score changes consistently predicted changes in QoL. According to the Qualidem, the development of QoL in patients who chronically used APs did not differ from AP-free patients, except on the restless tense behavior subscale. AP-free patients' "restless tense behavior" improved compared with patients who chronically used APs, who showed a slight deterioration in these symptoms; however, this effect did not significantly influence total QoL.Antipsychotic use does not necessarily have detrimental effects on the QoL of patients with dementia; rather, NPS consistently and negatively affects QoL. The use of APs to treat NPS is justified when used carefully (i.e., their benefits and side effects should be monitored).