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Background: Perception by workers of their health problems as work-related is possibly associated with sickness absence (SA). The aim of this study was to to study the relationship between perceived work-relatedness of health problems and SA among workers who visit their GP, taking the influence of other potential determinants into account and to study the influence of these determinants on SA. Design and setting prospective cohort study in 32 Dutch GP practices.Methods: A secondary analysis of RCT data among workers, aged 18-63 years, who visited their GP. We measured self-reported SA days in 12 months and high SA (>20 days in 12 months) and compared workers who perceived work-relatedness (WR+) with workers who did not (WR-). With multivariable linear and logistic regression models, we analyzed the influence of age, gender, experienced health, chronic illness, prior SA, number of GP consultations and perceived work ability.Results: We analyzed data of 209 workers, 31% perceived work-relatedness. Geometric mean of SA days was 1.6 (95% CI: 0.9-3.0) for WR+- workers and 1.2 (95% CI: 0.8-1.8) for WR- workers (P = 0.42). Incidence of high SA was 21.5 and 13.3%, respectively (odds ratio 1.79; 95% CI: 0.84-3.84). SA was positively associated with chronic illness, prior SA, low perceived work ability and age over 50.Conclusions: Perceived work-relatedness was not associated with SA. SA was associated with chronic illness, prior SA, low perceived work ability and age over 50. [ABSTRACT FROM AUTHOR]

Background. The Quebec Back Pain Disability Scale (QBPDS) has been translated into different languages, and several studies on its measurement properties have been done. Purpose. The purpose of this review was to critically appraise and compare the measurement properties, when possible, of all language versions of the QBPDS by systematically reviewing the methodological quality' and results of the available studies. Method. Bibliographic databases (PubMed, Embase, CINAHL, and PsycINFO) were searched for articles with the key words "Quebec," "back," "pain," and "disability" in combination with a methodological search filter for finding studies on measurement properties concerning the development or evaluation of the measurement properties of the QBPDS in patients with nonspecific low back pain. Assessment of the methodological quality was carried out by the reviewers using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist for both the original language version of the QBPDS in English and French and all translated versions. The results of the measurement properties were rated based on criteria proposed by Terwee et al. Results. The search strategy resulted in identification of 1,436 publications, and 27 articles were included in the systematic review. There was limited-to-moderate evidence of good reliability, validity, and responsiveness of the QBPDS for the different language versions, but for no language version was evidence available for all measurement properties. Conclusion. For research and clinical practice, caution is advised when using the QBPDS to measure disability in patients with nonspecific low back pain. Strong evidence is lacking on all measurement properties for each language version of the QBPDS. [ABSTRACT FROM AUTHOR]

Background: polypharmacy contributes to patients' non-adherence with physicians' prescriptions. Patients' knowledge about the indications for their medicines is one of the factors influencing adherence. Objective: to identify factors associated with appropriate knowledge about the indications for drugs prescribed to older patients with polypharmacy. Methods: in a primary care setting, using home interviews and postal questionnaires, patients aged 60 and over who were taking five or more prescribed drugs simultaneously were asked about their medication. Multiple logistic regression analysis was used to evaluate the association (odds ratio, OR) between medication knowledge and explanatory variables like medication use, sex, age, living situation and educational level. Results: seven hundred and fifty-four participants (mean age 73.2 years) reported an average daily intake of nine (SD 3.0) prescribed drugs. Only 15% of the patients were able to recall the indication for each of their prescribed drugs. Variables that were negatively associated with correct reporting of all indications were taking many prescribed drugs (e.g. >10 versus <5: OR 0.05), age 80 years or over (versus 60--69 years: OR 0.47) and male sex (OR 0.53). Patients living with a partner were more knowledgeable than patients living alone (OR 2.11). We did not find an association with educational level. Conclusion: among older patients using five or more prescribed drugs, there was little understanding of the indications for their drugs, especially among patients taking the highest number of drugs, patients aged 80 or over, and men. Patients living independently with a partner were more knowledgeable than others. [ABSTRACT FROM AUTHOR]

Background The prevalence of peripheral arterial occlusive disease (PAOD), including asymptomatic cases and cases unknown to the general practitioner (GP) was estimated in 18 884 men and women, aged 45–74 years, on the list of 18 general practice centres (GPC). Methods The study population (n = 3171) consisted of a stratified sample of the total population. In the GPC data were collected on intermittent claudication (IC), peripheral pulses, vascular risk factors, cardio- and cerebrovascular disease (CCVD) and the ankle brachial systolic pressure ratio (AB ratio) and PAOD was defined as an AB ratio <0.95 on two consecutive occasions. Results were recalculated for the total population. Results The prevalence of PAOD was 6.9% (95% confidence interval [CI]: 5.7–8.2%) of which one-third (2.2%) had an AB ratio <0.75. The prevalence of IC was 6.6% (95% CI: 5.2–7.9%), a quarter of which (1.6%) met the classic WHO criteria Peripheral arterial occlusive disease did not occur significantly more often among men than among women but men suffered more often from an advanced stage of PAOD. Of all PAOD cases, 22% were symptomatic. The proportion of symptomatic cases correlated positively with higher age, male gender and lower AB ratio. Among asymptomatic PAOD cases the prevalence of concomitant CCVD was three to four times as high as in the group of subjects without PAOD. Of all PAOD cases 88% were unknown to the GP and this group mainly represented less advanced cases of atherosclerosis. However, among PAOD cases with an AB ratio <0.75, 42% were unknown to the GP. Conclusions Our data on asymptomatic and unknown PAOD cases show that GPs can still enhance their efforts towards (secondary) prevention of atherosclerosis. [ABSTRACT FROM PUBLISHER]

The completeness of cancer registration in the IKL (Integraal Kankercentrum Limburg) cancer registry, Limburg, the Netherlands, was evaluated for the years 1988–1990 by means of the independent case ascertainment method. This study was performed in co-operation with the Registration Network of Family Practices (RNFP) of the Universrty of Limburg. The RNFP is a centralized database used by general practitioners (GP), containing their patients' background variables and diagnoses. The contents of the two databases were compared using computerized record linkage. If the information from both databases differed, this was verified using the source forms of the cancer registry and the GP in volved. By combining the information from both registries in this way it was determined which malignancies should have been registered by the cancer registry. The IKL cancer registry had recorded 307 of the 319 eligible malignancies (96.2%). Five of the 12 missed registrations could be attributed to systematic shortcomings in the notification procedures. The estimated completeness for all malignancies of the IKL cancer registry is comparable with the results from cancer registries outside the Netherlands which have been established for longer. [ABSTRACT FROM PUBLISHER]

Objective: We aimed to determine the complex of symptoms which has the highest predictive value for the diagnosis of influenza.Method: A questionnaire study with questions regarding the symptomatology of influenza among patients aged 60 and older (n = 1838). Thirty-four participating GPs recorded the symptomatology of patients who came to their general practice with influenza-like complaints. The validity of the diagnostic conclusion of the GP, as well as the diagnostic validity of the criteria of the International Classification of Health Problems in Primary Care (ICHPPC-2) and the Sentinel Stations in The Netherlands, was determined with the help of the predictive value and odds ratio, using serologically confirmed influenza as the gold standard. The same method was used to determine which complex of symptoms has the highest predictive value for influenza. The results were verified using logistic regression analysis.Results: The predictive value of the diagnostics of the GP amounted to 35%. The predictive values of the diagnostics according to the criteria of the two classification methods were 24% (Sentinel Stations) and 18% (ICHPPC-2). Of the individual symptoms, the combination of fever, coughing and acute onset had the highest predictive value (30.3%) for the diagnosis of influenza.Conclusion: It is recommended that the criteria of the Sentinel Stations in The Netherlands and the ICHPPC-2 be adapted in the following way: influenza is likely if, out of the entire complex of symptoms, at least fever, coughing and an acute onset occur. [ABSTRACT FROM AUTHOR]

Background: In a population of 85 general practitioners diagnostic test ordering behaviour has been changed by means of repeated individual feedback provided since 1985.Objectives: We studied practitioner and practice characteristics which may explain differences in test ordering behaviour and in the extent to which general practitioners tend to change their behaviour according to the feedback.Method: In order to trace such variables, 75 general practitioners were interviewed. In our study request data from individual general practitioners were related to data from several questionnaires.Results: We found no practice characteristics which were of influence on the number of test requests by the general practitioner. Explanatory practitioner characteristics for this were found to be years of experience and working hours per week in practice.Conclusions: More years of experience as a general practitioner and a shorter duration of consultations correlated with a better response to advice given in the feedback. [ABSTRACT FROM AUTHOR]

Background: Childhood experiences profoundly affect later functioning as an adult. Family practitioners are well-placed to discover the links between childhood troubles and later somatization, depression or anxiety.Objectives: We aimed to study the interrelation of somatization, depressive and anxiety disorders in frequently attending patients in general practice; to investigate whether these problems are related to a childhood history of illness experiences, deprivation, life events and abuse; and to determine the independent contributions of these childhood factors to the prediction of adult somatization, depressive and anxiety disorders.Methods: One hundred and six adult general practice patients with high consultation frequency were studied. Somatization was operationalized as a more comprehensive version of DSM-III-R somatization disorder (5 complaints; SSI 5/5). For depression (ever depressive and/or dysthymic) and anxiety (panic, phobias and/or generalized anxiety) DSM-III-R criteria were used. Using a structured questionnaire we assessed illness experiences, deprivation of parental care, abuse (sexual/physical) and other life events before age 19.Results: The overlap between somatization, depression and anxiety was largely accounted for by 16 patients with a triple problem: somatization and depression and anxiety. Somatization was specifically related to deprivation, depression to other life events. Abuse (prevalence 16%) independently predicted psychiatric problems in general. Youth experiences before age 12 were most important.Conclusions: The high prevalence of triple problems suggests a need to reconsider concepts like somatic anxiety and anxious depression. The specificity of the relation between deprivation and somatization and of the relation between other life events and depression indicates that distinct causal mechanisms (in youth) contribute to these problems. [ABSTRACT FROM AUTHOR]

Background. Previously published investigations suggest a positive effect of increased water intake on headache, but a randomised controlled trial has not been done.Objective. To investigate the effects of increased water intake on headache.Methods. Randomised controlled trial in primary care with two groups and a follow-up period of 3 months. Patients were included if they had at least two episodes of moderately intense headache or at least five mildly intense episodes per month and a total fluid intake of less than 2.5 l/day. Both groups received written instructions about stress reduction and sleep improvement strategies. The intervention group additionally received the instruction to increase the daily water intake by 1.5 l. The main outcome measures were Migraine-Specific Quality of Life (MSQOL) and days with at least moderate headache per month.Results. We randomised 50 patients to the control group and 52 patients to the intervention group. Drinking more water resulted in a statistically significant improvement of 4.5 (confidence interval: 1.3–7.8) points on MSQOL. In addition, 47% in the water group reported much improvement (6 or higher on a 10-point scale) on perceived intervention effect against 25% in the control group. However, drinking more water did not result in relevant changes in days with at least moderate headache.Conclusions. Considering the observed positive subjective effects, it seems reasonable to recommend headache patients to try this non-invasive intervention for a short period of time to see whether they experience improvement. [ABSTRACT FROM AUTHOR]

Background: Previously published investigations suggest a positive effect of increased water intake on headache, but a randomised controlled trial has not been done.Objective: To investigate the effects of increased water intake on headache.Methods: Randomised controlled trial in primary care with two groups and a follow-up period of 3 months. Patients were included if they had at least two episodes of moderately intense headache or at least five mildly intense episodes per month and a total fluid intake of less than 2.5 l/day. Both groups received written instructions about stress reduction and sleep improvement strategies. The intervention group additionally received the instruction to increase the daily water intake by 1.5 l. The main outcome measures were Migraine-Specific Quality of Life (MSQOL) and days with at least moderate headache per month.Results: We randomised 50 patients to the control group and 52 patients to the intervention group. Drinking more water resulted in a statistically significant improvement of 4.5 (confidence interval: 1.3-7.8) points on MSQOL. In addition, 47% in the water group reported much improvement (6 or higher on a 10-point scale) on perceived intervention effect against 25% in the control group. However, drinking more water did not result in relevant changes in days with at least moderate headache.Conclusions: Considering the observed positive subjective effects, it seems reasonable to recommend headache patients to try this non-invasive intervention for a short period of time to see whether they experience improvement. [ABSTRACT FROM AUTHOR]

Aims: Despite the known increased stroke risk associated with AF and the benefit of oral anticoagulation (OAC) in high-risk patients, still ∼20% of all ischaemic strokes are atrial fibrillation (AF) related. We aimed to evaluate the frequency of inappropriate anticoagulation in all patients admitted with AF associated ischaemic stroke and calculate the theoretical number of preventable strokes in case of proper guideline adherence and assess secondary stroke prevention at discharge. [ABSTRACT FROM PUBLISHER]

Patient adherence to medical treatment for dyspepsia is disappointing, whereas adherence is crucial for a proper evaluation of treatment. This prospective study used elements of the Integrated Change Model and Weiner's Attribution Theory to describe patients' important cognitions and their interrelationships regarding self-perceived adherence to short-term medical treatment for dyspepsia. Patient questionnaires measured the predictors before treatment and self-perceived adherence after treatment. Approximately one-quarter of the patients indicated that they were non-adherent (n 5 347). Univariate and multiple linear regression analyses revealed several significant predictors that explained 44% of the variance in self-perceived adherence. Patients with a low educational level, patients who claimed to regularly forget their medication in general, patients with a low self-efficacy or a low intention were less likely to be adherent. These results may indicate targets for interventions designed to improve adherence to medical treatment for dyspepsia. For instance, asking about expected difficulties in taking acid suppressants (e.g. forgetfulness or medication use at weekends) and making action plans to overcome these difficulties (e.g. using reminders) may result in improved adherence rates. Such an approachmay reach a substantial number of patients since one in five patients in our study experienced some difficulties in taking medication. [ABSTRACT FROM AUTHOR]

This study was part of a randomized controlled trial in which verbal and written advice about exclusive breast-feeding for 6 months was provided to Dutch women expecting a child with a high risk of developing asthmatic traits. Eighty-nine women completed a theory-based self-report questionnaire between the third and sixth months of pregnancy, which served as the baseline measurement. The aim of this study was to examine the factors that influence the duration of exclusive breast-feeding. Cox multiple regression analysis showed a positive significant association between the duration of exclusive breast-feeding and the mother's breast-feeding knowledge (P < 0.01), her intended hours of work per week after maternity leave (P < 0.01) and her age (P

Polybrominated diphenyl ethers (PBDEs) are isolated and recovered with acceptable percent recoveries from human serum via liquid–liquid extraction and column chromatographic cleanup and fractionation with quantitation using capillary gas chromatography–mass spectrometry with electron capture negative ion and selected ion monitoring. PBDEs are found in unspiked serum. An alternative sample preparation approach is developed using sheep serum that utilizes a formic acid pre-treatment followed by reversed-phase solid-phase disk extraction and normal-phase solid-phase cleanup using acidified silica gel that yields > 50% recoveries. When these percent recoveries are combined with a minimized phase ratio for human serum and very low instrument detection limits, method detection limits below 500 parts-per-trillion are realized. [ABSTRACT FROM AUTHOR]

Background. GPs have four main treatment options for lower urinary tract symptoms (LUTS): watchful waiting, α-blockers, 5-α-reductase inhibitors or (referral for) surgery. Guidelines do not provide clear cut-off values for (combinations of) symptoms and physical examination results to decide which treatment is best. [ABSTRACT FROM PUBLISHER]

Aims: A critical review of the evidence of effects of stressful life-events on alcohol use in the general population, with a particular focus on study design. Methods: A literature search in Medline was conducted, covering the period from 1990 to 2005, to identify articles in which the relationship between life-events and alcohol use in the general population (i.e. non-problem drinking population) was investigated. Samples with a limited age range (e.g. college students) were excluded. Twelve studies with a cross-sectional design, and four articles with a longitudinal design were included in this review. Results: Four cross-sectional studies found evidence that experiencing life-events is related to higher alcohol use, three other studies, however, found no such association. The relationship between specific life-events and alcohol use in the five remaining cross-sectional studies is less clear-cut. Being a victim of crime was associated with higher alcohol use, but divorce and financial problems were related to both higher and lower alcohol use. Health-related life-events were found to be associated with lower alcohol use. In studies with a longitudinal design, it was found that health-related life-events and financial problems caused a decrease in alcohol use, and life-events related to spouse, friends and relatives, and retiring led to an increase in alcohol use. Conclusions: Evidence points towards a relationship between the occurrence of life-events and alcohol use in the general population. The direction of the effect is, however, not unequivocal. When life-events are operationalized or categorized separately they are not only related to an increased alcohol use but also to a decreased alcohol use. Specification of the model to be tested, including buffering factors such as gender, social support, coping resources, as well as baseline consumption, is important for a correct estimation of the effect of negative life-events. [ABSTRACT FROM AUTHOR]

Background. Antibiotics are over-prescribed for lower respiratory tract infection (LRTI). The influence of clinicians'' history and examination findings on antibiotic prescribing for LRTI has not been directly assessed, and the extent to which these clinical findings predict appropriate antibiotic prescribing is unknown. A clearer understanding is crucial to achieving evidence-based prescribing.Objectives. To directly assess the influence of general practitioners'' history and examination findings on antibiotic prescribing for LRTI, and to explore the extent to which these clinical findings predict appropriate antibiotic prescribing.Methods. In this observational cohort study 25 GPs in The Netherlands were recruited during routine consultations and 247 adult patients with a clinical diagnosis of LRTI. The GPs recorded clinical information. Odds ratios (ORs) with 95% confidence intervals (CIs) for clinical variables predicting a prescription for an antibiotic were calculated. The relationship between antibiotic prescription and radiographic evidence of pneumonia was explored in order to gauge appropriateness of antibiotic prescribing.Results. Auscultation abnormalities (OR 11.5; 95% CI 5.4–24.7), and diarrhoea (OR > 11) were strongly associated with antibiotic prescribing. An antibiotic was prescribed for 195 (79%) patients. Assuming that an antibiotic definitely needs to be prescribed only for patients with pneumonia, antibiotics may have been inappropriately prescribed for 166/193 (86%) of the patients. Antibiotics were not prescribed for 5 of the 32 (16%) patients with a radiographic diagnosis of pneumonia.Conclusions. Abnormal findings on auscultation in patients with LRTI strongly predict antibiotic prescribing and this is probably inappropriate for most patients. These results should prompt GPs to consider the extent to which finding ‘crackles/rhonchi on auscultation’ influences their decisions to prescribe antibiotics for their patients with LRTI, and to consider the predictive value of individual clinical signs in reaching evidence-based prescribing decisions. [ABSTRACT FROM AUTHOR]

Background and objectives. This study examined the prevalence and severity of dyspnea in patients ≥70 years of age and its impact on the quality of life. We also examined the prognostic significance of dyspnea for mortality.Methods. The cohort study started with a mailed questionnaire, supplemented with an interview. From the population of elderly patients in a family practice health center, a one in five sample (n = 124) was randomly selected, similar in age and sex distribution to those not in the sample. Demographic and other relevant variables were examined for their association with dyspnea. Cox proportional hazards ratio analysis was done with dyspnea (MRC, BDI scores) as independent and mortality as dependent variable.Results. Baseline data indicated that 23% (MRC) to 37% (BDI) of the patients had moderate to severe dyspnea. Shortness of breath was associated with older age, poor perceived health, more anxiety and depressive symptoms, impaired daily functioning, and lower happiness. Moderate and severe dyspnea measured with BDI and MRC was a significant predictor of death within eight years due to cardiovascular or lung disease. Selective participation did not appear to have biased this outcome.Conclusions. Dyspnea occurs frequently in the elderly, is associated with poor health, and interferes with daily functioning. Results suggest that dyspnea contributes to mortality. Development and implementation of guidelines would be highly desirable. Early diagnosis is valuable because this provides opportunities to positively influence the patient's functional condition. [ABSTRACT FROM AUTHOR]

Background. Community pharmacists, pharmaceutical industry and differences in prescribing between GPs.Objective. To explore the role of the pharmacists and pharmaceutical industry representatives.Methods. A cross-sectional survey was undertaken of 1434 GPs in The Netherlands in 2001. Prescribing indicators based on general practice guidelines were used to assess the quality of prescribing. Three constructs, based on survey questions, were used as possible determinants for the quality of prescribing: cooperation with the pharmacist; quality of the Pharmacotherapeutic audit meeting (PTAM); and the GP's attitude towards the pharmacist's role. Data were collected about the frequency of visits by pharmaceutical industry representatives. Responses from 324 solo GPs were analysed using multiple linear regression.Results. Response rate: 71%. For the 324 solo GPs the average score for the 20 prescribing indicators was 64% (SD 3.7). For the non-solo GPs this score was 65% (SD 3.8, P < 0.05). The differences between solo and group practices were: the number of visits from pharmaceutical industry representatives (5.7 versus 3.8 visits per month), full time GPs (93% versus 50%), the number of patients per GP (2151, SD 693 versus 1506, SD 742), and the presence of a GP trainer (21 versus 38%). Of the solo GPs, 4.6% are female, compared with 26% of the GPs in non-solo practices. The quality of prescribing in solo practices was not correlated with the GP's attitude towards the pharmacist's role, the way in which GPs cooperated with pharmacists or the quality of the PTAM. More frequent visits from pharmaceutical industry representatives was associated with a lower quality of prescribing.Conclusion. There was a negative correlation between quality of prescribing by solo GPs and frequency of visits by pharmaceutical industry representatives. In day-to-day practice, no measurable effects of the cooperation between solo GP and pharmacist on the quality of prescribing were observed. [ABSTRACT FROM AUTHOR]

Prior epidemiologic research revealing cardioprotective effects of alcohol intake has systematically neglected lifetime exposure to alcohol, which may cause serious bias in conclusions regarding drinking and heart disease risk. Departing from use of an earlier interview schedule, the authors of the present 1996–2001 cohort study developed a self-administered Lifetime Drinking History questionnaire (LDH-q). A total of 16,211 Dutch men and women older than age 45 years participated by completing the baseline questionnaire. A random sample of 3,255 men and women was used to determine the reliability and validity of the LDH-q. Test-retest reliability was assessed by means of the intraclass correlation coefficient and kappa scores. Correlations between lifetime and current intake scores were used to assess discriminant and convergent validity. Both reliability and validity appeared to be reasonably high compared with results obtained by using interview formats to measure lifetime alcohol intake. Reliability of the LDH-q was higher for men than for women, probably because of the more frequent and regular drinking of men. Indices of validity were similar for men (0.75) and women (0.70). Results show that the LDH-q can be a useful instrument in large-scale cohort studies. [ABSTRACT FROM AUTHOR]

Background. Although the randomized controlled trial is widely accepted as the best design to investigate new interventions, conducting a trial in primary care may present researchers with many methodological problems.Objective. Our aim was to present an alternative trial design to overcome internal validity and recruitment problems.Methods. In a randomized controlled trial, fatigued employees absent from work were selected among the population of an occupational health service in the South of The Netherlands. Patients randomly assigned to the experimental condition received cognitive behavioural therapy by a research GP near their home address, whereas patients in the control group received no intervention. We describe our considerations for building an alternative design. Research GPs and patients were recruited separately for the study. The pre-randomization design was applied.Results. Nine research GPs performed all the interventions. Seventy-six experimental patients and 75 control patients were selected for study participation. Of these, only six patients in the experimental group and seven patients in the control group withdrew from the study at some point during follow-up.Conclusion. Results suggest that recruitment and randomization procedures in the alternative design served their purpose well. The alternative design proposed here might have several advantages compared with conventional trial procedures. However, our design is not widely applicable and there are ethical aspects involved that should be considered. Researchers should address their creativity when trying to minimize the problems they may encounter in designing a study. [ABSTRACT FROM AUTHOR]

In the decades to come, molecular genetic insights and techniques will have great influence on prevention and health care. Health care providers should anticipate important new developments rather than just wait and see. For community doctors, who can impossibly oversee all relevant developments in sufficient detail, close communication with the community and clinical genetic specialists is necessary to keep pace with progress. With regard to genetic counselling and reproductive medicine, working agreements between primary care and specialist centres are important. General communication about hereditary issues can be dealt with by well informed GPs, with appropriate computerized decision support, but in order to address specific risks and disorders consultation at a clinical genetic centre is preferred. In clinical medicine, much work is being done on DNA-based ''dia-prognosis'' and more targeted interventions. Estimations of when such innovations will really have an impact range from 2005 to beyond 2020, and there are still many uncertainties, especially regarding common multifactorial disorders. Community-based genetic epidemiology has become a basic science in understanding the human genome. Clinical epidemiological methodology can contribute a lot to the quality of molecular clinico-genetic studies. Long-term follow-up to evaluate predictions and interventions needs more attention, and can easily be integrated into primary care medicine. In view of the ambition to develop more tailormade interventions, research methodology will be challenged regarding n = 1 studies. With respect to counselling and clinical practice, many ethical issues, relevant for community medicine, have to be considered in the domains of both reproductive medicine and clinical practice. Doctors, patients and society, traditionally battling to reduce diagnostic and prognostic uncertainties, must now learn to cope with approaching certainties. As for all new technologies, cost-effectiveness is an important topic for genetics. Increased cost-effectiveness because of better targeted interventions may be counterbalanced by the price of the new technologies and an expanding indicated population. In view of current developments, community practitioners must integrate community genetics into their daily routine, and critically anticipate possibly relevant innovations. More efforts in genetic risk assessment and communication are necessary in undergraduate and postgraduate training. A multidisciplinary approach is needed, in collaboration with primary care-oriented genetic specialists. Efforts to educate the public and (potential) patients should start at an early age, and must focus on what (future) health care users need for a balanced appraisal of genetic information and for optimal decision making in health promotion and health care. [ABSTRACT FROM AUTHOR]

Although a lot of research has been performed on the relation between depression and subsequent mortality, the results show contradictory findings. In this study, the authors investigated mortality in depressed people compared with nondepressed people in a large-scale retrospective cohort study based in general practice in the province of Limburg, the Netherlands. All subjects diagnosed with depression between 1975 and 1990 were included and compared with subjects matched on birth year who never were diagnosed with depression. Follow-up ended on April 30, 2000. Hazard ratios and their 95% confidence intervals were calculated using stratified Cox proportional hazards models adjusted for age, sex, and socioeconomic status. Subgroups based on sex and age at the diagnosis of depression were evaluated separately. A total of 68,965 patients were followed for an average of 15 years. Among 1,362 depressed subjects 132 died, and among 67,603 nondepressed subjects 4,256 died. The adjusted hazard ratio for depressed versus nondepressed subjects was 1.39 (95% confidence interval: 1.16, 1.65). A significant interaction was observed between the age at diagnosis of depression and sex. A moderate positive association between depression and subsequent mortality was identified. [ABSTRACT FROM PUBLISHER]

Objectives: The aim of the present study was to describe the patient's perspective on the GP's care after violent events: which role is the GP assigned; and how is the care appreciated. Events studied were serious accidents, burglary, robbery, physical and sexual abuse, disasters and war.Method: A postal questionnaire was sent to a random sample of 2997 patients (> or =20 years) from the practice population of 32 GPs (67 500 patients).Results: The response was 50%. Forty-two per cent of the respondents had experienced one or more events. Twenty-eight per cent of the victims desired some kind of professional help; more than half of them desired that care from their GP, three-quarters actually seeking it. Most frequently sought care was sympathy, "a number of good talks", and care for physical complaints. Overall, contentment with the GP's contribution was high; patients especially appreciate sympathy and support, as well as initiative on the GP's part in commencing and pursuing care. Of those who felt no need for professional help, 88% found that they could cope with the traumatic event well enough, with or without the help of family and friends. For those who did not seek help, although they did desire it, the main reasons were that they considered their problems insufficiently medical or felt that their GP lacked the time. In the case of physical and sexual abuse, feelings of guilt and issues of patient confidentiality played a role for some patients.Conclusions: The number of events experienced by our respondents is lower than in previous studies for burglary, robbery, physical and sexual abuse (adults and children); the occurrence of accidents is similar. The majority of the people who experience traumatic events cope with them well enough without professional help. For those seeking help, the GP plays an important role. Care could be improved as follows: the GP should make it clear to patients that he/she can play a role in caring for them in the aftermath of a traumatic event and stress the confidential nature of the consultation. On the whole, GPs should be more supportive and attentive when being consulted about this topic; also patients would like their doctors to be more active in raising the subject, as well as in initiating follow-up. [ABSTRACT FROM AUTHOR]

The current study describes the age- and sex-specific incidence rates and risk factors for asymptomatic and symptomatic peripheral arterial occlusive disease (PAOD) among 2,327 subjects and the incidence of intermittent claudication in asymptomatic PAOD subjects. The study population was selected from 18 general practice centers in the Netherlands. PAOD was assessed with the ankle-brachial blood pressure index, and intermittent claudication was assessed with a modified version of the Rose questionnaire. After 7.2 years, the overall incidence rate for asymptomatic PAOD, using the person-years method, was 9.9 (95% confidence interval (CI): 7.3, 18.8) per 1,000 person-years at risk. The rate was 7.8 (95% CI: 4.9, 20.3) for men and 12.4 (95% CI: 7.7, 24.8) for women. For symptomatic PAOD, the incidence rate was 1.0 (95% CI: 0.7, 7.5) overall, 0.4 (95% CI: 0.3, 10.0) for men, and 1.8 (95% CI: 1.0, 10.3) for women. Multivariate analyses showed that increasing age, smoking, hypertension, and diabetes mellitus were the most important risk factors. The overall incidence rate for intermittent claudication among PAOD subjects who were asymptomatic at baseline was 90.5 per 1,000 person-years at risk (95% CI: 36.4, 378.3). The incidence of asymptomatic PAOD was higher than the incidence of symptomatic PAOD, with women developing PAOD more often than men. In the development of preventive strategies, modification of atherosclerotic risk factors, such as smoking, hypertension, and diabetes, should be the main goals. Am J Epidemiol 2001;153:666-72. [ABSTRACT FROM AUTHOR]

The reproduction of social structure occurs with regularity, even when it is not in the interest of the group, the individual, or the society. This article uses the theories of structural ritualization and expectation states to examine a specific case of social reproduction: the reproduction of hierarchical group procedure and practices in small task groups The experimental test examines forty-four task groups under three different conditions: a baseline condition under which group leaders observe no task groups; a condition under which leaders observe two groups characterized by hierarchical ritual and relatively authoritarian leaders; a condition under which leaders observe two groups characterized by lesser levels of hierarchical ritual and procedure. Based upon the two theories, we predicted that leaders would transform their own groups in the image of those they observed. This would occur even though there were no incentives for particular procedures and rituals, and even though the observed groups were not involved in tasks similar to the tasks given to the leader and his group. The experimental tests generally support the theory. [ABSTRACT FROM AUTHOR]

In the Netherlands, several general practice registrations exist. Groups of general practitioners register elements of patient care according to agreed-upon criteria, and these data are collected in a central database. By means of a questionnaire the authors interviewed the managers of all nine computerized registration networks extensively about the possibilities and limitations of their registration. In addition, respondents answered some questions with data from the central database of their network. Various items are collected by nearly all the registration networks, while other items are collected by only one network. Answering questions with data from the central database turned out to be difficult. Organization and manpower are the main obstacles. [ABSTRACT FROM AUTHOR]

Background and Objective: While the prevalence of hydronephrosis is very low in obduction studies, a prevalence of 3-13% is reported for patients with an obstruction who are listed for prostatectomy. In order to evaluate the usefulness of transabdominal ultrasound in primary care, we determined the occurrence of hydronephrosis in males with symptoms of urinary obstruction in a general practice setting.Method: A micturition questionnaire (a modified Boyarsky) was sent to all men of 55 years or more who were registered in 10 general practices in Maastricht, and was followed by an examination at their general practice. Men with obstructive symptoms and/or with a free-flow abnormality were examined in the hospital with transabdominal ultrasound in order to detect dilatation of the upper urinary tract. This ultrasound was repeated approximately 15 months later.Results: At the first measurement, none of the examined men (n = 178) had hydronephrosis, and this was still the case for 94 men 15 months later.Conclusion: Renal ultrasound is not necessary in general practice for men with uncomplicated obstructive complaints. [ABSTRACT FROM AUTHOR]

Background: Non-response analysis is often restricted to the influence of age, sex and socio-economic status on response status. In this study the health status of responders and non-responders was also compared.Results: Responders were comparable to non-responders with regard to the number of diagnosed disorders as well as to the prevalences of disorders within body systems. Non-responders only showed psychological disorders more often.Conclusion: It is useful to assess the relation between non-response and morbidity patterns in other studies as well, in order to detect selective non-response and bias. [ABSTRACT FROM AUTHOR]

Investigates the effects of withdrawal of long-term diuretic drugs from elderly patients. Methodological evaluation; Patient profile; Biochemical measurements.

Assesses the effect of a program for improving knowledge of and attitude toward cholesterol guidelines in the Netherlands. Barriers to the implementation of cholesterol guidelines; Details of guideline implementation; Information on the Dutch College of General Practitioners standard.

In order to obtain an overview of the incidences, risk factors and health consequences of falls among elderly persons living in the community from the available literature, a Medline computer search of publications over the period 1981-1994 was carried out. Fourteen studies met the following inclusion criteria: i) the study is an original investigation of falls among the elderly, ii) the study deals with the incidence, risk factors and/or consequences of falls among the elderly and iii) the study refers to a population at risk consisting of persons aged 60 years or over belonging to a population relevant to general practice. The selected studies were subjected to a methodological assessment on the basis of 10 methodological criteria. All the studies were independently assessed by 1 author and 1 assistant to obtain a methodological--consensus. The relevant outcomes of these studies are reported. Pooling of data was not performed because of relevant differences between the studies. Two studies met all methodological criteria and 2 other studies were second best. These 4 studies were given preference. Approximately 30% of subjects older than 65 years fall at least once a year and approximately 15% fall recurrently. The main risk factors for falls among the elderly belong to the intrinsic (patient-related) risk factors: cognitive impairment, balance and gait disorders, use of sedatives and hypnotics, a history of stroke, advanced age, arthritis of the knee and a high level of dependence. Extrinsic (environment-related) risk factors did not play a significant role in any of the studies. Not all studies dealt with the health consequences of falls among the elderly. Major injuries were reported in 0.5-9% and fractures in 3-14%. [ABSTRACT FROM AUTHOR]

In The Netherlands general practice attenders are not usually questioned about their drinking habits. The objective of this study was to determine to what extent easily available data (e.g. age, gender) can be used to identify categories of patients who are at risk of problem drinking as a preliminary to more intensive screening. Sixteen practices with a total population of 32,000 patients were involved in the study. All problem drinkers known by their GPs and a random sample of one in ten patients not thought to be problem drinkers were admitted to the study at their first surgery visit during a 1-year period. A screening questionnaire was used to find hidden problem drinkers amongst the individuals thought to be non-problem drinkers. The overall response rate was 91% (n=1405). Problem drinking was detected in 6% (n=82) of the group regarded by the GPs as non-problem drinkers (n=1283). Male gender, smoking, life events and chronic social problems were the strongest non-alcohol-related predictors of hidden problem drinking. We conclude that a pre-selection of patients with a greater risk of problem drinking can be made without information related directly to alcohol. Case-finding in this category is much more effective and probably much more acceptable both to the GP and the patients, than the screening of all patients. [ABSTRACT FROM PUBLISHER]

Background: Factors related to physical health have been implicated in both normal and pathological aging of cognitive abilities. To substantiate this notion, we studied existing morbidity, as diagnosed by the general practitioner according to well-defined criteria, as a potential predictor of cognitive test performance.Methods: A sample of 1360 individuals, aged 24-81 years and living in the community, was stratified for age, sex, and general ability. Active and total morbidity in this group were classified according to the International Classification of Primary Care. Neurocognitive tests were used to assess the domains of verbal memory, sensorimotor speed, and cognitive flexibility.Results: Multiple regression analyses with adjustment for age, sex, and educational level showed both insulin-dependent and noninsulin-dependent diabetes to be negatively associated with all cognitive measures. More specific negative associations were found for chronic bronchitis (performance speed) and presbyacusia (memory). Single or aggregated cardiovascular morbidity (including hypertension) was unrelated to test performance.Conclusions: Existing morbidity as a whole contributes only modestly (up to 3.5%) to total variance in cognitive function. However, some specific, relatively common diseases of the elderly, such as diabetes and chronic bronchitis, may aggravate the age-related decline in cognitive ability. [ABSTRACT FROM AUTHOR]

Background: Complaints possibly caused by arrhythmias are frequently seen in general practice. It is unclear to what extent such complaints can differentiate between arrhythmias and other pathology in general practice.Objectives: We aimed to assess the value of symptoms (a) in diagnosing arrhythmias in general practice and (b) in identifying patients with clinically relevant arrhythmias.Method: During a 2-year period, a structured history from 762 patients with new complaints possibly related to an arrhythmia was taken by the GP, and a transtelephonic electrocardiogram (ECG) was made.Results: In 28.3% of the patients, arrhythmias were detected and 8.8% were clinically relevant. Several patient characteristics, symptoms and medical history findings have high predictive values in diagnosing arrhythmias. In the logistic regression analysis, age and, to a lesser extent, male gender, palpitations and dyspnoea during consultation and the use of cardiovascular drugs are associated with the presence of arrhythmias. In detecting clinically relevant arrhythmias the same parameters apart from gender are important, as well as a history of arrhythmias. The use of central nervous system medication and frequent psychosomatic complaints are negatively associated with the presence of clinically relevant arrhythmias.Conclusions: In general practice, patient characteristics, symptoms and medical history findings can be used in the detection of arrhythmias and the assessment of their severity. They can help in the decision of whether to make an ECG recording. [ABSTRACT FROM AUTHOR]

Background.Complaints possibly caused by arrhythmias are frequently seen in general practice. It is unclear to what extent such complaints can differentiate between arrhythmias and other pathology in general practice. [ABSTRACT FROM PUBLISHER]

The aim of the study is to determine the diagnostic value of (combinations of) signs, symptoms and simple laboratory test results for colorectal cancer in patients with rectal bleeding presenting in general practice. Initial complaints and findings were compared with the final diagnoses based on clinical follow-up after at least 1 year. Patients studied were those presenting overt rectal bleeding to the general practitioner (83 GPs in the South of the Netherlands). Outcome measures are sensitivity, specificity, predictive values, odds ratios and a predicition model derived from multiple logistic regression analysis. Age, change in bowel habit and blood mixed with or on stool show a statistically significant independent value in the discrimination between patients with a low and those with a high probability of colorectal cancer. Many other variables did not show predictive value. The prediction model has a sensitivity of 100% and a specificity of 90%. Although the number of patients with colorectal cancer is small (=9) it was possible to identify three characteristics which can be helpful in the prediction of presence or absence of colorectal cancer in general practice. Application of the model presented might prevent 90% of ‘unnecessary’ invasive diagnostic procedures for patients with rectal bleeding who do not have colorectal cancer (true negative). Testing the performance of the model in other general practice populations is recommended. [ABSTRACT FROM PUBLISHER]

Five hundred and seventy-eight consecutive cases of non-acute abdominal pain presenting to 11 general practices were included in a descriptive study and were followed during 15 months. Females predominated in the younger age groups. Eighty per cent of these patients visited their GP not more than three times for abdominal complaints during the follow-up period. Eighty-three per cent were managed entirely in the practice and 64% received a prescription. Only 20% of patients were additionally investigated in anyway by the GP. There were hardly any differences in final diagnoses between patients who had complaints less than 1 week or more than 1 week before presenting to the GP. Non-acute abdominal pain is a condition that is seen and managed mainly in general practice. [ABSTRACT FROM PUBLISHER]

The objective of the studies reported in this paper was to determine the incidence as well as the final diagnostic outcome of rectal bleeding presenting in general practice. Because of the wide variety observed in incidence rates among 83 general practitioners (GPs) in the first study (A) an additional study (B) was undertaken. In study B with 10 GPs special efforts were made to maximize the catchment rate. The mean ‘consultation incidence rate’ was 7 per 1000 people per year. A follow-up period of at least 1 year was applied to establish the final diagnostic conclusion. Occurrence of colorectal cancer was found in 3% of patients with rectal bleeding. This may represent an overestimation of the prior probability since there was a selection in favour of patients with clinically relevant rectal bleeding. In about 90% of patients rectal bleeding was related to minor ailments or self-limiting disorders. Further study on predictive values of (combinations of) other signs and symptoms is necessary to develop clinical recommendations. [ABSTRACT FROM PUBLISHER]

The number of good quality studies on the effect of feedback and reminders on diagnostic and preventive activities in ambulant practice is still low. The interventions and procedures studied differ widely, and the reporting of the results is insufficiently precise. This makes comparison difficult and quantitative pooling impossible. Nevertheless, the literature supports the contention that feedback reduces the use of diagnostic tests and the costs thereby engendered. It also discloses a positive effect of feedback on the adherence of medical practice to guidelines or standards. In this respect, the effect of reminders seems to exceed that of classical methods of feedback. There is still a need for research on the effect of feedback, reminders and other instruments for quality assurance on various aspects of medical performance in different settings. [ABSTRACT FROM PUBLISHER]

The rectal examination is a much advocated procedure for assessing abdominal and urinary symptoms. A Medline literature search yielded only a few studies, not one of them in a general practice setting. The sensitivity of the rectal examination to rectal carcinoma and appendicitis is low, while it is high for prostate carcinoma. When reviewing the likelihood ratios of normal and abnormal findings of rectal examinations it was concluded that it may be a useful procedure in the case of abnormal findings in patients presenting rectal problems and in assessing men with prostate problems, although it does not seem useful in diagnosing appendicitis. However, since the diagnostic values in general practice and in referred populations may be difterent, there is a need for further prospective studies in settings of general medical practice. [ABSTRACT FROM PUBLISHER]

In most textbooks of gastroenterology, diseases with their symptoms are discussed. The exact diagnostic value of these symptoms, however, regarding the differentiation between organic and functional disease, is not mentioned. A criteria-based meta-analysis of the few existing studies in this field was done. From the 14 identified studies, there were two that did not find any significant symptoms. In the other studies the diagnostic value of colonic symptoms showed great variability. Methodological deficiencies in these studies are probably responsible for the latter. The generalization of these results into general practice is not straightforward and needs research in general practice patients. [ABSTRACT FROM PUBLISHER]

The extent to which computerized medical administration facilitates quality control was studied using as an example the quality of blood glucose regulation in diabetics supervised by general practitioners in 11 computerized practices. Systematic use of the general practice computer rapidly provided an unequivocal answer that 37% of such patients were not regulated in accordance with the guidelines for type 2 diabetes mellitus of the Dutch College of General Practitioners. The extra workload for the participating general practitioners was minimal. Automated recording of problem lists, as applied in the general practices belonging to the Registration Network, facilitates access to data on chronic diseases and risk factors for purposes of research, quality control and quality assessment. [ABSTRACT FROM PUBLISHER]

In this study, exploring the worry experienced by patients in the GP waiting room and the reasons for being worried, 791 patients completed a structured questionnaire just before they consulted their GP, and afterwards. The perceptions of the patients concerning the complaint and the need for more information about the complaint played an important role in the degree of worry. Patients who wanted more information about the complaint were more worried than the patients who did not feel they needed more information. Not surprisingly, the more serious the patients perceived the complaint to be and the greater the perceived chance of serious disease, the more worried they were. General health status and frequency of consultations per year were related to the degree of general worry. According to the patient self-reports, worry was almost never due to information from the mass media or from other persons, or to a concern for the consultation itself. Patients generally evaluated the consultation as positive with respect to the way their worry was discussed. The decrease in worry after consulting the GP, in patients who were positive about the consultation was significantly higher than that in patients who were less positive. The theoretical and practical implications of this study are discussed. [ABSTRACT FROM PUBLISHER]