Herman Bueving

Influenza vaccination in asthmatic children: effects on quality of life and symptoms

This study aimed to detect the effect of influenza vaccination on quality of life, symptomatology and spirometry in asthmatic children. A randomised double-blind placebo-controlled trial in 696 (296 in 1999–2000 and 400 in 2000–2001) asthmatic children aged 6–18 yrs, which were vaccinated with either vaccine or placebo, was performed. Children participated for only one influenza season. They recorded symptoms in a diary and reported when symptom scores reached a predefined severity level. If this occurred research nurses visited them twice, first to take a pharyngeal swab and spirometry, and a week later to assess quality of life over the past illness week. Compared with placebo, vaccination improved health-related quality of life in the weeks of illness related to influenza-positive swabs. However, no effect was found for respiratory symptoms recorded in the diaries during those weeks. Similarly, no differences were found for quality of life in all weeks of illness or for respiratory symptoms throughout the seasons. Influenza vaccination was found to have a moderately beneficial effect on quality of life in influenza-positive weeks of illness in children with asthma.

Is influenza vaccination in asthma helpful

Purpose of reviewInfluenza infections are frequently involved in asthma exacerbations. During influenza epidemics substantial excess morbidity due to respiratory tract complications is reported in all age categories as well as excess mortality among the elderly. Vaccines are available for protection against influenza. Worldwide, vaccination is advised and considered a quality point for asthma care. However, the protective effect of influenza vaccination in patients with asthma is still disputed. In order to establish the current state of affairs we reviewed the recent literature on the protective effect of influenza vaccination and its usefulness in patients with asthma. Recent findingsSeveral studies were found addressing influenza and the protective aspects of vaccination. They discussed the incidence, the adverse effects of vaccination, the coverage of influenza vaccination among patients with asthma and the effectiveness of the vaccine. SummaryInfluenza vaccination can safely be used in patients with asthma. Allegations that vaccination could provoke asthma exacerbations are convincingly invalidated by previous and recent research. Although patients with asthma are one of the major target groups for immunization, vaccine coverage in all age categories remains low. So far, no unequivocal beneficial effect of influenza vaccination in patients with asthma was found in observational and experimental studies in the sense of reduction of asthma exacerbations and other complications. Recent studies confirm these negative findings. More long-term randomized, placebo-controlled studies, focusing on influenza- proven illness in patients with asthma, are needed to address the question of how helpful influenza vaccination is in these patients.

Do patients’ disruptive behaviours influence the accuracy of a doctor's diagnosis? A randomised experiment

Background Literature suggests that patients who display disruptive behaviours in the consulting room fuel negative emotions in doctors. These emotions, in turn, are said to cause diagnostic errors. Evidence substantiating this claim is however lacking. The purpose of the present experiment was to study the effect of such difficult patients’ behaviours on doctors’ diagnostic performance. Methods We created six vignettes in which patients were depicted as difficult (displaying distressing behaviours) or neutral. Three clinical cases were deemed to be diagnostically simple and three deemed diagnostically complex. Sixty-three family practice residents were asked to evaluate the vignettes and make the patients diagnosis quickly and then through deliberate reflection. In addition, amount of time needed to arrive at a diagnosis was measured. Finally, the participants rated the patients likability. Results Mean diagnostic accuracy scores (range 0–1) were significantly lower for difficult than for neutral patients (0.54 vs 0.64; p=0.017). Overall diagnostic accuracy was higher for simple than for complex cases. Deliberate reflection upon the case improved initial diagnostic, regardless of case complexity and of patient behaviours (0.60 vs 0.68, p=0.002). Amount of time needed to diagnose the case was similar regardless of the patients behaviour. Finally, average likability ratings were lower for difficult than for neutral-patient cases. Conclusions Disruptive behaviours displayed by patients seem to induce doctors to make diagnostic errors. Interestingly, the confrontation with difficult patients does however not cause the doctor to spend less time on such case. Time can therefore not be considered an intermediary between the way the patient is perceived, his or her likability and diagnostic performance.

Why patients’ disruptive behaviours impair diagnostic reasoning: a randomised experiment

Background Patients who display disruptive behaviours in the clinical encounter (the so-called ‘difficult patients’) may negatively affect doctors’ diagnostic reasoning, thereby causing diagnostic errors. The present study aimed at investigating the mechanisms underlying the negative influence of difficult patients’ behaviours on doctors’ diagnostic performance. Methods A randomised experiment with 74 internal medicine residents. Doctors diagnosed eight written clinical vignettes that were exactly the same except for the patients’ behaviours (either difficult or neutral). Each participant diagnosed half of the vignettes in a difficult patient version and the other half in a neutral version in a counterbalanced design. After diagnosing each vignette, participants were asked to recall the patients clinical findings and behaviours. Main measurements were: diagnostic accuracy scores; time spent on diagnosis, and amount of information recalled from patients’ clinical findings and behaviours. Results Mean diagnostic accuracy scores (range 0–1) were significantly lower for difficult than neutral patients’ vignettes (0.41 vs 0.51; p<0.01). Time spent on diagnosing was similar. Participants recalled fewer clinical findings (mean=29.82% vs mean=32.52%; p<0.001) and more behaviours (mean=25.51% vs mean=17.89%; p<0.001) from difficult than from neutral patients. Conclusions Difficult patients’ behaviours induce doctors to make diagnostic errors, apparently because doctors spend part of their mental resources on dealing with the difficult patients’ behaviours, impeding adequate processing of clinical findings. Efforts should be made to increase doctors’ awareness of the potential negative influence of difficult patients’ behaviours on diagnostic decisions and their ability to counteract such influence.

Determinants of (sustained) overweight and complaints in children and adolescents in primary care: the DOERAK cohort study design.

BackgroundAlmost half of the adult Dutch population is currently overweight and the prevalence of overweight children is rising at alarming rates as well. Obese children consult their general practitioner (GP) more often than normal weight children. The Dutch government has assigned a key role to the GP in the prevention of overweight.The DOERAK cohort study aims to clarify differences between overweight and non-overweight children that consult the GP; are there differences in number of consultations and type and course of complaints? Is overweight associated with lower quality of life or might this be influenced by the type of complaint? What is the activity level of overweight children compared to non-overweight children? And is (sustained) overweight of children associated with parameters related to the energy balance equation?Methods/DesignA total of 2000 overweight (n = 500) and non-overweight children (n = 1500) aged 2 to 18 years who consult their GP, for any type of complaint in the South-West of the Netherlands are included.At baseline, height, weight and waist circumference are measured during consultation. The number of GP consultations over the last twelve months and accompanying diagnoses are acquired from the medical file. Complaints, quality of life and parameters related to the energy balance equation are assessed with an online questionnaire children or parents fill out at home. Additionally, children or parents keep a physical activity diary during the baseline week, which is validated in a subsample (n = 100) with an activity monitor. Parents fill out a questionnaire about demographics, their own activity behaviour and perceptions on dietary habits and activity behaviour, health and weight status of their child. The physical and lifestyle behaviour questions are repeated at 6, 12 and 24 months follow-up.The present study is a prospective observational cohort in a primary care setting.DiscussionThe DOERAK cohort study is the first prospective study that investigates a large cohort of overweight and non-overweight children in primary care. The total study population is expected to be recruited by 2013, results will be available in 2015.

Uitwisselen van ervaringen in de huisartsopleiding

SamenvattingVeen M, Snijders Blok B, Bareman F, Bueving H. Uitwisselen van ervaringen in de huisartsopleiding Huisarts Wet 2015;58(1):6-10.Achtergrond Om inzicht te krijgen in de ontwikkeling en achtergronden van het uitwisselen van ervaringen (UvE; ‘spuien’, leren van ervaringen, onderlinge consultatie) plaatsen wij deze onderwijsvorm in een historisch kader.MethodeWe hebben schriftelijke bronnen onderzocht en semigestructureerde interviews afgenomen bij (oud-)stafleden die bij de ontwikkeling van het UvE betrokken waren.ResultatenDe motivatie om het UvE in de huisartsopleiding op te nemen hangt samen met de maatschappelijke, sociale en onderwijskundige context van de jaren zeventig van de vorige eeuw. De opleiding richtte zich niet alleen op het medische aspect van het huisartsenvak, maar vooral ook op de arts-patiëntrelatie en de rol die de persoonlijkheid van de dokter hierin speelde. Het UvE vormde de basis van het onderwijsprogramma, waarin de vrijheid van aios om hun opleiding vorm te geven vooropstond. Het UvE stelde aios in staat om hun ervaringen te delen en van elkaar te leren, en diende daarnaast als bron van het resterende onderwijs op de terugkomdag. De Balint-methode was een belangrijke inspiratiebron voor huisartsen uit die tijd en diende als model voor het invoeren van het UvE en het daarbij betrekken van gedragswetenschappers. Het UvE moest na de basisopleiding een cultuuromslag bewerkstelligen en bijdragen aan de profilering van de huisartsgeneeskunde als ‘continue, integrale en persoonlijke zorg’. Tegenwoordig is het terugkomdagonderwijs van tevoren vastgesteld en is de bronfunctie van het UvE komen te vervallen. Ook het doel van het realiseren van een cultuuromslag is niet langer relevant. Het tweeledige doel om aios van elkaars ervaringen te laten leren en onderlinge steun te ervaren is echter onverminderd van kracht gebleven.Conclusie De kern van het UvE is door de jaren heen niet veranderd. De plaats die het binnen het curriculum inneemt is verschoven – het UvE vormt niet langer de basis van het onderwijs, maar maakt onderdeel uit van de reguliere onderwijsprogramma’s. De nadruk is meer komen te liggen op structuur en inhoud.AbstractVeen M, Snijders-Blok B, Bareman F, Bueving H. Experiential learning during general practice education and training. Huisarts Wet 2015;58(1):6-10.Background To gain insight into the background and development of experience-sharing during general practice training, from a historical perspective.Method The literature was searched and members of staff who were involved in the development of experiential learning were interviewed.Results The motivation to incorporate experiential learning in general practice education and training is a consequence of the social and educational context of the 1970s. Training not only focuses on the medical aspects of general practice but especially on the doctor–patient relationship and the role of the doctor’s personality in this. Experiential learning formed the basis of the educational programme, in which emphasis was on the freedom of trainee doctors to structure their own education. Experiential learning enabled students to share their experiences and to learn from each other and formed the basis of education and training on refresher days. The Balint method was a source of inspiration for GPs in the 1970s and served as model for the introduction of experiential learning and the involvement of behavioural scientists. After the undergraduate phase of training, experiential learning was expected to bring about a change of culture and contribute to general practice medicine as ’continuous, integral, and personalized care’. Nowadays, the content of refresher days is established in advance and the function of experience-sharing as the source of the educational programme on refresher days has elapsed. The aim of cultural changes is also no longer relevant. However, the goal that general practice trainees share experiences and support each other is still very relevant.Conclusion The essence of experiential learning has not changed over the years, but its place in the medical curriculum has. It no longer forms the basis of medical education but is part of the educational programme. Nowadays, emphasis is more on structure and content.

Discussing overweight in primary care

Several clinical guidelines have been developed over the last couple of years to help general practitioners (GPs) with weight management in children.1 ,2 However, GPs experience barriers to discussing weight with children and parents. We therefore explored weight management in a cohort of Dutch children presenting in general practice. GPs measured height and weight of 715 enrolled children (2–18 years) during regular consultation in 73 general practices. Details on procedure and measurements have been published.3 Data were extracted from medical records on the reason for consultation at recruitment and in the previous 12 months and on whether weight was reported as relevant information in the medical history. Weight management by the GP was determined by whether GPs gave healthy lifestyle advice during consultations with overweight and obese children, planned a follow-up appointment to discuss weight, or referred children for weight intervention. Child …

What is the role of virus vaccination in patients with asthma

It is estimated that viruses play a role in 30% to 80% of asthma exacerbations. Thus, virus vaccination in patients with asthma could play an important role in preventing asthma exacerbations and other complications. Influenza is the only agent for which a routine vaccine is currently available. This article discusses whether influenza vaccination in patients with asthma, based on the available evidence, is justified. Cost-effectiveness of (influenza) vaccination for patients with asthma is questionable. For the other major viruses involved, the present state of affairs is described. Although progress is being made, a vaccine may be available in the near future only for respiratory syncytial virus (RSV). Meanwhile, clinicians and patients should aim for an optimal treatment with the currently available asthma medication.

Griepvaccinatie bij kinderen met astma: een gerandomiseerd dubbelblind placebo-gecontroleerd onderzoek

Achtergrond In de meeste westerse landen wordt geadviseerd kinderen met astma te vaccineren tegen griep. Er is echter weinig bewijs dat griepvaccinatie resulteert in minder astma-exacerbaties. We onderzochten of griepvaccinatie effectiever is dan placebo ter voorkoming van aan influenza gerelateerde astma-exacerbaties bij kinderen met astma in de leeftijd van 6 tot 18 jaar. Methoden We voerden gedurende 2 seizoenen (1999-2000 en 2000-2001) een gerandomiseerd dubbelblind placebogecontroleerd parallelonderzoek uit bij kinderen met astma die in de huisartsenpraktijk werden gerekruteerd. In aanmerking kwamen kinderen van 6 tot 18 jaar die in het voorafgaande jaar medicatie hadden gebruikt in verband met astma. De kinderen werden parenteraal gevaccineerd met geinactiveerd influenzavaccin of placebo. Luchtwegklachten werden bijgehouden in een dagboek. Wanneer de symptoomscore een bepaald tevoren gedefinieerd niveau bereikte, moesten de deelnemers de onderzoeksverpleegkundige bellen. De verpleegkundige bezocht het kind en nam een keelwat af. De primaire uitkomstmaat was het aantal astma-exacerbaties gerelateerd aan een virologisch aangetoonde influenza-infectie. Resultaten In totaal werden 696 kinderen geincludeerd; 347 ontvingen het vaccin en 349 ontvingen placebo. De keelwatten die positief waren voor influenza hadden betrekking op 42 astma-exacerbaties, waarvan er 24 voorkwamen in de groep die gevaccineerd werd en 18 in de placebogroep: een verschil van 33% ten gunste van placebo (31% na correctie voor confounders; 95%-BI –34-161). De ernst van de aan influenza gerelateerde astma-exacerbaties verschilde niet, maar in de vaccingroep duurden de exacerbaties 3,1 dagen korter (95%-BI –6,2-0,002 dagen; p=0,06). Conclusie Griepvaccinatie bij kinderen met astma resulteerde niet in een significante afname van het aantal, de ernst of de duur van de astma-exacerbaties als gevolg van griep. Vertaling voorHuisarts en Wetenschap van het oorspronkelijke Engelstalige artikel ‘Influenza vaccination in children with asthma, randomized double-blind placebo-controlled trial’ dat verscheen in het American Journal of Respiratory and Critical Care Medicine (2004;169:488-93)

Overweight and obese children do not consult their general practitioner more often than normal weight children for musculoskeletal complaints during a 2-year follow-up

Background Childhood obesity is associated with self-reported musculoskeletal complaints, injuries and fractures. In the current study, we investigated the association between weight status of children and the frequency and type of musculoskeletal consultations at the general practitioner (GP) during a 2-year follow-up. Methods Data from a prospective longitudinal cohort study including children aged 2–18 years presenting in general practices in the Netherlands were used. Height and weight were measured at baseline, at 6-month, 1-year and 2-year follow-ups. Electronic medical files were used to collect information on the frequency and type of consultations at the GP during the 2-year follow-up period. Associations between weight status and frequency and type of GP consultations were calculated. Results Of the 617 included children, 111 (18%) were overweight or obese and 506 (82%) were non-overweight. Overweight children were significantly older (mean age in years (SD): 9.8 (3.6)vs7.8 (4.0), p=0.004). Overweight children consulted the GP in general significantly more frequent during the 2-year follow-up than non-overweight children (mean (SD): 7.3 (5.7)vs6.7 (5.4), OR 1.09, 95% CI 1.01 to 1.18). No significant difference was seen in the number of overweight and non-overweight children consulting their GP for musculoskeletal complaints (OR 1.20 (0.86 to 1.68)). Additionally, no significant difference between overweight and non-overweight children was seen for the number of consultations for further specified musculoskeletal disorders. Conclusion No association was seen between childhood weight status and the frequency and type of musculoskeletal consultations at the GP during a 2-year follow-up.