J.T.M. van Eijk

Comorbidity of chronic diseases in general practice

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

On the course of low back pain in general practice: a one year follow up study

OBJECTIVES Knowledge on the clinical course of low back pain presented in general practice is poor. Preceding studies offer a fragmentary view only, whereas further knowledge is important to enable the assessment of the prognosis. The object of this study is to investigate the course of low back pain presented in general practice to enable the assessment of the prognosis. METHODS A one year follow up study on the clinical course of low back pain in consecutive cases receiving usual care in general practice. During a period of two years 15 general practitioners from Amsterdam and surrounding areas included consecutive patients with both chronic and recent onset low back pain. After the initial visit, each patient was monitored for a period of 12 months. The follow up consisted of monthly postal questionnaires on the course of the low back pain and the related disability. RESULTS A total of 443 of 605 patients identified were included in the follow up, which was fully completed by 269 patients. In general, patients with less serious low back pain participated less often or did not complete the follow up. At 12 weeks 35% and at the end of the follow up 10% of the population, respectively, still suffered from low back pain. Both the pain and the disability seemed to diminish quickly after the initial visit, and both seemed to stabilise at a lower level if the low back pain did not disappear completely. About three of four patients, whose pain disappeared before the end of the follow up, endured one or more relapses within a year. The median time to a relapse was about seven weeks, and its median duration about six weeks. Both the pain and the disability turned out to be less severe during relapses. The median time to recovery for patients whose low back pain developed more than seven weeks before the initial visit, was four weeks longer than for patients with more recently developed low back pain at the initial visit. CONCLUSIONS The clinical course of low back pain presented in general practice, for the most patients, clearly is less favourable than expected. It takes more than just a few weeks to recover, and relapses occur within a year in most cases. Fortunately, both the pain and the disability quickly diminish, even if the low back pain does not resolve within a few weeks.

Which source should we use to measure quality of life in children with asthma: the children themselves or their parents.

This study compares the reproducibility, construct validity and responsiveness of self-report and parent-report quality of life questionnaires How Are You (HAY) for 8–12-year-old children with asthma. A total of 228 Dutch children with asthma and their parents completed the HAY and daily recorded the childs asthma symptoms in a diary. Additionally 296 age- and -gender matched healthy children and their parents completed the generic part of the HAY. Reproducibility and responsiveness were examined in a sub-group of 80 children with asthma. In this group, three measurements were carried out, at baseline, after one week and once during the following 6 month when the clinical asthma status had changed. The within-subject standard deviations (SD) of three dimensions (physical activities, social activities, self-management) differed significantly (p < 0.05) in favour of the parent-version, indicating that the reproducibility of the parent version was better than that of the child version. The mean score-differences between children with asthma and healthy children as reported by parents did not significantly differ from those reported by children, except for cognitive activities (e.g. be able to concentrate on school work). The mean differences with regard to children with a different actual asthma status (symptom analysis), as reported by both informants, did not differ. Compared to the child-version, the parent-version showed greater ability to detect changes in childrens quality of life over time for all but one dimension, indicating better responsiveness. The results indicate that in discriminative studies child and parents reports can be substituted on a group-level. In longitudinal studies data have to be obtained from parents. Consequently, caregivers collecting quality of life data for longitudinal purposes in daily practice should collect these data simply from parents.

Sensitivity of microscopy versus enzyme immunoassay in the laboratory diagnosis of giardiasis

The substitution of enzyme immunoassay (EIA) techniques for microscopy as a screening tool forGiardia lamblia infection was assessed. Paired stool samples obtained within a ten-day period from 366 patients with persistent diarrhea were examined by microscopy. In addition, two commercially availableGiardia lamblia-specific ElAs were performed. Compared with microscopy, EIA for coproantigen detection was more sensitive, based on examination of either one or two stool samples. Repeated examinations increased the number of cases detected, more so for microscopy than EIA. The negative predictive values of the two EIAs performed on the first stool sample were 98.7% and 97.8%. The results show that EIA for detection of copro-antigens in a single stool sample may be almost as sensitive for identifyingGiardia infection as repeated microscopy on two sequential stool samples.

What predicts change in pulmonary function and quality of life in asthma or COPD

Information about predictors of decline in pulmonary function (forced expiratory volume in 1 second [FEV1]) or health-related quality of life (HRQoL) in patients with asthma or (chronic obstructive pulmonary disease [COPD]) might help to determine those who need additional care. A 2-year prospective cohort study was conducted among 380 asthma and 120 COPD patients. In both asthma and COPD patients, a 2-year change in FEV1 was only weakly associated with a 2-year change in HRQoL (r =. 0.19 and 0.24, respectively). In both groups, older age, living in an urban environment, and a lower peak expiratory flow rate (PEFR) at baseline were associated with a decline in FEV1. Additional predictors of FEV1 decline were greater body weight, less chronic cough or sputum production, and less respiratory symptoms in asthma patients and current smoking in COPD patients. A decline in HRQoL was associated with older age, non-compliance with medication, more dyspnea, and a lower PEFR in asthma patients and with male gender, lower education, lower body weight, more dyspnea, and more respiratory symptoms in COPD patients. Our results show that FEV1 and HRQoL appear to represent different disease aspects influenced by different predictors.

VALIDITY OF DIAGNOSES OF CHRONIC DISEASES IN GENERAL PRACTICE THE APPLICATION OF DIAGNOSTIC CRITERIA

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

The Nottingham Health Profile: score distribution, internal consistency and validity in asthma and COPD patients

This cross-sectional study among patients with asthma or Chronic Obstructive Pulmonary Disease (COPD) in general practice examined the psychometric properties of the Nottingham Health Profile (NHP). From 380 asthma patients and 170 COPD patients, data were obtained on the NHP, subjective measurements (i.e. sleep disturbances, problems in performing household activities, dyspnoea) and more objective measurements (peak expiratory flow rate, consultation rate, comorbidity). These data were used to compute score distributions, internal consistency (Cronbachs α-coefficient) and construct validity. Score distributions were very skewed, with more than 50% of the patients achieving the best score. The internal consistency was moderate in the asthma group (mean α = 0.68) and acceptable in the COPD group (mean α = 0.74). Acceptable construct validity was found in both groups. Correlations between the NHP and the subjective measurements were, in general, statistically significant and higher than between the NHP and the more objective measurements. In conclusion, acceptable internal consistency and construct validity implies that the NHP can be used in cross-sectional studies concerning asthma and COPD patients in general practice, and in studies comparing these patients with other patient populations. Further research on the responsiveness of the NHP is needed to justify its use in longitudinal studies.

Does offering prenatal screening influence pregnant women's attitudes regarding prenatal testing?

Objectives: This study aims to find out whether offering prenatal screening for Down syndrome and neural tube defects influences pregnant women’s attitudes toward having a screening test. Methods: Women were randomised into a group that was offered prenatal screening and a group that was not offered screening (controls). Both groups completed questionnaires before screening was offered, after the offer (not the control group), and in the last trimester of pregnancy. Results: Women with a neutral attitude at baseline who accepted the screening test had a more positive attitude, decliners became more negative and the attitude of the control group did not change. Conclusion: Offering prenatal screening triggers a change in some pregnant women’s attitude regarding prenatal testing. This instability of women’s attitudes may pose a problem for determining whether some women made an informed choice.

Diet or diuretic? Treatment of newly diagnosed mild to moderate hypertension in the elderly

The aim of this study was to assess the effectivity of dietary measures in the treatment of hypertension. Therefore, a single-blind randomised clinical trial was carried out in elderly persons with recently diagnosed hypertension. Patients were recruited from a general practice (6555 persons) during visits or after written invitation or invitation by phone. New hypertensive patients (with measurements taken on three different occasions >159 mm Hg systolic and/or >94 mm Hg diastolic), aged 60–80 years, without target-organ damage, dementia, diabetes mellitus or malignant disease entered a 3-month intervention programme of either intensive dietary counselling, receiving a sodium-reduced (<100 mmol/24h), potassium-enriched (>75 mmol/24h), and weight-reducing diet (BMI <25), or only 25 mg chlorthalidone a day. forty-two newly diagnosed hypertensive subjects met the inclusion criteria. two dropped out from the chlorthalidone group, one with side effects and another after a myocardial infarction. although blood pressure (bp) in the diet group decreased less than in the drug group, of the patients in the diet group 45% fell back to a normal systolic and 50% to a normal diastolic bp (drug treatment group, systolic 75% and diastolic 85%). in contrast with the diet group, lipid spectrum and blood glucose concentration in the diuretic group, however, deteriorated slightly. the dietary intervention was effective in elderly patients with a systolic or diastolic bp in the range of 160–180 and 95–100 mm hg, respectively. reduction in weight should be the primary aim. it is argued that sodium reduction can be achieved better by collective measures. in patients with a bp of more than 180 mm hg systolic or 100 mm hg diastolic, dietary advice and drug treatment should be combined.

General practitioners' opinions on consultation of another physician in case of euthanasia

Objectives: Purpose of this study is to gain insight in the opinions of general practitioners (GPs) about different aspects of consultation, one of the ways in which euthanasia and physician-assisted suicide (EAS) can be safeguarded.Methods: Data from two studies were used. In the Amsterdam study, all GPs working in Amsterdam (n = 398) received a questionnaire in which they were asked to indicate to what extent they agreed with a list of 17 statements about different aspects of consultation. In the nationwide study, a stratified random sample of 405 Dutch GPs and other physicians was interviewed. In the interviews, two questions about consultation were asked.Results: Of Dutch GPs, 81% are of the opinion that consultation should take place in all cases of physician-assisted death. In general, GPs from Amsterdam consider the role of consultation in the decisionmaking in cases of EAS, the consultants skills and activities, and consultation as method of review to be important. For instance, a large majority ...