J.W. van Ree

Quality of life in older patients with systolic and diastolic heart failure

To get insight into the quality of life of a clinical practice sample of patients with heart failure that are admitted to the hospital. Secondly to determine differences between patients with systolic and diastolic dysfunction and finally to describe factors relating to quality of life.

Lifestyle factors of a five-year community-intervention program: the Hartslag Limburg intervention

BACKGROUND Community-based health promotion is a widely advocated strategy in public health to favorably alter lifestyle. The aim of this study was to investigate the net effect of a cardiovascular disease-prevention program (Hartslag Limburg) on lifestyle factors after 5 years of intervention (1998-2003). METHODS In a cohort study, 5-year mean changes in lifestyle factors (energy intake; fat intake; time spent on leisure-time physical activity; walking, bicycling, and sports; and smoking behavior) between subjects from the intervention area (n=2356) and the control area (n=758) were compared for men and women and for those with a low (less than intermediate secondary education) and a moderate (intermediate vocational or higher secondary education) or high (higher vocational education or university) educational level. Adjustments were made for age and the mean of the individual pre- and post-intervention measurement of the variable under study. When stratifying for gender, adjustments were made for educational level, and vice versa. RESULTS In general, lifestyle factors changed unfavorably in the control group, whereas changes were less pronounced or absent in the intervention group. The adjusted difference in mean change in lifestyle factors between the intervention group and the control group was significant (p<or=0.05) for energy intake (-0.2 megajoule per day among both women and those with a low educational level); fat intake (-2.5 grams per day [g/d] among women and -3 g/d among those with a low educational level); time spent walking (+2.2 hours per week [hrs/wk] among women and +2.3 hrs/wk among those with a low educational level); time spent on total leisure-time physical activity (+2.1 hrs/wk among women); and time spent bicycling (+0.6 hrs/wk among those with a low educational level). CONCLUSIONS The community intervention Hartslag Limburg succeeded in preventing age- and time-related unfavorable changes in energy intake, fat consumption, walking, and bicycling, particularly among women and those with low SES.

The NECTAR-Study: development of nutrition modules for general practice vocational training; determinants of nutrition guidance practices of GP-trainees

Objective: To identify determinants of nutrition guidance practices of general practitioner-trainees (GP-trainees), to investigate whether these determinants differ from those found by experienced general practitioners; to reveal educational directions towards the development of computer-based instruction on nutrition.Design: Cross-sectional study by means of validated questionnaires.Subjects: All GP-trainees in training at the eight university departments for vocational training in the Netherlands in September, 1998 (n=985).Main outcome measures: Reliability of determinants of nutrition guidance practices was calculated by means of Crohnbach’s alpha. The mechanism of action of determinants was identified by means of linear structural relationship analysis (LISREL) using a model developed for GPs.Results: Crohnbach’s alphas for factors ranged from 0.58–0.90. The empirical GP-trainee-data fitted with the corresponding GP-model on the mechanism of action.Conclusions: The same predisposing factors, driving forces and barriers as found with GPs were identified with GP-trainees. Comparing the GP-and GP-trainee-models, only minor differences were found in the path coefficients between factors. Lack of nutrition training and education proved to be of great influence on the extent of nutrition information given. The GP-trainee-model will be of use in developing computer-based instruction on nutrition. It is expected that GPs may also benefit from this instruction.Sponsorship: The study was carried out at Maastricht University, supported by research grants from the Dutch Sugar Bureau, the Dairy Foundation for Nutrition and Health, and the Dutch Meat Board.

No Relevant Seasonal Influences on Office and Ambulatory Blood Pressure Data from a Study in Borderline Hypertensive Primary Care Patients

Our objective was to study seasonal influences on office and ambulatory blood pressure. We therefore designed a prospective 7-month study of 47 borderline hypertensive patients in a primary care setting. We used no interventions. Our main outcome measures were the differences between summer and winter office and ambulatory blood pressures and 95% confidence intervals. Results showed that winter minus summer differences ranged from 0 to 3 mm Hg. Only one significant difference was found: ambulatory systolic daytime pressure was significantly higher (3 mm Hg) in winter than in summer. Our results do not confirm the data of earlier studies in hypertensives. In view of the small and clinically irrelevant winter-summer differences, it seems unnecessary to modify antihypertensive treatment of borderline hypertensives according to the season.

Comparison of randomization techniques for clinical trials with data from the HOMERUS-trial.

Background. Several methods of randomization are available to create comparable intervention groups in a study. In the HOMERUS‐trial, we compared the minimization procedure with a stratified and a non‐stratified method of randomization in order to test which one is most appropriate for use in clinical hypertension trials. A second objective of this article was to describe the baseline characteristics of the HOMERUS‐trial. Methods. The HOMERUS population consisted of 459 mild‐to‐moderate hypertensive subjects (54% males) with a mean age of 55 years. These patients were prospectively randomized with the minimization method to either the office pressure (OP) group, where antihypertensive treatment was based on office blood pressure (BP) values, or to the self‐pressure (SP) group, where treatment was based on self‐measured BP values. Minimization was compared with two other randomization methods, which were performed post‐hoc: (i) non‐stratified randomization with four permuted blocks, and (ii) stratified randomization with four permuted blocks and 16 strata. In addition, several factors that could influence outcome were investigated for their effect on BP by 24‐h ambulatory blood pressure monitoring (ABPM). Results. Minimization and stratified randomization did not lead to significant differences in 24‐h ABPM values between the two treatment groups. Non‐stratified randomization resulted in a significant difference in 24‐h diastolic ABPM between the groups. Factors that caused significant differences in 24‐h ABPM values were: region, centre of patient recruitment, age, gender, microalbuminuria, left ventricular hypertrophy and obesity. Conclusion. Minimization and stratified randomization are appropriate methods for use in clinical trials. Many outcome factors should be taken into account for their potential influence on BP levels. Recommendation. Due to the large number of potential outcome factors that can influence BP levels, minimization should be the preferred method for use in clinical hypertension trials, as it has the potential to randomize more outcome factors than stratified randomization.

The effects on lifestyle factors of a five year community intervention program in the Netherlands: The Hartslag Limburg intervention.

BACKGROUND Community-based health promotion is a widely advocated strategy in public health to favorably alter lifestyle. The aim of this study was to investigate the net effect of a cardiovascular disease-prevention program (Hartslag Limburg) on lifestyle factors after 5 years of intervention (1998-2003). METHODS In a cohort study, 5-year mean changes in lifestyle factors (energy intake; fat intake; time spent on leisure-time physical activity; walking, bicycling, and sports; and smoking behavior) between subjects from the intervention area (n=2356) and the control area (n=758) were compared for men and women and for those with a low (less than intermediate secondary education) and a moderate (intermediate vocational or higher secondary education) or high (higher vocational education or university) educational level. Adjustments were made for age and the mean of the individual pre- and post-intervention measurement of the variable under study. When stratifying for gender, adjustments were made for educational level, and vice versa. RESULTS In general, lifestyle factors changed unfavorably in the control group, whereas changes were less pronounced or absent in the intervention group. The adjusted difference in mean change in lifestyle factors between the intervention group and the control group was significant (p<or=0.05) for energy intake (-0.2 megajoule per day among both women and those with a low educational level); fat intake (-2.5 grams per day [g/d] among women and -3 g/d among those with a low educational level); time spent walking (+2.2 hours per week [hrs/wk] among women and +2.3 hrs/wk among those with a low educational level); time spent on total leisure-time physical activity (+2.1 hrs/wk among women); and time spent bicycling (+0.6 hrs/wk among those with a low educational level). CONCLUSIONS The community intervention Hartslag Limburg succeeded in preventing age- and time-related unfavorable changes in energy intake, fat consumption, walking, and bicycling, particularly among women and those with low SES.

Neurologische Verschijnselen van Voorbijgaande aard: Multiple Sclerose?

Joke is al lang patiente in de praktijk. Haar ouders waren ook patient en de huisarts heeft Joke zien opgroeien van baby op het zuigelingenbureau tot een gezonde jonge vrouw van nu 24 jaar. Ze bezoekt de praktijk alleen voor een herhaalrecept voor de pil en vorige maand voor een verwijskaart voor de oogarts omdat ze dacht dat ze misschien een bril nodig had. Vorige week kwam ze op het spreekuur omdat ze niet zo goed kon zien. Bij navraag bleek dat ‘niet goed zien’ eigenlijk klachten waren die wezen op onscherp zien. Soms had ze het idee dat ze beelden dubbel zag, maar zeker was ze er niet van. Verder had ze geen klachten. Geen hoofdpijn, geen duizeligheid en geen prikkelingen in de vingers.

Licht Traumatisch Hoofd- en/of Hersenletsel (Hersenschudding)

Het is bijna half tien en het ochtendspreekuur loopt goed. De patienten zijn cooperatief en er zijn tot nu toe geen ernstige klachten gepresenteerd. Totdat de assistente belt, wat alleen in ernstige gevallen gebeurt! Op de speelplaats van de basisschool, een straat verder, is een ongeluk gebeurd meldt ze, en de leerkracht vraagt in paniek of u ‘zo snel mogelijk daar naar toe komt’. ‘Het kind kon’, zoals telefonisch wordt gemeld ‘wel een hersenschudding hebben opgelopen’. Als u bij het schoolplein arriveert staat er een groep kinderen en leerkrachten rond een jongetje van een jaar of 10, dat op de grond ligt. U ziet direct dat het geen zeer ernstig ongeval is. Zijn kleur is normaal, hij kijkt u aan, weet hoe hij heet en vertelt wat er is gebeurd: bij het spelen liep hij met zijn hoofd tegen de ijzeren paal van het fietsenhok. Hij wist wel dat hij daar niet mocht spelen, maar omdat ze hem bijna ‘getikt hadden’, was hij uitgeweken en pardoes tegen de paal aangelopen. Toen was hij gevallen en alles was zwart voor de ogen geworden. Ook was hij helemaal ‘draaierig’ geworden en hij is nu nog wat misselijk. Hij denkt dat hij wel kan opstaan, maar van de leraar moest hij blijven liggen. Hij heeft wel veel pijn aan de bult op zijn hoofd.

Duizeligheidsklachten, Neurologisch, Vestibulair of…?

Gewoon rechtop lopen en dingen doen zonder het evenwicht te verliezen, lukt bijna altijd feilloos en ook nog zonder enige bewuste inspanning.