Severe acute respiratory infections surveillance for early signals in the community

BACKGROUND

Surveillance of acute respiratory infections (ARI) in the Netherlands and other European countries is based mostly on primary care data, with little insight into the severe spectrum of the disease. We compared time-trends for ARI in secondary care with influenza-like illness (ILI), ARI and pneumonia in primary care, and crude mortality, in order to assess the value of routinely collected data on respiratory infections in hospitals and the added value of severe acute respiratory infections (SARI) surveillance.

METHODS

We calculated incidence of ARI in secondary care, ILI, ARI, and pneumonia in primary care, and crude mortality using five historical databases (2008-2016).

RESULTS

Over eight years, seasonal incidence peaks of ARI in secondary care occurred earlier than ILI and ARI incidence peaks in primary care, except during the 2009 influenza A(H1N1) pandemic and post-pandemic season. The median time-lag between ARI in secondary care and ILI, ARI and pneumonia in primary care was 6.5 weeks, 7 weeks, and 1 week, respectively. Crude mortality lagged a median 5 weeks behind ARI in secondary care.

CONCLUSION

This observational study demonstrates that routinely collected data can be used for describing trends of ARI in secondary care and may be suitable for near real-time SARI surveillance. In most seasons, the incidence peaks for ARI in secondary care preceded the peaks in primary care and crude mortality with a considerable time-lag. It would be of great value to add microbiological test results to the incidence data to better explain the difference in time-lag between these surveillance systems.

What are essential elements of high-quality palliative care at home? An interview study among patients and relatives faced with advanced cancer

Background

In the Netherlands, general practitioners (GPs) and community nurses play a central role in the palliative care for home-dwelling patients with advanced cancer and their relatives. To optimize the palliative care provision at home, it is important to have insight in the elements that patients and relatives consider essential for high-quality palliative care, and whether these essentials are present in the actual care they receive.

Methods

Qualitative semi-structured interviews were conducted with 13 patients with advanced cancer and 14 relatives. The participants discussed their experiences with the care and support they received from the GP and community nurses, and their views on met and unmet needs. Interview data were analysed according to the principles of thematic analysis.

Results

Patients as well as relatives considered it important that their GP and community nursing staff are medically proficient, available, person-focused and proactive. Also, proper information transfer between care professionals and clear procedures when asking for certain resources or services were considered essential for good palliative care at home. Most interviewees indicated that these essential elements were generally present in the care they received. However, the requirements of ‘proper information transfer between professionals’ and ‘clear and rapid procedures’ were mentioned as more difficult to meet in actual practice. Patients and relatives also emphasized that an alert and assertive attitude on their own part was vital in ensuring they received the care they need. They expressed worries about other people who are less vigilant regarding the care they receive, or who have no family to support them in this.

Conclusions

Medical proficiency, availability, a focus on the person, proper information transfer between professionals, clear procedures and proactivity on the part of GPs and community nursing staff are considered essential for good palliative care at home. Improvements are particularly warranted with regard to collaboration and information transfer between professionals, and current bureaucratic procedures. It is important for care professionals to ensure that the identified essential elements for high-quality palliative care at home are met, particularly for patients and relatives who are not so alert and assertive.

Antibiotic resistance of Escherichia coli isolated from uncomplicated UTI in general practice patients over a 10-year period

Recommendations of first choice antibiotic therapy need to be based on actual antibiotic susceptibility data. We determined the antibiotic susceptibility of E. coli in uncomplicated UTI among women and compared the results with 2004 and 2009. In 30 sentinel general practitioner practices of Nivel Primary Care database, urine samples were collected from women with symptoms of uncomplicated UTI. Patient characteristics, E. coli susceptibility, and ESBL production were analyzed. Six hundred eighty-nine urine samples were collected; E. coli was the most isolated uropathogen (83%). Antibiotic susceptibility was stable over time except for ciprofloxacin (96% in 2004, 97% in 2009, and 94% in 2014; P < 0.05). The susceptibility to co-amoxiclav was 88%, 87%, and 92% in 2004, 2009, and 2014, respectively. The prevalence of ESBL-producing E. coli increased from 0.1% in 2004 to 2.2% in 2014 (P < 0.05). Regional differences in antibiotic susceptibility for co-trimoxazole were found being the highest in the west (88%) and the lowest in the north (72%, P = 0.021). Ciprofloxacin susceptibility was related to antibiotic use in the past 3 months (97% no use versus 90% use, P = 0.002) and age > 70 years (P = 0.005). In 2014, prescription of fosfomycin increased compared to 2009 (14.3% versus 5.6%) at the expense of co-amoxiclav, co-trimoxazole, and fluoroquinolones (P < 0.05). The susceptibility percentages to most antimicrobial agents tested were stable over 10 years’ period although the prevalence of E. coli and ESBLs significantly increased. Performance of a survey with regular intervals is warranted.

[Effectiveness of influenza vaccine in the Netherlands: predominant circulating virus type and vaccine match are important conditions]

OBJECTIVE

To investigate the relationship between circulating influenza virus A types and subtypes and influenza B lineages, their match with the vaccine and the effectiveness of the influenza vaccine (IVE).

DESIGN

Test negative case control study.

METHOD

We used data from the Dutch Sentinel Practices of the Netherlands Institute for Health Services Research (NIVEL) Primary Care Database. Participating general practitioners took nose and throat swabs for viral studies from patients with influenza-like illness or another acute respiratory infection. Cases were those patients whose samples were positive for an influenza virus and controls were those whose samples were negative for influenza virus. We determined the IVE of 11 influenza seasons 2003/2004 to 2013/2014, for all seasons together and stratified by influenza virus type and to vaccine match or mismatch.

RESULTS

Over all seasons, the IVE was 29% (95% CI:11-43). In seven of the 11 seasons there was a mismatch between vaccine and circulating virus type. The IVE was 40% (95% CI: 18-56) for those seasons in which there was a vaccine match, and 20% (95% CI: - 5-38) for seasons with a mismatch. When the influenza A/H3N2 virus was dominant, the IVE was 38% (95% CI: 14-55). The IVE against the influenza virus A/H1N1, A/H1N1/pdm09 and against both influenza B lineages was 77% (95% CI: 37-92), 47% (95% CI: 22-64) and 64% (95% CI: 50-74), respectively.

CONCLUSION

The IVE was particularly low when there was a mismatch between the vaccine and the circulating virus type and when A/H3N2 was the dominant influenza subtype.

[Trends in suicidal behaviour in Dutch general practice, 1983-2013]

OBJECTIVE

We investigated trends in suicidal behaviour as reported by Dutch general practices from 1983 to 2013. Also, we analysed the relationship with patient characteristics and with the financial crisis of 2008.

DESIGN

Retrospective observational study.

METHOD

We estimated age-adjusted and gender-specific trends in suicides (342) and attempted suicides (1614), as registered in 1983-2013 under ICPC code P77 by 40 Dutch general practices participating in the NIVEL Primary Care Database sentinel station. Secondary outcomes, on the basis of supplementary questions in the GP Information System (Huisartsen Informatie Systeem), were the relationship between suicidal behaviour, earlier treatments and patient characteristics. Also, we analysed separate frequencies for the periods 1983-2007 and 2008-2013.

RESULTS

Join-point analyses revealed a significant rise in male suicides from 2008 (b = 0.32, SE = 0.1, p = 0.008), and an increase in male suicide attempts since 2009 (b = 0.19, SE = 0.04, p < 0.001). Female suicidal behaviour showed a steady decrease in 1989-2013: b = -0.03, SE = 0.007, p < 0.0001 for female suicide, b = -0.02, SE = 0.002, p < 0.001 for female attempts. Almost half of the suicidal patients had visited their GP one month before the event. In 31% of these patients, the GP had recognized suicidal behaviour.

CONCLUSIONS

Since 2008, there was a rise in the male suicide rate while female suicide behaviour has continued to decline. Training in the early recognition of suicide ideation in depressive patients might improve suicide prevention in primary care.

Three decades of eating disorders in Dutch primary care: decreasing incidence of bulimia nervosa but not of anorexia nervosa

BACKGROUND

Whether the incidence of eating disorders in Western, industrialized countries has changed over time has been the subject of much debate. The purpose of this primary-care study was to examine changes in the incidence of eating disorders in The Netherlands during the 1980s, 1990s and 2000s.

METHOD

A nationwide network of general practitioners (GPs), serving a representative sample (~1%) of the total Dutch population, recorded newly diagnosed patients with anorexia nervosa (AN) and bulimia nervosa (BN) in their practice during 1985-1989, 1995-1999, and 2005-2009. GPs are key players in the Dutch healthcare system, as their written referral is mandatory in order to get access to specialized (mental) healthcare, covered by health insurance. Health insurance is virtually universal in The Netherlands (99% of the population). A substantial number of GPs participated in all three study periods, during which the same case identification criteria were used and the same psychiatrist was responsible for making the final diagnoses. Incidence rates were calculated and for comparison between periods, incidence rate ratios.

RESULTS

The overall incidence rate of BN decreased significantly in the past three decades (from 8.6 per 100,000 person-years in 1985-1989 to 6.1 in 1995-1999, and 3.2 in 2005-2009). The overall incidence of AN remained fairly stable during three decades, i.e. 7.4 per 100,000 person-years in 1985-1989, 7.8 in 1995-1999, and 6.0 in 2005-2009.

CONCLUSIONS

The incidence rate of BN decreased significantly over the past three decades, while the overall incidence rate of AN remained stable.

Missed opportunities to offer HIV tests to high-risk groups during general practitioners' STI-related consultations: an observational study

OBJECTIVES

Prior research has shown that Dutch general practitioners (GPs) do not always offer HIV testing and the number of undiagnosed HIV patients remains high. We aimed to further investigate the frequency and reasons for (not) testing for HIV and the contribution of GPs to the diagnosis of HIV infections in the Netherlands.

DESIGN

Observational study.

SETTING

(1) Dutch primary care network of 42-45 sentinel practices where report forms during sexually transmitted infection (STI)-related consultations were routinely collected, 2008-2013. (2) Dutch observational cohort with medical data of HIV-positive patients in HIV care, 2008-2013.

OUTCOME MEASURES

The proportion of STI-related consultations in patients from high-risk groups tested for HIV, with additional information requested from GPs on HIV testing preconsultation or postconsultation for whom HIV testing was indicated, but not performed. Next, information was collected on the profile of HIV-positive patients entering specialised HIV care following diagnosis by GPs.

RESULTS

Initially, an HIV test was reported (360/907) in 40% of STI-related consultations in high-risk groups. Additionally, in 26% of consultations an HIV test had been performed in previous or follow-up consultations or at different STI-care facilities. The main reasons for not testing were perceived insignificant risk; 'too' recent risk according to GPs or the reluctance of patients. The initiative of the patient was a strong determinant for HIV testing. GPs diagnosed about one third of all newly found cases of HIV. Compared with STI clinics, HIV-positive patients diagnosed in general practice were more likely to be older, female, heterosexual male or sub-Saharan African.

CONCLUSIONS

In one-third of the STI-related consultations of persons from high-risk groups, no HIV test was performed in primary care, which is lower than previously reported. Risk-based testing has intrinsic limitations and implementation of new additional strategies in primary care is warranted.

Continued seasonal circulation of enterovirus D68 in the Netherlands, 2011-2014

Enterovirus D68 (EV-D68) continued to circulate in a seasonal pattern in the Netherlands, after the outbreak in 2010. Outpatient EV-D68 cases, mainly in the under 20 and 50–59 years age groups, presented with relatively mild respiratory disease. Hospital-based enterovirus surveillance identified more severe cases, mainly in children under 10 years of age. Dutch partial VP1 genomic region sequences from 2012 through 2014 were distributed over three sublineages similar to EV-D68 from the outbreak in the US in 2014.

Internet-based monitoring of influenza-like illness in the general population: experience of five influenza seasons in The Netherlands

Like in most other countries, influenza surveillance in The Netherlands is based upon influenza-like illness (ILI) consultations reported by sentinel general practitioners (GP). In addition, an internet-based monitoring of ILI in the general population started in 2003/2004 (Great Influenza Survey (GIS)). We compared GIS results over 5 influenza seasons with results from the GP system. Weekly ILI incidence from GIS correlated well with ILI incidence from the GP system the same week and even better 1 week later. This suggests that GIS is useful for early detection of trends in influenza activity. However, two important vulnerable groups, children and the elderly, are clearly underrepresented in the GIS. Furthermore, virological confirmation is lacking in the GIS. So, GIS can be a useful addition to the GP system, especially when representativeness can be improved and when participation remains at the current high level.

The population structure of Staphylococcus aureus among general practice patients from The Netherlands

To investigate the prevalence, the antibiotic resistance pattern and the population structure of Staphylococcus aureus, S. aureus isolates from the anterior nostrils of patients of general practitioners (GPs) were analysed. Insight into the S. aureus population structure is essential, as nasal carriers of S. aureus are at increased risk of developing an S. aureus infection. S. aureus was isolated from nasal swabs from 2691 patients with no sign of an infection collected in 29 GP practices in The Netherlands. The susceptibility pattern for several classes of antibiotics was determined, as well as the S. aureus genetic background, using spa typing. S. aureus was isolated from 617 of the 2691 (23%) nasal swabs. The prevalences of resistance to ciprofloxacin, co-trimoxazole, fusidic acid, macrolides and mupirocin were 0.2%, 0%, 6%, 5% and 1%, respectively. Half of the isolates were associated with a genetic background common to the major methicillin-resistant S. aureus (MRSA) clones, e.g. clonal complex (CC)1, CC5, CC8, CC22, CC30 and CC45, and the remainder were mainly associated with CC7, CC12, CC15, CC26, CC51 and CC101. The low prevalences of resistance suggest that, in the Dutch situation, S. aureus isolates from patients visiting their GP because of complaints not related to infection do not represent a large reservoir of antibiotic resistance genes. Although no MRSA isolates were found, the genetic background of some of the S. aureus isolates is commonly observed among community-associated (CA)-MRSA clones (CC1, CC8 and CC30), and this might suggest that these isolates have the potential to become CA-MRSA.

[Influenza season 2007/'08 in the Netherlands: antigenic variation, oseltamivir resistance and vaccine composition for the 2008/'09 season]

The first signs of influenza activity during the 2007/'08 influenza season in the Netherlands were sporadic isolations of influenza viruses between week 40 and week 52 of 2007. The frequency of virus isolations and clinical influenza activity increased after week 1 of 2008 and peaked around week 9. In this week, 7.2 patients with influenza-like illness were recorded per 10,000 inhabitants. The influenza epidemic was caused primarily by influenza A/H1N1 viruses and influenza B viruses. Two antigenically distinct variants of influenza A/H1N1 viruses were isolated, which resembled the 2007/'08 vaccine reference strain A/Solomon Islands/3/06 and the new vaccine reference strain A/Brisbane/59/07, respectively. The most remarkable finding was that 27% of the A/H1N1 viruses isolated in the Netherlands during the 2007/'08 epidemic were resistant to the neuraminidase inhibitor oseltamivir. The isolated influenza B viruses originated from the B/Yamagata/16/88 lineage and did not match the vaccine strain, which originated from a different and antigenically distinct lineage of influenza B viruses (B/Victoria/2/87). Only a small number of influenza A/H3N2 viruses was isolated, which were related to the vaccine strain for this subtype (A/Wisconsin/67/05). Thus in contrast to previous influenza seasons, A/H3N2 viruses did not play a major role in the 2007/'08 influenza season in the Netherlands. For the 2008/'09 influenza season, the World Health Organization has recommended the following vaccine composition: A/Brisbane/59/07 (H1N1), A/Brisbane/10/07 (H3N2) and B/Florida/4/06.

[The 2006/'07 influenza season in the Netherlands and the vaccine composition for the 2007/'08 season]

The influenza epidemic of 2006/'07 began late in the season, like the two previous influenza epidemics. In week 8 a peak of modest height was reached. As usual, the causal strains were mainly A/H3N2 viruses and to a lesser extent A/H1N1 and B viruses. A new A/H1N1 virus variant has emerged, an event that on average takes place only every 10 years. However, almost all A/H1N1 virus isolates belonged to the old variant and were similar to the vaccine virus. The A/H3N2 virus isolates appeared to deviate from the vaccine strain, but after antigenic cartographic analysis and correction for low avidity they proved also closely related to the vaccine strain. The few type B virus isolates belonged to the B/Yamagata/16/88 lineage, whereas the used B vaccine virus had been chosen from the B/Victoria/2/87 lineage. The vaccine therefore will have provided almost optimal protection against the circulating influenza A/H1N1 and A/H3N2 viruses but not against the influenza B viruses. For the 2007/'08 influenza season the World Health Organization has recommended the following vaccine composition: A/Solomon Islands/3/06 (H1N1) (new), A/Wisconsin/67/05 (H3N2), and B/Malaysia/2506/04.

[The 2005-2006 influenza season in the Netherlands and the vaccine composition for the 2006-2007 season]

The first sign of influenza activity in the Netherlands during the 2005-2006 influenza season was the isolation of influenza viruses in the last week of 2005. From Week 1 of 2006 onwards, an increase in clinical influenza activity was also observed that did not return to baseline levels until Week 15. Two waves of influenza activity were observed with peak incidences of 13.8 and 9.8 influenza-like illnesses per 10,000 inhabitants on Weeks 7 and 12, respectively. The first wave of influenza was caused primarily by influenza B viruses, whereas the second wave was caused predominantly by influenza A/H3N2 viruses. The influenza B viruses appeared to belong to two different phylogenetic lineages and were antigenically distinguishable from the vaccine strain. The isolated influenza A/H3N2 viruses were closely related to the vaccine strain for this subtype and only minor antigenic differences with the vaccine strain were observed for a limited number of isolates. Only a small number of influenza A/H1N1 viruses were isolated, which all closely resembled the H1N1 vaccine strain. For the 2006-2007 influenza season, the World Health Organization has recommended the following vaccine composition: A/Wisconsin/67/05 (H3N2), A/New Caledonia/20/99 (H1N1) and B/Malaysia/2506/05.

[Increasing trend in prescription of methylphenidate in general practices in the north-east of The Netherlands, 1998-2003]

OBJECTIVE

To obtain information on the frequency of and the indications for prescription of methylphenidate in general practices in the north-east of The Netherlands.

DESIGN

Descriptive.

METHOD

Data were collected from 1998 to 2003 from 6 general practices in the north-east of The Netherlands (17 general practitioners, approximately 30,000 patients) that were affiliated to the Registration Network in Groningen. The number of new and existing patients who were prescribed methylphenidate was calculated by age group per 1000 person-years per calendar year. The indication on which the drug was prescribed was looked at, as was the number of patients who were referred to a specialist on that indication.

RESULTS

The number of new users per 1000 person-years more than doubled from 17 in 1999 to 42 in 2003. In all years studied the highest number of new users fell into the age group 5-9 years. The total number of users per 1000 person-years tripled (boys: 1.8 in 1998 and 6.2 in 2003; girls: 0.5 in 1998 and 0.8 in 2003). The prevalence of use in boys was 3 to 8 times as high as that of girls and increasing more quickly. In people under 59 years of age attention deficit hyperactivity disorder (ADHD) was the most frequent indication (55%). In the group aged > or = 60 years methylphenidate was mainly prescribed in the palliative phase of somatic morbidity. Over half of the 140 new patients (57%) were referred nor to a specialist in the year before neither in the year after the first prescription of methylphenidate.

[Erection due to 'high flow' priapism in a 5-year old: an emergency]

A healthy 5-year-old child was brought to the general practitioner with priapism that had been observed for a few days, without any other symptoms. Angiography revealed an arteriovenous fistula originating from the left A. dorsalis penis, which was successfully embolised. The diagnosis was 'high flow' priapism. A possible cause in the anamnesis was a fall from a swing two weeks before the embolisation. The doctor's delay was caused by unfamiliarity with this rare disorder; due to the risk of impotence (impotentia coeundi), it is an emergency situation.

Symptom attribution after a plane crash: comparison between self-reported symptoms and GP records

BACKGROUND

On 4 October 1992, an El Al Boeing 747-F cargo aeroplane crashed on two apartment buildings in Amsterdam. Thirty-nine residents on the ground and the four crew members of the plane died. In the years after, a gradually increasing number of people attributed physical signs and symptoms to their presence at the disaster scene.

AIM

To investigate the consistency between patients' symptoms attributed to the crash and GPs' diagnoses and perception of the association with the crash.

DESIGN OF STUDY

Comparison between self-reported symptoms to a call centre and GPs' medical records on onset and type of symptoms, diagnoses, and GPs' perception of association with the disaster, assessed by questionnaire.

SETTING

Consenting patients (n = 621) contacting the call centre and their GPs.

METHOD

Patients were interviewed by the call centre staff and interview data were recorded on a database. Questionnaires were sent to the consenting patients' GPs, requesting their opinions on whether or not their patients' symptoms were attributable to the effects of disaster. Baseline differences and differences in reported symptoms between interviewed patients and their GP records were tested using the chi2 test.

RESULTS

The 553 responders reported on average 4.3 symptoms to the call centre. The majority of these symptoms (74%) were reported to the GP. Of the ten most commonly reported symptoms, fatigue, skin complaints, feeling anxious or nervous, dyspnoea, and backache featured in 80% of symptoms reported to the GP. One out of four symptoms was either reported to the GP before the disaster took place, or six or more years after (1998/1999, during a period of much media attention). Depression (7%), post-traumatic stress disorder (PTSD) (5%) and eczema (5%) were most frequently diagnosed by GPs. They related 6% of all reported symptoms to the disaster.

CONCLUSIONS

Most of the symptoms attributed to a disaster by patients have been reported to their GP, who related only a small proportion of these to the disaster.

Hormone replacement therapy: changes in frequency and type of prescription by Dutch GPs during the last decade of the millennium

OBJECTIVE

The present study was conducted in order to determine the change of frequency and type of hormone replacement therapy (HRT) regimen newly prescribed by Dutch GPs.

METHODS

A comparison was made of two data sets (multi-stage random samples) collected in 1987/88 and from 1995 to 1998 concerning women 40 years and older who were newly prescribed HRT.

RESULTS

Compared with 1987/88, 50% more patients were newly prescribed HRT in 1998 (2.0 in 1987/88 and 3.0 in 1998 per 1000 registered women, P < 0.01). The age distribution remained about the same, with a peak between 50 and 54 years in each year of registration. Unopposed oestrogens (including plasters) were prescribed less frequently (1.3 per thousand in 1987/88 versus 0.7 per thousand in 1998, P < 0.001), and combinations of oestrogen and progestogen more frequently in 1998 (0. 2 per thousand in 1987/88 versus 1.8 per thousand in 1998, P < 0. 01). Sequential therapy was prescribed slightly more frequently than continuous therapy (65% sequential therapy in 1995; 55% in 1998). The most frequent reason for starting HRT in 1995-1998 was climacteric symptoms (89-98%), followed by osteoporosis prevention (16-28%) and early menopause (13-25%). Rarely were preventive goals the only reason (6%) for prescribing HRT.

CONCLUSIONS

The number of HRT prescriptions increased by 50% over the last decade of the millennium. The age distribution remained the same. There was a tendency to shift from prescribing unopposed oestrogens to combinations of oestrogens and progestogens. Alleviation of climacteric symptoms was the main reason for prescribing HRT throughout the registration period. Prescription of HRT for prevention of osteoporosis and/or cardiovascular disease has so far not been adopted on a large scale by Dutch GPs.

Patients with irritable bowel syndrome: health status and use of health care services

BACKGROUND

The reason for consulting a physician is more related to illness behaviour than to the severity of complaints. Yet, little is known about the course of complaints, the health care seeking behaviour, and psychosocial factors influencing these items in patients with irritable bowel syndrome (IBS) attending the general practitioner (GP).

AIM

To study health status, lifestyle, and use of health care services of patients with IBS in order to indicate problem areas accessible for intervention strategies.

METHOD

Structured interviews of 53 patients with IBS aged 15 years and older compared with a general population of 12,975 in the same age range, all drawn from the Dutch National survey of Morbidity and Intervention in General Practice.

RESULTS

Patients with IBS revealed a lower grade of education (P < 0.001), poorer health (P < 0.001), a higher mean complaint score (8.3 versus 4.0, P < 0.001), a higher score on the General Health Questionnaire (P < 0.001), a higher score on the biographic problem list (BIOPRO, 2.3 versus 1.4, P < 0.001), and more absence from work (32% versus 18% in two months, P < 0.01). Patients with IBS consulted the family physician (1.6 versus 0.8 in three months, P < 0.001), the physical therapist (30% versus 15% in one year, P < 0.001), and the alternative therapist (32% versus 15% in five years, P < 0.001) more often than those without.

CONCLUSIONS

The study shows an excess of comorbidity, psychosocial problems, use of health care services, and absence owing to disease in patients with IBS. Special guidelines and training of GPs to apply a more integral approach may reduce the cost of health care and may lead to a more favourable course in patients with IBS.

[Management of psoriasis in family practice is now in closer agreement with the guidelines of the Netherlands Society of Family Physicians]

OBJECTIVE

To assess changes in incidence of psoriasis and to study changes in the management of psoriasis in general practice after the sending of guidelines on management of psoriasis to general practitioners (GPs) by the NHG.

DESIGN

Secondary data analysis.

SETTING

Netherlands Institute for Health Care Research (NIVEL), Utrecht, the Netherlands.

METHOD

Data on the incidence of psoriasis and its management by general practitioners were collected from a file predating the publication of the NHG guideline 'Psoriasis' in 1994, namely the 'Dutch National Survey of General Practice' (NS; 1987/'88), and from a subsequent file, the 'Registration Network Groningen' (RNG; 1995).

RESULTS

In the NS there were 106 new patients with psoriasis (incidence: 1.3/1000/year; 95% confidence interval (95% CI): 1.2-1.4) while in the RNG there were 24 (incidence: 1.2/1000/year; 95% CI: 0.7-1.9). In all, there were 466 psoriasis patients in the NS and 125 in the RNG. The number of referrals to dermatologists was halved in 1995 (7.2%) compared with 1987/'88 (14.4%; p < 0.05). The most frequently prescribed dermatologica in psoriasis was in 1995 corticosteroid group 3 (32.8%; in 1987/'88: 28.5%), but the rise was stronger in corticosteroid group 2 (29.6%; in 1987/'88: 16.0%; p < 0.001) and group 4 (16.0%; in 1987/'88: 8.8%; p < 0.05).

CONCLUSION

The incidence of psoriasis in general practice had not changed between 1987/'88 en 1995. Referral pattern and prescription shifted towards the guidelines issued by the NHG.

Epilepsy patients: health status and medical consumption

OBJECTIVE

To study the health status and medical consumption of outpatients with active epilepsy in comparison with the general population.

DESIGN

Descriptive population study (multi-stage random sample).

SETTING

Structured questionnaire.

PATIENTS

Thirty-nine epilepsy patients compared with a general population of 12,975.

RESULTS

Epilepsy patients revealed poorer health, a higher mean complaint score (5.3 versus 3.7, P < 0.05), a higher score on the General Health Questionnaire (P < 0.05), a somewhat higher score on the bio-logical problem list (BIOPRO) (1.8 versus 1.4, P > 0.05), less active sports engagement (16% versus 39%, P < 0.01), more fatigue (46 vs 29%, P < 0.05), dizziness (33 vs 10%, P < 0.01), nervousness (28 vs 18%, P > 0.05), sleep disturbance (23 vs 15%, P > 0.05) and excitability (33 vs 15%, P < 0.01) when compared with the general population. The BIOPRO showed problems in epilepsy patients on specific items related to self-confidence (P < 0.001) Epileptic patients do not show more absence due to illness, from work, school or at home (15 vs 18%, P > 0.05) and/or more problems at work or in the family when compared with the general population. Almost half of epilepsy patients had consulted a specialist in the past 2 months (46 vs 23% of the general population, P < 0.001). Epilepsy patients consulted the family physician slightly more often than other responders (3.0 versus 2.3, P > 0.05) and contacted the family physician's assistant considerably more often (2.3 versus 0.7, P < 0.001). One-third of epilepsy patients consulted an alternative healer in the past 5 years versus 14% in the general population (P < 0.001).

CONCLUSIONS

The study shows an excess of psychosocial problems and medical consumption in epilepsy patients, but not more absence from work or problems at work or in the family. Further development of a quality of life instrument specific to epilepsy is advised.

Low birth weight and serum lipid concentrations at age 7-11 years in a biracial sample

The relation between birth weight and serum lipid concentrations at age 7 through 11 years was examined in a sample of 1,411 black children and white children in Washington Parish, Louisiana. Two data sets of the Bogalusa Heart Study were merged: 1) newborn cohort participants (n = 225) initially examined at birth, 1973-1974, and reexamined in 1984-1985 at age 9 through 11 years; and 2) subjects examined at ages 7 through 11 years in 1987-1988 (n = 1,186) whose birth weight was collected from birth certificates in 1991. The prevalence ratios for being in the race-, sex-, and age-specific upper decile of serum lipid concentrations in children born with low birth weight (< 2,500 g) versus those with birth weight > or = 2,500 g were calculated per race-sex group. Among white boys with low birth weight, higher than expected percentages of subjects were in the highest decile group of triglyceride concentrations (0.01 < p < 0.05). The prevalence ratio was 2.42 (95% confidence interval 1.19-4.91). When premature infants were excluded, only for white girls was a greater than expected percentage of subjects with low birth weight found to be in the highest decile group of triglyceride concentrations. The corresponding prevalence ratio for white girls was 3.23 (95% confidence interval 1.16-9.00). In analyses that either included or excluded premature infants, prevalence infants, prevalence ratios for triglyceride concentrations in black boys and black girls and for the low density lipoprotein cholesterol/high density lipoprotein cholesterol ratio, total cholesterol concentration, and very low density lipoprotein cholesterol concentration in all race-sex groups were not significantly different from one. To our knowledge, this is the first study finding associations between low birth weight and elevated triglyceride concentrations in later childhood. A follow-up study among adults is recommended.

Low birth weight and blood pressure at age 7-11 years in a biracial sample

The hypothesis that birth weight predicts blood pressure inversely at age 7 through 11 years was examined in 1,446 white children and black children in Washington Parish, Louisiana. Two data sets of the Bogalusa Heart Study were merged: 1) newborn cohort participants (n = 233), initially examined at birth, 1973-1974, and reexamined in 1984-1985 at ages 9 through 11 years; and 2) subjects examined at ages 7 through 11 years in 1987-1988 (n = 1,213) whose birth weight was collected from birth certificates in 1991. The prevalence ratios for being in the race-, sex-, and age-specific upper decile of diastolic blood pressure in children born with low birth weight (< 2,500 g) versus those with birth weight > or = 2,500 g were 0.85 (95% confidence interval 0.28-2.56) for white boys, 2.66 (95% confidence interval 1.24-5.70, p < 0.05) for black boys, 1.38 (95% confidence interval 0.63-3.03) for white girls, and 1.05 (95% confidence interval 0.40-2.75) for black girls. For systolic blood pressure, the corresponding prevalence ratio for each race-sex group did not differ from one. When the analyses were restricted to full-term births, prevalence ratios in any race-sex group did not differ from one for systolic and diastolic blood pressure. In multiple linear regression analyses, the concurrently determined Quetelet index (p < 0.001) was a much stronger correlate of systolic and diastolic blood pressure after appropriate adjustment than was birth weight (p > 0.05). From this study, there is some evidence that low birth weight may determine a risk for subsequent high blood pressure in black boys in the age group 7 through 11 years, but the inconsistency of the results for other race-sex groups was unexpected and remains unexplained, if the underlying hypothesis is true.

Multiple sclerosis: management in Dutch general practice

BACKGROUND AND OBJECTIVES

A descriptive study on 118 MS patients in general practice, to describe the family physician's role in diagnosis, treatment and follow-up of patients.

METHOD

Random sample of 103 general practices (161 family physicians) throughout The Netherlands with a total list of 335,000 patients.

RESULTS

MS patients had on average 5.7 encounters with general practice in 3 months compared to 2.3 in all other patients (P < 0.001). Home visits counted for 38.7% of all family physician's encounters in MS patients compared to 16.6% in all other patients (P < 0.01). The average encounter lasted 12.9 minutes per MS patient compared to 7.8 in all other patients (P < 0.01). Counselling by the family physician took place in all new patients and in 53% of known patients. Follow-up appointments were made with all new patients and 65.9% of all MS patients. Fifteen patients (12.7%) were newly referred to a specialist and 28 patients (24%) were still treated by specialists. No medication was prescribed to almost 40% of patients. Vitamin B, benzodiazepines, laxatives, antibiotics for treatment of urinary tract infections and muscle relaxants are the most frequently prescribed drugs. The average dose of vitamin B complex was 1.94 times the defined daily dose.

CONCLUSIONS

The family physician spends more time than average on MS patients, carries out more home visits and takes care of treatment of symptoms and complications of MS. Counselling and follow-up of patients takes an important place in family physician's management of MS. Vitamin B complex is being prescribed (too) frequently in a (too) high dose.

[Multiple sclerosis in family practice]

OBJECTIVE

To study the family physician's role in the diagnosis and treatment of multiple sclerosis (MS) patients.

DESIGN

Descriptive.

SETTING

Nederlands Instituut voor Onderzoek van de Gezondheidszorg, Utrecht, The Netherlands.

METHOD

In the Dutch National survey of morbidity and intervention in general practice, data were collected by 161 general practices throughout the Netherlands (161 family physicians) regarding contacts with patients during three months. These data were examined for contacts which resulted in the diagnosis of MS and for comorbidity.

RESULTS

MS patients (n = 118) had 4.3 encounters per 3 months with their family physician and (or) the practice assistant. In 5 patients MS was diagnosed for the first time. Apart from neurological complaints characteristic of MS the family physician was consulted most frequently for sleeping disorders, urinary tract infections and urine incontinence. One-third of patients depended on social security and 26% had a paid job.

CONCLUSION

The family physician was consulted relatively frequently by MS patients. Apart from sleeping disorders remarkably few psychic complaints were noted.

Factors associated with serum cholesterol level in a pediatric practice. Cholesterol screening in a pediatric practice

The associations between age, sex, height, Quetelet index, blood pressure, and serum cholesterol level were examined among 1406 routinely screened children, aged 4 to 19 years, in a pediatric practice. After adjustment for sex and age, height and Quetelet index were associated with serum cholesterol levels. Quetelet index was shown by multiple linear regression to be positively related to cholesterol levels (b = 0.780, P < 0.01), but the predictive value of screening based on an elevated Quetelet index was marginal. Clustering of elevated serum cholesterol level, Quetelet index, and systolic blood pressure was observed. Familial aggregation of cholesterol levels was demonstrated using analysis of variance for 742 children from 342 families included in the regression analysis (F341,400 = 1.56, P < 0.0001). The intraclass correlation coefficient, a measure of familial aggregation, was 0.205 (P < 0.0001). Age, sex, height, Quetelet index, and familial aggregation accounted for 10.6% of the variance in serum cholesterol levels. Siblings of children with high cholesterol levels are a high-yield group in cholesterol screening.

Cholesterol screening in pediatric practice

Four pediatricians introduced a portable cholesterol analyzer into their group practice. Their experience is described on the basis of 12 months of screening in 1665 children and adolescents. The overall 50th and 90th percentile values for a subgroup of 1406 routinely screened children were 156 and 197 mg/dL, respectively, but there was marked variation in these values among specific age and sex groups. Cholesterol levels decreased by age group during the early teenage years and increased thereafter, these changes occurring at ages approximately 2 years younger for girls than for boys. Further analysis of screening results for 398 sibling pairs demonstrated significant concordance between paired cholesterol levels when classified by the respective age- and sex-specific 90th percentile values for each member of the pair. Sibling pairs in which both members' cholesterol values exceeded their 90th percentile value were identified 2.4 times as frequently as expected (confidence interval 1.1 to 4.5, P = .029). The observations reported here indicate that office-based cholesterol screening in a pediatric practice may be both practical and useful, although further consideration of screening criteria is needed. Age- and sex-specific reference values for cholesterol levels during childhood could improve screening results. Special emphasis should be directed toward screening siblings of children in whom high cholesterol levels have been detected.