Shifts in the care for patients presenting in primary care with anxiety; stepped collaborative care parameters from more than a decade.

BACKGROUND: The mental health burden on primary care is substantial and increasing. Anxiety is a major contributor. Stepped collaborative care (SCC) is implemented worldwide to improve patient outcomes, but long term real-world evaluations of SCC do not exist. Using routinely used electronic medical records from more than a decade, we investigated changes in anxiety prevalences, whether physicians made distinction between non-severe and severe anxiety, and whether these groups were referred and treated differently, both non-pharmacologically and pharmacologically. METHODS: Retrospective assessment of anxiety care parameters recorded by 54 general practitioners between 2003 and 2014, in the electronic medical records of a dynamic population of 49,841-69,413 primary care patients. RESULTS: Substantial shifts in anxiety care parameters have occurred. The prevalence of anxiety symptoms doubled to 0.9% and of anxiety disorders almost tripled to 1.1%. Use of ICPC codes seemed comprehensive and use of instruments to support in anxiety level differentiation increased to 13% of anxiety symptom and 7% of anxiety disorder patients in 2014. Minimal interventions were used more frequently, especially for anxiety symptoms (OR 21 [95% CI 5.1-85]). The antidepressant prescription rates decreased significantly for anxiety symptoms (OR 0.5 [95% CI 0.4-0.8]) and anxiety disorders (OR 0.6 [95% CI 0.4-0.8]). More patients were referred to psychologists and psychiatrists. CONCLUSIONS: We found shifts in anxiety care parameters that follow the principles of SCC. Future primary care research should comprehensively assess the use of the SCC range of therapeutic options, tailored to patients with all different anxiety severity levels.

Comparative analysis of the reproducibility and applicability of the condom catheter method for noninvasive urodynamics in two Dutch centers.

OBJECTIVES: We compared the applicability and reproducibility of the condom catheter method for noninvasive urodynamics in two Dutch studies. MATERIALS AND METHODS: A longitudinal study of changes in bladder contractility secondary to benign prostatic enlargement is taking place at the Erasmus MC in Rotterdam. Volunteers aged 38-77 years will be studied three times in 5 years. The first series of measurements has been completed in 1,020 men. A randomized controlled trial to test the effect of additional water intake on bladder function has been completed at the University of Maastricht. 184 subjects aged 55-77 years with International Prostate Symptom Scores of 8-19 were investigated twice in 6 months. Bladder contractility was measured noninvasively with the condom method. Two consecutive measurements were attempted in each subject. Reproducibility was tested according to Bland and Altman and compared by calculating the normalized standard deviation of the differences by dividing by the difference. RESULTS: The success rate for single measurements was 95% in both studies. The success rates for double measurements varied from 87 to 90%. The normalized standard deviation of the differences between the double measurements was 0.15 for the longitudinal noninvasive study and randomized controlled trial at baseline, and 0.13 for the randomized controlled trial at 6 months. CONCLUSION: Both studies showed good reproducibility of the noninvasive method comparable to invasive urodynamics.

Increasing the daily water intake for the prophylactic treatment of headache: a pilot trial.

Dehydration is commonly believed to result in headache, but the effectiveness of increasing the water intake in patients who frequently suffer from headaches has not been studied thus far. In a pilot study, we examined the possible effects and feasibility of increased water intake in headache patients. Eighteen headache patients (all had migraine, two also had tension-type headache) were randomly allocated to placebo medication, or the advice to additionally drink 1.5 l of water per day, for a period of 12 weeks. Effect measurements consisted of a 2 weeks headache diary and the Migraine Specific Quality of Life (MSQOL) questionnaire. The advice to increase the daily fluid intake by 1.5 l increased the fluid intake in the intervention group by approximately 1 l. This reduced the total hours of headache in 2 weeks by 21 h (95% CI: -48 to 5). Mean headache intensity decreased by 13 mm (95% CI: -32 to 5) on a visual analogue scale (VAS). The effects on MSQOL, number of headache episodes, and medication seemed to be small. The data of the present study suggest a reduction in the total number of hours and intensity of headache episodes after increased water intake. Our results seem to justify larger scaled research on the effectiveness of increased water intake in headache patients.

The validity and ethics of giving placebo in a randomized nonpharmacologic trial was evaluated.

OBJECTIVE: When studying the effects of a non-pharmacologic intervention, the choice of a control group is often difficult. In a study on the effectiveness of increased water intake on voiding dysfunction in elderly men we used an unusual design. This article addresses the internal validty and ethics of this design. STUDY DESIGN AND SETTING: The randomized trial we evaluated had a 6-month follow-up period and was carried out among 141 elderly men with moderate lower urinary tract symptoms. The experimental group was given the instruction to drink more water, the control group received placebo medication. The participants were not informed that there was a 50% chance of receiving placebo. We measured whether the prior expectations and preferences were comparable for the two study groups, whether blinding was preserved throughout the study period, and whether the participants considered this design ethical. RESULTS: Prior to randomization, patients had higher expectations for the experimental intervention, but there was not statistically significant difference in their preference. During the study period, two out of 71 patients in the control group unmasked the placebo. In general, both groups fully agreed with the informed consent procedure. CONCLUSION: This design can be considered when the effects of a non-pharmacologic interventions are studied.

Pathophysiological aspects of bladder dysfunction: a new hypothesis for the prevention of 'prostatic' symptoms.

This article reviews the literature on the pathophysiology of male lower urinary tract symptoms (LUTS) with the intention of developing a new preventive intervention for this bothersome disease. Traditionally, male voiding dysfunction has been thought to arise from bladder outlet obstruction (BOO) caused by prostatic enlargement. Many years of research, however, have shown that a clear relationship between the size of the prostate and the occurrence or severity of symptoms is doubtful. Because of its crucial role in urination, it is increasingly being accepted that the clinical manifestation of voiding dysfunction relies on the functional behaviour of the bladder. Several animal studies have shown that bladder performance can be improved by increasing urine output. Contrary to alterations observed in pathologic situations, an increased urine output provides a physiologic stimulus for animal bladder function improvement. We hypothesise that a trained bladder should be less susceptible to the harmful effects of ageing and obstruction. Future symptoms may thus be prevented. In humans an increased urine output can be achieved by drinking additional water, which could be an adequate preventive intervention.