Impact of Q-fever fatigue syndrome on patients' work status.

BACKGROUND: Chronic illnesses can increase the risk of unemployment, but evidence on the specific impact of Q-fever fatigue syndrome (QFS) on work is lacking. AIMS: The aim of this study was to describe and quantify the impact of QFS on work. METHODS: Changes in work status from 1 year prior to 4 years after acute Q-fever infection of QFS patients were retrospectively collected with a self-report questionnaire measuring employment status and hours of paid work per week. In addition, information on work ability, job satisfaction and need for recovery after work was collected in 2016. Data were compared to participants from the general population. RESULTS: The proportion of employed QFS patients from 1 year prior to 4 years after acute infection decreased from 78 to 41%, while remaining relatively constant in the general population (82 to 78%). Working QFS patients showed a decrease in mean hours of paid work from 35 to 22 h per week, which is significantly steeper compared to the general population (31-28 h per week) (P < 0.001). QFS patients showed a significantly lower work ability (P < 0.001), lower job satisfaction (P = 0.006) and greater need for recovery (P < 0.001) compared to the general population. CONCLUSIONS: The number of QFS patients with paid work decreased over the years, while patients who continue to work experience lower work ability, job satisfaction and increased need for recovery. Occupational physicians should be aware of the occurrence and severity of the impact of QFS on work, even after many years.

Towards healthy settings for people with intellectual disabilities.

People with intellectual disabilities (ID) depend on their environment for support to live healthily. The characteristics of healthy settings for people with ID are unknown. This study aims to conceptualize healthy settings for people with ID by conducting an international and multidisciplinary concept mapping study. As theoretical framework the settings approach, an ecological model with a whole system focus toward health promotion, was used. The integrative mixed-methods approach of this study involved concept mapping with researchers specialized in healthcare for people with ID and researchers specialized in healthy settings. The 41 participants generated statements that were later sorted and rated. Findings encompass 13 clusters relating to the social environment, the physical environment and societal preconditions. Specific factors of healthy settings for people with ID include: (i) universal design of the physical environment, (ii) the role of care professionals in the social environment to empower people with ID, (iii) possibilities for care providers to contribute to a health-promoting setting and (iv) preconditions that allow people to engage in society. These factors can be used in strategies to apply the approach in practice and give directions to put in place policies on developing enabling environments and decreasing health inequities.

[Influence of Luxury Foodstuffs on Glaucoma]. / Einfluss von Genussmitteln auf das Glaukom.

The term "luxury foodstuffs" refers to foods which are not consumed because of their nutritional value. Classic modern luxury foodstuffs are alcohol, caffeine-containing drinks, cocoa, sugar and tobacco. The following review article examines some of these modern luxury foodstuffs in detail, as well as their influence on glaucoma. Thus, small quantities of alcohol lower high intraocular pressure and have a positive influence on the blood circulation of the optic nerve. In addition, red wine polyphenols exert vasoprotective effects. In general, however, alcohol consumption appears to have no significant effect on the prevalence of glaucoma. The most important source of caffeine intake is coffee consumption. In some studies, coffee consumption caused no changes in intraocular pressure, while others reported a rise. A large study showed a connection between heavy coffee consumption and the risk of pseudoexfoliation glaucoma. Green and black teas are rich sources of flavonoids with antioxidant activity. In addition, a slight trend for lowering the intraocular pressure has been measured. As regards chocolate, flavonoid-rich dark chocolate should be favoured, due to its antioxidant activity. It lowers blood pressure and improves endothelium-dependent vascular relaxation. Excessive sugar consumption over many years can lead to increased body mass index (BMI) and type 2 diabetes. Many studies show a positive relationship between BMI and intraocular pressure. Some studies have identified significant correlations between type 2 diabetes and the risk of glaucoma. Smoking is a very widespread stimulant; it narrows the blood vessels and thus reduces the blood circulation of the optic nerve. Otherwise, studies on the role of smoking as a risk factor for glaucoma have been very inconsistent. Luxury foodstuffs may effect glaucoma and should be included in the medical history.

Clinical course and complications following diagnostic bronchoalveolar lavage in critically ill mechanically ventilated patients.

BACKGROUND: Flexible, fibreoptic bronchoscopy (FFB) and bronchoalveolar lavage (BAL) have been used for diagnostic purposes in critically ill ventilated patients. The additional diagnostic value compared to tracheal aspirations in ventilator-associated pneumonia (VAP) has been questioned. Nevertheless, BAL can provide extra information for the differential diagnosis of respiratory disease and good antibiotic stewardship. These benefits should outweigh potential hazards caused by the invasiveness of this diagnostic technique. The focus of the present study was on the clinical course and complications of patients following BAL procedures up to 24 h. METHODS: Hundred sixty-four FFB guided BAL procedures for suspected pneumonia were analysed in an observational study. The clinical course of patients was monitored by respiratory and haemodynamic data before BAL, 1 and 24 h after BAL. Complications were defined and registered. Factors associated with complications were analysed by logistic regression. CLINICAL COURSE: a decrease in average pO2/FiO2 ratio 1 h after BAL from 29 kPa (218 mmHg) to 25 kPa (189 mmHg) (p < 0.05) was observed which fully recovered within 24 h. Respiratory complications: the incidence of procedure related hypo-oxygenation (SaO2 ≤ 88 %) and/or bronchospasm was 9 %; a decrease of >25 % PaO2/FiO2 ratio 1 h after BAL was found in 29 % of patients; no bleeding or pneumothorax were registered. Haemodynamic complications: there were no cases of hypertension and cardiac rhythm disturbances; haemodynamic instability within the first 24 h after BAL was recorded in 22 %; this was correlated with a cardiovascular diagnosis at admission (OR 2.9; 95 % CI 1.2 - 6.7) and the presence of cardiovascular co-morbidity (OR 3.5; 95 % CI 1.5 - 8.3). The incidence of bacteraemia was 7 %. There was no case of procedure related death. DISCUSSION: Frequently occurring haemodynamic and respiratory instability but no cases of cardiac rhythm disturbances, bleeding, pneumothorax or procedure related death were attributable to diagnostic FFB and BAL. The procedures should be conducted under careful supervision by experienced physicians. Only a randomized controlled trial that compares diagnostic FFB and BAL with a non-invasive strategy could ultimately establish the safety profile and clinical utility of these procedures in critically ill ventilated patients.

[Preservatives from the perspective of glaucoma surgery]. / Konservierungsmittel aus Sicht der Glaukomchirurgie.

Trabeculectomy is still the gold standard in the surgical treatment of glaucoma patients. Development of a bleb is the primary goal of this procedure and the conjunctival status is therefore decisive. Only a good functioning bleb renders good intraocular pressure (IOP) control. Scar tissue formation leads to bleb failure which is quite common despite the use of antiproliferative agents, such as mitomycin C and 5 fluoruracil. Wound healing is important and is influenced and impaired by the chronic use of topical antiglaucoma drugs. Therefore, complete abstinence is recommended from 4-6 weeks prior to a planned trabeculectomy; however, it seems mandatory to completely abolish preservatives such as drops containing benzalkonium chloride to enhance trabeculectomy success rates.

[Morphological alterations induced by preservatives in eye drops]. / Morphologische Veränderungen durch Konservierungsmittel in Augentropfen.

A large number of experimental and clinical investigations carried out recently have confirmed that the chronic application of eye drops induces significant cytological and histological impairment in ocular tissues. It is also generally accepted that preservatives are the components responsible for the observed changes. The most commonly used preservative in ophthalmology is benzalkonium chloride (BAC), which has a relatively high toxicity. Possible consequences of preservatives on the eye are chronic inflammation and subsequent fibrosis of the subconjunctiva and cell loss and structural changes in the conjunctival epithelium as well as in the epithelial and endothelial layers of the cornea. Frequently, dry eye symptoms occur or deteriorate during therapy. During the last few years new preservatives have been developed which seem to have fewer side effects; however, relatively little data are available with regard to these new substances. To minimize impairments of the eye, preservative-free formulations should be considered for therapy.

[Intravitreal implants: drug carriers and carriers of hope?]. / Intravitreale Implantate: Wirkstoff- und "Hoffnungsträger"?

Immunosuppressive agents are used for the therapy of noninfectious uveitis if intraocular quiescence and freedom from recurrences are not achievable with oral steroids at a low dosage. Partially, severe side effects are tolerated to preserve visual acuity even if the disease is limited to the eyes. Because of this a therapy would be desirable which is highly effective, limited to the eyes and with few side effects. For this fluocinolone acetonide and dexamethasone drug delivery systems were developed. Dexamethasone implants were already approved for the therapy of retinal vein occlusions and are used successfully. Diabetic macular edema would be another possible indication for dexamethasone implants.

Malnutrition and socio-demographic factors associated with pulmonary tuberculosis in Timor and Rote Islands, Indonesia.

OBJECTIVE: To identify nutritional and socio-demographic factors for the development of tuberculosis (TB) in Timor and Rote Island, Indonesia, so that intervention programmes can be developed to address these factors. METHODS: In a case-control study, we enrolled new sputum smear-positive pulmonary TB patients as cases, and neighbours matched for sex and age as controls. Data obtained included history of TB, socio-demographic factors and nutritional status. RESULTS: In the study, 121 TB patients and 371 controls participated. The mean age was 30 years: 56.3% were male and 43.7% female. Of the TB patients, 87% had malnutrition compared to 33% among controls. The mean body mass index (BMI) of the patients was significantly lower than that of the controls (16.1 +/- 2.3 kg/m(2) vs. 19.4 +/- 3.0 kg/m(2)). Factors associated with the development of TB were BMI (OR 0.5, 95%CI 0.4-0.6), family history of TB (OR 3.2, 95%CI 1.6-6.4), living in an extended family (OR 2.7, 95%CI 1.5-4.8), being non-indigenous to Timor and Rote Islands (OR 2.9, 95%CI 1.2-6.8) and being unemployed (OR 3.8, 95%CI 1.7-8.6). CONCLUSION: Among patients with active pulmonary TB, the prevalence of malnutrition was very high. Malnutrition, which is a general problem for the whole community and particularly among people not indigenous to Timor and Rote, should be addressed in the fight against TB.

Vitamin A deficiency and other factors associated with severe tuberculosis in Timor and Rote Islands, East Nusa Tenggara Province, Indonesia.

BACKGROUND: Plasma zinc and vitamin A concentrations have been reported to be low in tuberculosis (TB) patients in some studies, although it is not clear whether this constitutes a risk for a more severe clinical presentation among TB patients. The acute phase reaction may also deplete zinc and vitamin A in the plasma. Therefore, we further studied these associations. METHODS: We carried out a cross-sectional study among newly diagnosed sputum smear-positive TB patients in East Nusa Tenggara. The patients were categorized as either mild TB when Karnofsky Score (KS) > or =80 or severe TB (KS <80). Body mass index (BMI), mid upper arm circumference (MUAC), chest radiograph, and the results of hemoglobin, erythrocyte sedimentation rate, albumin, C-reactive protein (CRP), zinc and vitamin A in plasma were correlated with TB category. RESULTS: A total of 300 TB patients participated in the study (63% male and 37% female), and were categorized as mild TB (53%) or severe TB (47%). Vitamin A, hemoglobin and plasma albumin were significantly lower, and CRP was significantly higher, in severe TB than in mild TB, and the active lesion area on the chest radiograph was greater among severe TB patients. In a multiple regression analysis, after adjustment for CRP, low vitamin A (beta=3.2, 95%CI (confidence interval) 1.6-4.9, P=0.000) but not zinc, correlated with the severity of TB. MUAC was better than BMI as a predictor of TB severity (beta=1.3, 95%CI 0.6-6.2, P=0.000). CONCLUSIONS: Severe TB was associated with vitamin A deficiency. MUAC can be applied as a measure of TB severity.

Primary groin irradiation vs primary groin surgery for early vulvar cancer.

BACKGROUND: Despite changes in technique, morbidity after surgical treatment for vulvar cancer is considerable and mainly related to the groin dissection. Primary radiotherapy to the groin is expected to result in lower morbidity. However, studies on the efficacy of primary radiotherapy for the groins in terms of groin recurrences and survival show conflicting results. OBJECTIVES: To determine whether the effectiveness and safety of primary radiotherapy to the inguino-femoral lymph nodes is comparable with surgery SEARCH STRATEGY: The literature search was carried out using the criteria set by the Cochrane Gynaecological Cancer Group. A MEDLINE and EMBASE search using the Mesh Heading 'vulvar neoplasms' and textword 'vulva' was performed. Publications on the effectiveness of primary radiotherapy treatment of early squamous cell carcinoma of the vulva were selected. TYPE OF STUDY: Randomized clinical trials, case-control and observational studies of primary radiotherapy of the groin Type of participants: Patients with early squamous cell cancer of the vulva Type of interventions: inguino-femoral lymph node dissection and primary radiotherapy of the inguino-femoral lymph nodes. Type of outcome measurements: incidence of groin recurrences, survival and morbidity DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed study quality and extracted results MAIN RESULTS: Out of nine reviewed papers only three met the selection criteria. From these studies, (one randomised controlled trial [RCT] one case-control and one observational study) it became clear from the RCT that the incidence of groin recurrences after primary radiotherapy is higher compared with surgery. survival was also worse in the radiotherapy group. The other two studies showed a higher than expected number of groin recurrences after primary radiotherapy. Morbidity after primary radiotherapy was lower compared with surgery. The conclusion of the RCT was criticized on the grounds of the depth of the radiotherapy administered. The depth of 3 cm used in the RCT, is too shallow to administer an optimal dose to the deeper groin nodes. REVIEWER'S CONCLUSIONS: As shown in an RCT, primary radiotherapy to the groin results in less morbidity but also in a higher number of groin recurrences compared with surgery. Although the technique of radiotherapy in the RCT was criticized, other uncontrolled data do not give evidence for a similar or better groin control for radiotherapy when compared to surgery. This means that surgery is still to be considered the cornerstone of therapy for the groin nodes in women with vulvar cancer. Individual patients not fit enough to withstand surgery can be treated with primary radiotherapy.

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.

The elimination of selected chronic diseases in a population: the compression and expansion of morbidity.

OBJECTIVES: This study evaluates the effect of eliminating a specific disease on the mortality, long-term disability, and overall health status of a population. Primarily, it examines whether elimination leads to a compression of morbidity. METHODS: The Sullivan method was used to calculate disability-free life expectancy. Cause-deleted disability prevalence was estimated with a multiple logistic regression model that used data from the Dutch National Survey of General Practice. Cause-deleted probabilities of dying were derived with the cause-elimination life-table technique, assuming independence among competing causes of death. RESULTS: Eliminating disabling nonfatal diseases such as arthritis/back complaints results in a decline in life expectancy with disability--that is, an absolute compression of morbidity. Eliminating highly fatal diseases such as cancer leads to an increase in the number of years and the proportion of life with disability--that is, a relative expansion of morbidity. CONCLUSIONS: While eliminating fatal diseases leads to an increase in disability-free life expectancy, life expectancy with disability may increase as well. This represents an increasing burden to society. On the other hand, eliminating nonfatal disabling diseases leads to absolute compression of morbidity.

Do out-of-office laboratory tests affect diagnoses in general practice?

OBJECTIVE: To find out whether the GP diagnosis changed by out-of-office laboratory test results and whether his diagnosis became more certain. DESIGN: Descriptive study. SETTING: Dutch survey of morbidity and interventions in general practice: stratified random sample of 161 GPs with a total list of 335,000 patients. SUBJECTS: 2,081 episodes of illness with at least one consultation with clinical chemistry, haematology, or serology tests and at least one follow-up consultation. MAIN OUTCOME MEASUREMENTS: Change in ICPC component or chapter between the consultation in which a laboratory test was ordered and the follow up contact; change in exact ICPC code in cases with important diseases (infectious diseases, haematological disorders, endocrine abnormalities, auto-immune processes and malignancies (n = 330)); change in certainty of a diagnosis and change in somatic/psychosocial orientation. RESULTS: After laboratory tests done in the first consultation the ICPC component changed in 46% of the diagnoses. Of the diagnoses made in first consultations without laboratory tests 41% changed in the follow up consultation. The diagnosis after laboratory tests was the same as before in 51% of the consultations with important diseases. Certainty about a diagnosis increased significantly after laboratory tests (p < 0.001). An abnormal laboratory result did not affect the clinical certainty of the general practitioner or the percentage of altered diagnoses. CONCLUSION: The usefulness of tests should be assessed not only in terms of the number of diagnoses changed or of the percentage of abnormal results, but also in terms of the changed certainty concerning a diagnosis.

Cholesterol management in Dutch general practice. A comparison with national guidelines. Dutch College of General Practitioners.

OBJECTIVE: To examine cholesterol diagnosis and treatment by Dutch general practitioners (GPs) in the period before publication of national guidelines, in order to develop implementation strategies based on discrepancies found between daily practice and the guidelines. DESIGN: Data of the 'Dutch National Survey of General Practice', in which GPs were involved in extensive consultation registration, were used. Patients were included for analysis if serum cholesterol, or the ICPC-code lipid metabolism disorder, or cholesterol-lowering treatment was registered. SETTING: General practice. PARTICIPANTS: 161 GPs, 177 practice-nurses. OUTCOME MEASURES: Reasons for consultation, diagnoses, therapy, inter-doctor variation. RESULTS: The main discrepancies between daily practice and the guidelines concerned indications for cholesterol measurement, repeated measurements to diagnose hypercholesterolaemia, and attention for diet advice. A remarkable inter-doctor variation in diagnosis, and less so in treatment, was also found. CONCLUSION: The inter-doctor variation justifies the publication of the standard guidelines. Implementation strategies should aim at indications for cholesterol testing, repeating measurements for diagnosis, and advice on diet.

Prescription of antibiotics and prescribers' characteristics. A study into prescription of antibiotics in upper respiratory tract infections in general practice.

There is a growing concern about rational prescribing of antibiotics. That is why a secondary analysis of prescribing antibiotics in upper respiratory tract infections has been conducted by means of a nationwide study of morbidity and interventions in The Netherlands. The mean percentage of antibiotic prescriptions varied from about 20% for acute otitis media and acute upper respiratory tract infections to about 70% for sinusitis and tonsillitis. Only attitude--toward prescribing antibiotics in sore throat--and years of settlement were important predictor variables. The other characteristics studied--type of practice, list size, frequency of use of Het Farmacotherapeutisch Kompas, containing national pharmacotherapeutical guidelines, and urbanization level were not. The importance of attitude, however, was less for general practitioners who went into practice after 1975. This means that the influence of a personal characteristic as attitude might have become less influential since the introduction of vocational training for general practice.

List size, composition of practice and general practitioners' workload in The Netherlands.

Workload of general practitioners plays an important role in discussions about list size and remuneration in health care systems with fixed patient lists and capitation payments, such as in the Netherlands and in the United Kingdom. Against the background of the fairness of differences in income level between GPs the question is posed to what extent differences in list size reflect differences in workload and to what extent differences in patient characteristics influence workload. Both list size and practice composition relate to the demand led character of general practice. Data collected in the National Study of Morbidity and Interventions in General Practice are used. Central to this study is a three month recording of all contacts of 161 general practitioners (and their locums, assistant GPs and trainees) in the Netherlands. For each practice a patient register has been made to relate contacts to the practice population. The participating GPs kept a detailed diary covering 24 hr a day during one week. As indicators of workload several contact rates, hours worked in practice per week (in direct patient care and in other activities) and average length of office consultations are used. Demand related characteristics have the strongest relation to the number of hours worked by GPs, particularly the number of hours spent in patient-related activities. Rates of contacts, with the exception of the office contact rate, are not related to list size, but mainly to practice composition. The average length of consultations is negatively related to list size and some characteristics of the practice population.

Dutch general practice care for patients with epilepsy: results from the Dutch National Survey of Morbidity and Interventions.

This study aimed to assess the share which Dutch general practice has in the care of patients with epilepsy. During a 3-month period 400,000 patient contacts in 103 general practices with a total list of 335,000 patients were registered, 1536 of these, concerning 1059 patients, concerned epilepsy. Contacts with patients with known epilepsy in Dutch General Practice were handled mainly by the practice nurse and most involved repeat prescriptions. Patients suspected of having epilepsy had more attention from the General Practitioner. The involvement of General Practitioners in the care of epilepsy was found to be small, but not unimportant. GPs are in a crucial position as regards the detection of epilepsy. They can enlarge their role in respect of patients with known epilepsy and improve continuity of care.

Evaluation of different DNA-DNA hybridisation techniques in detection of HPV 16 DNA in cervical smears and biopsies.

The sensitivities of dot blot hybridisation and in situ filter hybridisation for the detection of HPV DNA were compared. Dot blot hybridisation was 10-50 times more sensitive than in situ filter hybridisation in detecting HPV 16 DNA in the cervical cancer cell lines SiHa and CaSki. Cervical smears collected from 51 women with a history of one or more abnormal cervical smears were tested by both hybridisation techniques for the presence of HPV 16 DNA; 11 were positive in the in situ filter hybridisation, 35 in the dot blot hybridisation. Thirty-five cervical biopsies available from this group of 51 women were processed for dot blot hybridisation. In 30 of the 35 cases the results of this hybridisation corresponded with the results of the dot blot hybridisation on the smears.