Systemic corticosteroids for acute gout.

BACKGROUND: Gout is one of the most frequently occurring rheumatic diseases, worldwide. Given the well-known drawbacks of the regular treatments for acute gout (non-steroidal anti-inflammatory drugs (NSAIDs), colchicine), systemic corticosteroids might be safe alternatives. OBJECTIVES: To assess the efficacy and safety of systemic corticosteroids in the treatment of acute gout in comparison with placebo, NSAIDs, colchicine, other active drugs, other therapies, or no therapy. SEARCH STRATEGY: Searches were done in the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007); MEDLINE (1966 to 2007) through PubMed; EMBASE (1974 to 2007); Web of Science (1975 to 2007); LILACS (1986 to 2007); and databases of ongoing trials (up to April 2007). SELECTION CRITERIA: Randomized controlled trials and controlled clinical trials investigating the use of systemic corticosteroids in the treatment of acute gout were included. DATA COLLECTION AND ANALYSIS: Two review authors decided independently which trials to include. The same review authors also collected the data in a standardised form and assessed the methodological quality of the trial using validated criteria. When possible, continuous and dichotomous data were summarised statistically. MAIN RESULTS: Three head to head trials involving 148 patients (74 systemic corticosteroids; 74 comparator drugs) were included. Placebo-controlled trials were not found. In the studies, different kinds of systemic corticosteroids and different kinds of control drugs were used, both administered in different routes. Intramuscular triamcinolone acetonide was compared respectively to oral indomethacine, and intramuscular adrenocorticotropic hormone (ACTH); oral prednisolone (together with a single intramuscular diclophenac injection) was compared to oral indomethacine (together with a single placebo injection). Outcome measurements varied: average number of days until total relief of signs, mean decrease of pain per unit of time in mm on a visual analogue scale (VAS) - during rest and activity. In the triamcinolone-indomethacine trial the clinical joint status was used as an additional outcome. Clinically relevant differences between the studied systemic corticosteroids and the comparator drugs were not found; important safety problems attributable to the used corticosteroids were not reported. The quality of the three studies was graded as very low to moderate. Statistical pooling of results was not possible. AUTHORS' CONCLUSIONS: There is inconclusive evidence for the efficacy and effectiveness of systemic corticosteroids in the treatment of acute gout. Patients with gout did not report serious adverse effects from systemic corticosteroids, when used short term.

Prognosis and vascular co-morbidity in dementia a historical cohort study in general practice.

BACKGROUND: Disease management of dementia in general practice (GP) is hampered by a lack of data on the prognosis of dementia. AIM: To gain more insight into the life expectancy of and the effects of cardiovascular and cerebrovascular co-morbidity in dementia patients in GP. DESIGN OF STUDY: Historical cohort. SETTING: 4 general practices in Nijmegen, The Netherlands. POPULATION: All patients in these practices participating in the Continuous Morbidity Registration (CMR). METHODS: The patient cohort was diagnosed with dementia between January 1st 1985 and December 31st 2002. The control cohort consisted of patients matched one-to-one with demented patients on age, sex, and socio-economic status. Cardiovascular and cerebrovascular co-morbidity was studied from 5 years before the diagnosis of dementia till the endpoints of data collection. RESULTS: 251 couples of patients and controls were formed (79 men, 172 women, mean age 81.4+/-7.0 years). The median life expectancy after diagnosis was 2.3 years for the dementia patients, and 3.7 years for the controls. Median time from diagnosis till nursing home placement was 1.4 years. Cerebrovascular and cardiovascular morbidity preceding dementia diagnosis decreased survival of cases with dementia with a relative risk of 1.54 (95%CI: 1.13-2.09) and in controls with a relative risk of 1.91 (95%CI: 1.48-2.46). Obesity was associated with a lower risk of dementia (RR=0.77 (95%-CI 0.63-0.94)). Hypertension and obesity diagnosed after the dementia diagnosis were significantly associated with an increase in survival. CONCLUSION: In general practice, the diagnosis of dementia is made at a late stage, when patients will continue to live at home only for a short time. Moreover, life expectancy at diagnosis is very limited and prognosis is furthermore negatively influenced by preceding cardio- and cerebrovascular co-morbidity.

Treatment of mental health problems in general practice: a survey of psychotropics prescribed and other treatments provided.

OBJECTIVE: Real-life data on the treatment of patients with mental health problems are important as a reference to evaluate care and benchmarking. This study describes the treatment of mental health problems in general practice as diagnosed by general practitioners (GP). MATERIAL AND METHODS: Data on mental health problems were available from structured psychiatric interviews in the general population and data on mental health problems diagnosed by general practitioners. Pharmacological and non-pharmacological treatment data were taken from patients records held electronically in general practices. RESULTS: GPs diagnosed a mental health problem in 13.2% of the 1,756 cases examined and 86% of these patients were treated by the GPs themselves. Of the 16% referrals, the majority were referred within primary care. Nearly all patients with a mental health problem received counseling or advice from their GP. Half of the patients with a medication-related disorder, a (single) mood disorder or an (single) anxiety disorder and all patients with a combined anxiety and depressive disorder received a prescription for psychotropic drugs (antidepressants and/or benzodiazepines). Nearly all patients with a sleep disorder received a prescription for benzodiazepine. In patients with psychosocial problems, 20% received benzodiazepines. CONCLUSION: The majority of mental health problems, when professionally treated, are treated in primary care. More than half the patients are treated with antidepressants and/or benzodiazepines. Most patients also receive supportive counseling or advice.

[Gout not induced by diuretics in a case-control study in general practice]. / Jicht niet uitgelokt door diuretica in een patiënt-controleonderzoek in de huisartspraktijk.

OBJECTIVE: To determine the relation between diuretics and the development of gout, taking into account the possible confounding by hypertension and cardiovascular diseases. DESIGN: Case-control study. METHOD: With the aid of the data on morbidity and medication from the electronic medical files ofa dispensing general practitioner, all patients with a first gout registration during the period from October 1994 to September 2002 were identified as cases; in the same practice, for each patient, 3 controls of the same age and sex who were known not to have gout were selected at random. Conditional logistic regression analyses were carried out to estimate the odds ratio (OR) for gout in patients who had used diuretics for at least 3 months and in patients suffering from hypertension, heart failure, or myocardial infarction. The statistical interaction between variables was investigated after stratification for diuretic use. RESULTS: Via the medical files, 70 gout patients (59 men), with a mean age of 55.1 years (SD: 13.5) were identified, plus 210 matched controls. When assessed without correction, the use ofdiuretics seemed to be associated with a definite risk of gout: OR: 2.8 (95% CI: 1.2-6.6). But after adjustment for the cardiovascular variables hypertension, heart failure and myocardial infarction, the risk of gout associated with diuretic use disappeared: OR: 0.6 (95% CI: 0.2-2.0). An independent risk of gout was demonstrated for hypertension (OR: 3.9; 95% CI: 1.6-10.0), and to a lesser degree for myocardial infarction (OR: 1.5; 95% CI: 0-5-4.1). The risk of gout associated with heart failure was also calculated (OR: 40.1; 95% CI: 3.8-437.2), but diuretic independency could not be proven as all patients with heart failure were on diuretics and there was no heart failure among those not using diuretics. CONCLUSION: In this case-control study, the use of diuretics did not increase the risk of gout. The cardiovascular indications for prescribing diuretics were significant confounders.

Alpha-glucosidase inhibitors for people with impaired glucose tolerance or impaired fasting blood glucose.

BACKGROUND: Alpha-glucosidase inhibitors (AGIs) reduce blood glucose levels and may thus prevent type 2 diabetes and cardiovascular disease in patients with impaired glucose tolerance. These possible effects, and the effects on quality of life, plasma lipids and body weight, have never been investigated in a systematic literature review and meta-analysis. OBJECTIVES: To assess the effects of alpha-glucosidase inhibitors in patients with impaired glucose tolerance (IGT) or impaired fasting blood glucose (IFBG), or both. SEARCH STRATEGY: We searched The Cochrane Library (Clinical Trials database, formerly known as CENTRAL), PUBMED, EMBASE, Web of Science, LILACS, databases of ongoing trials, reference lists of relevant reviews, and we contacted experts and manufacturers. Date of last search was February 2006. SELECTION CRITERIA: Randomised controlled trials of at least one-year duration in patients with IGT or IFBG, or both, comparing AGI monotherapy with any other intervention. DATA COLLECTION AND ANALYSIS: Two reviewers read all abstracts, assessed quality and extracted data independently. Discrepancies were resolved by consensus or by the judgement of a third reviewer. MAIN RESULTS: We included five trials (2360 participants), all investigating acarbose, that included patients with IGT or patients 'at increased risk for diabetes' (n = 1). Study duration was one, three (n = 2), five and six years. One study was at low risk of bias and four studies at high risk of bias. Except for the outcome incidence of type 2 diabetes in acarbose versus no treatment (two studies), meta-analyses were not possible. Data from the study at low risk of bias suggests that acarbose decreases the occurrence of type 2 diabetes (NNT = 10), cardiovascular events (NNT = 50, based on 47 events, study not initially powered for this outcome), post-load blood glucose (-0.6 mmol/L, 95% CI -1.0 to -0.3) and body mass index (0.3 kg/m(2), 95% CI -0.1 to -0.5). No statistically significant effects were observed on mortality, other morbidity, glycated haemoglobin, fasting blood glucose, lipids and blood pressure. The effects on the incidence of type 2 diabetes were confirmed in two studies at high risk of bias (OR 0.2, 95% CI 0.1 to 0.6). Adverse effects were mostly of gastro-intestinal origin (OR 3.5, 95% CI 2.7 to 4.4). AUTHORS' CONCLUSIONS: There is evidence that acarbose reduces the incidence of type 2 diabetes in patients with IGT. However, it is unclear whether this should be seen as prevention, delay or masking of diabetes. Acarbose may prevent the occurrence of cardiovascular events, but this finding needs to be confirmed in more studies.

The absence of benzodiazepine craving in a general practice benzodiazepine discontinuation trial.

This study aimed to assess benzodiazepine craving longitudinally and to describe its time course by means of the Benzodiazepine Craving Questionnaire (BCQ). Subjects were long-term benzodiazepine users participating in a two-part treatment intervention aimed to reduce long-term benzodiazepine use in general practice in The Netherlands. Four repeated measurements of benzodiazepine craving were taken over a 21-month follow-up period. Results indicated that (1) benzodiazepine craving severity decreased over time, (2) patients still using benzodiazepines experienced significantly more severe craving than patients who had quit their use after one of the two interventions, and (3) the way in which patients had attempted to quit did not influence the experienced craving severity over time, however, (4) patients who had received additional tapering off, on average, reported significantly more severe craving than patients who had only received a letter as an incentive to quit. Although benzodiazepine craving is prevalent among (former) long-term benzodiazepine users during and after discontinuation, craving severity decreases over time to negligible proportions. Self-reported craving can be longitudinally monitored and quantified by means of the BCQ.

Alpha-glucosidase inhibitors for type 2 diabetes mellitus.

BACKGROUND: Alpha-glucosidase inhibitors such as acarbose or miglitol, have the potential to improve glycemic control in type 2 diabetes mellitus. The true value of these agents, especially in relation to diabetes related mortality and morbidity, has never been investigated in a systematic literature review and meta-analysis. OBJECTIVES: To assess the effects of alpha-glucosidase inhibitors s in patients with type 2 diabetes mellitus. SEARCH STRATEGY: We searched The Cochrane Library, MEDLINE, EMBASE, Current Contents, LILACS, databases of ongoing trials, reference lists of reviews on the topic of alpha-glucosidase inhibitors and we contacted experts and manufacturers for additional trials. Date of most recent search: December 2003 (Current Contents) and April 2003 (other databases). SELECTION CRITERIA: Randomised controlled trials of at least 12 weeks duration comparing alpha-glucosidase inhibitor monotherapy in patients with type 2 diabetes with any other intervention and that included at least one of the following outcomes: mortality, morbidity, quality of life, glycemic control, lipids, insulin levels, body weight, adverse events. DATA COLLECTION AND ANALYSIS: Two reviewers read all abstracts, assessed quality and extracted data independently. Discrepancies were resolved by consensus or by the judgement of a third reviewer. A statistician checked all extracted data entrance in the database. We attempted to contact all authors for data clarification. MAIN RESULTS: We included 41 trials (8130 participants), 30 investigated acarbose, seven miglitol, one trial voglibose and three trials compared different alpha-glucosidase inhibitors. Study duration was 24 weeks in most cases and only two studies lasted amply longer than one year. We found only few data on mortality, morbidity and quality of life. Acarbose had a clear effect on glycemic control compared to placebo: glycated haemoglobin -0.8% (95% confidence interval -0.9 to -0.7), fasting blood glucose -1.1 mmol/L (95% confidence interval -1.4 to -0.9), post-load blood glucose -2.3 mmol/L (95% confidence interval -2.7 to -1.9). The effect on glycated haemoglobin by acarbose was not dose-dependent. We found a decreasing effect on post-load insulin and no clinically relevant effects on lipids or body weight. Adverse effects were mostly of gastro-intestinal origin and dose dependent. Compared to sulphonylurea, acarbose decreased fasting and post-load insulin levels by -24.8 pmol/L (95% confidence interval -43.3 to -6.3) and -133.2 pmol/L (95% confidence interval -184.5 to -81.8) respectively and acarbose caused more adverse effects. AUTHORS' CONCLUSIONS: It remains unclear whether alpha-glucosidase inhibitors influence mortality or morbidity in patients with type 2 diabetes. Conversely, they have a significant effect on glycemic control and insulin levels, but no statistically significant effect on lipids and body weight. These effects are less sure when alpha-glucosidase inhibitors are used for a longer duration. Acarbose dosages higher than 50 mg TID offer no additional effect on glycated hemoglobin but more adverse effects instead. Compared to sulphonylurea, alpha-glucosidase inhibitors lower fasting and post-load insulin levels and have an inferior profile regarding glycemic control and adverse effects.

[Adenotonsillectomy in children only under exceptional circumstances]. / Adenotonsillectomie bij kinderen: neen, tenzij.

More and more evidence is becoming available that throws doubt on the value of adenotonsillectomy in children with frequent throat infections or hypertrophic tonsils and adenoids. Tonsillectomy and adenoidectomy have a limited range of indications. Objective symptoms such as the size of the tonsils and subjective symptoms of obstruction and sore throat are not always related to each other. Children with only moderate symptoms should not be operated on.

Consumption of fructooligosaccharides does not favorably affect blood glucose and serum lipid concentrations in patients with type 2 diabetes.

BACKGROUND: Fructooligosaccharides have been claimed to lower fasting glycemia and serum total cholesterol concentrations, possibly via effects of short-chain fatty acids produced during fermentation. OBJECTIVE: We studied the effects of fructooligosaccharides on blood glucose, serum lipids, and serum acetate in 20 patients with type 2 diabetes. DESIGN: In a randomized, single-blind, crossover design, patients consumed either glucose as a placebo (4 g/d) or fructooligosaccharides (15 g/d) for 20 d each. Average daily intakes of energy, macronutrients, and dietary fiber were similar with both treatments. RESULTS: Compliance, expressed as the proportion of supplements not returned, was near 100% during both treatments. Fructooligosaccharides did not significantly affect fasting concentrations (mmol/L) of serum total cholesterol (95% CI: -0.07, 0.48), HDL cholesterol (-0.04, 0.04), LDL cholesterol (-0.06, 0.34), serum triacylglycerols (-0.21, 0.44), serum free fatty acids (-0.08, 0.04), serum acetate (-0.01, 0.01), or blood glucose (-0.37, 0.40). CONCLUSIONS: We conclude that 20 d of dietary supplementation with fructooligosaccharides had no major effect on blood glucose, serum lipids, or serum acetate in patients with type 2 diabetes. This lack of effect was not due to changes in dietary intake, insufficient statistical power, or noncompliance of the patients.

Review article: symptom improvement through eradication of Helicobacter pylori in patients with non-ulcer dyspepsia.

The aim of this article is to determine, by reviewing the literature, whether treatment of Helicobacter pylori infection in patients with non-ulcer dyspepsia affects symptoms. Ten publications were identified through a computerized and manual literature search, and the percentage of patients with symptom improvement after successful or unsuccessful eradication therapy for H. pylori infection was calculated. In the 10 studies, symptom improvement after treatment was found in 73% of the patients that became H. pylori-negative and 45% of the patients that remained H. pylori-positive. Symptom improvement was modified by various clinical features and methodological aspects. If eradication of H. pylori failed, symptoms only improved over a short period. Symptom improvement was more pronounced in dyspeptic patients in whom H. pylori was eradicated than in those in whom H. pylori infection persisted.

Randomized controlled trial of omeprazole or endoscopy in patients with persistent dyspepsia: a cost-effectiveness analysis.

BACKGROUND: Cost-effectiveness analysis, Helicobacter pylori research and the development of proton pump inhibitors are having an increasing impact on the management of dyspepsia. However, clinical trials have not always included both H. pylori diagnosis and proton pump inhibitors in their protocols. METHODS: Patients who were referred for upper gastrointestinal endoscopy by their general practitioner were randomized to either prompt endoscopy followed by directed medical treatment (conventional group, n=38), or to empirical treatment with omeprazole and, in the case of symptom relapse, serological screening for H. pylori infection followed by eradication therapy in seropositive patients (empirical group, n=42). The study lasted for up to 1 year. RESULTS: In the empirical group, only 13 patients (31%) underwent endoscopy. The average number of days for which the patients kept records of their dyspeptic symptoms was 266 (95% CI: 226-307) in the empirical group, of which 166 (95% CI: 128-204) were symptom-free. In the conventional group, 159 (95% CI: 119-198) out of 255 days (95% CI: 209-302) were recorded as symptom-free. The average medical cost in the empirical group was $284 (95% CI: 218-350) and in the conventional group $491 (95% CI: 383-600). In the empirical group, two malignancies were found, whereas in the conventional group one malignancy was found. CONCLUSIONS: The empirical drug treatment strategy in patients with persistent dyspeptic symptoms resulted in 69% fewer diagnostic endoscopies with lower medical costs and equal effectiveness in the first year, compared to prompt endoscopy followed by directed medical treatment.

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.

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.

Development and psychometric evaluation of the Benzodiazepine Craving Questionnaire.

AIM: To assess the scalability, reliability and validity of a newly constructed self-report questionnaire on craving for benzodiazepines (BZs), the Benzodiazepine Craving Questionnaire (BCQ). SETTING AND PARTICIPANTS: The BCQ was administered once to a sample of 113 long-term and 80 former long-term general practice BZ users participating in a large BZ reduction trial in general practice. MEASUREMENTS: (1) Unidimensionality of the BCQ was tested by means of the Rasch model. (2) The Rasch-homogeneous BCQ items were assessed for subject and item discriminability. (3) Discriminative and construct validity were assessed. FINDINGS: The BCQ met the requirements for Rasch homogeneity, i.e. BZ craving as assessed by the scale can be regarded as a unidimensional construct. Subject and item discriminability were good. Construct validity was modest. Highest significant associations were found with POMS depression (Kendall's tau-c = 0.15) and Dutch Shortened MMPI negativism (Kendall's tau-c = 0.14). Discriminative validity was satisfactory. Highest discriminative power was found for a subset of eight items (Mann-Whitney U Z = - 3.6, P = 0.000). The first signs of craving are represented by the acknowledgement of expectations of positive outcome, whereas high craving is characterized by direct intention to use. CONCLUSIONS: The BCQ proved to be a reliable and psychometrically sound self-report instrument to assess BZ craving in a general practice sample of long-term BZ users.

Control group characteristics and study outcomes: empirical data from a study on mortality of patients with type 2 diabetes mellitus in Dutch general practice.

STUDY OBJECTIVE: Control group characteristics as comorbidity and chronic psychosocial problems may play an important part in study outcomes. A primary care data base was used to quantify the effects of varying the case mix of participants. DESIGN: Historical cohort study. SETTING: Data were collected from 1967-1996 in four Dutch general practices performing the Continuous Morbidity Registration Nijmegen. PATIENTS AND CONTROLS: All newly diagnosed type 2 diabetic patients in the period 1967-1989 fulfilling the WHO criteria (n = 265); for each type 2 diabetic patient a control was matched for practice, sex, age, and social class; from these controls subgroups were selected based on the absence of different types of morbidity; these subgroups were also matched for practice, sex, age, and social class. MAIN RESULTS: The relative risk of mortality in type 2 diabetic patients in comparison with various subsets of controls ranged from 1.33 (95% CI 0.97, 1.81) to 2.16 (95% CI 1.46, 3.20). CONCLUSION: Control group characteristics as comorbidity and chronic psychosocial problems turned out to influence the risk estimation in a cohort study. General practice data enhance the study of these aspects.

Who uses over-the-counter psychotropics? Characteristics, functioning, and (mental) health profile.

As part of a population study on the prevalence of psychopathology, users of "Over-The-Counter" Psychotropics (OTC-Ps) were studied. First, their mental health profile was examined by a number of subjective and objective assessments. Second, the medical consumption of the users was studied with special attention to the psychotropic drugs prescribed. The prevalence of psychological problems and symptoms of psychological distress was higher among OTC-P users than among non-users. Somatic problems and symptoms were comparable in the two groups; social support was better in the OTC-P users. Half of the users were known to have mental health problems by their Primary Care Physician (PCP). The DSM IV Axis I disorders were mostly mood and anxiety disorders. A benzodiazepine had been prescribed to one-third of the OTC-P users. No other psychotropic drugs had been prescribed, and the medical consumption was comparable in the two groups. PCPs should be aware of concomitant OTC-Ps use.

GPs' referral to mental health care during the past 25 years.

Previous research has shown that mental disorder in the community has remained fairly constant over the past 30 years. As a result there has been a shift in mental health care from primary care to specialised mental health care. This shift should be visible in higher referral figures from general practice. In this longitudinal analysis of mental health referrals (1971 to 1997), the authors aimed to answer whether these higher referral rates have occurred, whether there are increases in referral for specific groups, and whether the referral pattern has changed. The results demonstrate an increase in referral rate with a factor of 4.5. It is concluded that we are witnessing a pull from mental health care together with a push from general practice, thus reinforcing each other.

Consultation rates and incidence of intercurrent morbidity among patients with chronic disease in general practice.

BACKGROUND: Information on frequency of consultation and presented morbidity among patients with chronic disease is relevant to the management of these patients in view of the increasing prevalence of chronic diseases. AIM: This study set out to examine consultation rates and incidence of intercurrent morbidity in general practice in cohorts of patients with five common chronic diseases: hypertension, chronic ischaemic heart disease, diabetes mellitus, chronic respiratory disease and osteoarthritis. METHOD: In seven practices with 15 general practitioners the records of all patients were screened for inclusion in the study. The data used for analysis were from 962 patients, whose diagnoses were made in agreement with diagnostic criteria, who were not under specialist care, and who were followed up for 21 months. A distinction was made between patients with one, or two or more of the five chronic diseases studied. For the single disease subgroups of patients with hypertension or diabetes two reference groups of people without a chronic disease, standardized for age and sex, were identified from the population in the same practices. RESULTS: Consultation rates were higher for patients with comorbidity than for patients with a single disease. Intercurrent diseases were presented more frequently to the general practitioner by patients with comorbidity than by patients with a single disease. Most intercurrent morbidity consisted of acute common diseases such as myalgia, upper respiratory tract infection and urinary tract infection. Patients with only hypertension or only diabetes had higher consultation rates than the corresponding reference group but did not have higher total incidence rates of intercurrent morbidity. CONCLUSION: Patients with chronic disease consult their general practitioner frequently, and patients with more than one chronic disease consult even more frequently. The general practitioner has to deal with chronic disease and intercurrent acute disease in a single patient.

Insulin therapy in poorly controlled type 2 diabetic patients: does it affect quality of life?

BACKGROUND: Strict glycaemic control in type 2 diabetic patients is recommended in a number of treatment protocols. However, although better glycaemic control prevents or postpones chronic diabetic complications, it remains uncertain how this affects quality of life in the short and long term. AIM: To study the impact of insulin therapy on glycaemic control and quality of life in type 2 diabetic patients, with secondary failure on maximal oral medication. DESIGN OF STUDY: Two separate sets of analyses were performed: a longitudinal analysis of those patients converted to insulin therapy and a comparison of 12-week outcomes between the two randomisation groups. SETTING: Ten general practices, participating in the Nijmegen Monitoring Project. METHOD: Patients, poorly controlled on maximal oral therapy, were stratified with respect to age and sex, and randomly allocated to insulin therapy in two different schedules: (a) after a 12-week period with enhanced compliance to diet and oral therapy: or (b) as soon as secondary failure was established. Patients were referred to a diabetologist to start insulin therapy and were referred back to their general practitioner (GP) as soon as glycaemic control was stable. We assessed fasting blood glucose, HbA1c functional health, and quality of life (Sickness Impact Profile, COOP/WONCA charts, Diabetes Symptom Checklist) at baseline, after the patient was referred back to the GP, and nine months later. RESULTS: Of the 38 included patients, three patients dropped out and seven patients were not switched over to insulin therapy. In patients starting insulin therapy, mean HbA1c and fasting blood glucose level decreased from 9.5% to 7.6%, and from 12.0 mmol to 8.4 mmol, respectively (P < 0.001). The better control was accompanied by a decrease in hyperglycaemic complaints (P = 0.01). No increase in hypoglycaemic complaints was found. There were no statistically significant changes in quality-of-life parameters. After 12 weeks, patients directly referred to insulin therapy showed a statistically significant improvement in HbA1c and fasting glucose level, in contrast to patients with enhanced compliance. Quality-of-life scores did not significantly differ statistically. CONCLUSION: Insulin therapy in poorly controlled type 2 diabetic patients from general practice resulted in a significant clinical improvement of glycaemic control, accompanied by a reduction of hyperglycaemic complaints, without an increase in hypoglycaemic complaints or an adverse influence on quality of life.

Differences in health status between long-term and short-term benzodiazepine users.

BACKGROUND: Despite generally accepted advice to keep treatment short, benzodiazepines are often prescibed for more than six months. Prevention of long-term benzodiazepine use could be facilitated by the utilisation of risk indicators for long-term use. However, the characteristics of long-term benzodiazepine users described in the literature are based on studies in which long-term users were compared with non-users. Thus these characteristics may be imprecise. AIM: To study the characteristics of long-term benzodiazepine users by comparing their demographic data and health status (mental and physical) with those of short-term users. DESIGN OF STUDY: Cross-sectional comparison of short-term and long-term benzodiazepine users. SETTING: Patients from 32 GP practices of the Nijmegen Health Area, The Netherlands. METHOD: The characteristics of 164 short-term and 158 long-term benzodiazepine users in general practice were compared, using interview data and morbidity referral and prescription data from GP records. RESULTS: Long-term benzodiazepine users were (a) older, (b) had a more severe history of mental health problems for which they had received more serious treatment, (c) used more psychotropic drugs, (d) had a higher hospital specialist consultation frequency, (e) had more diagnoses of the following: diabetes, asthma, chronic obstructive pulmonary disease, hypertension a serious skin disorder, and (f) reported a lower perceived general health status. There were no sex differences. CONCLUSION: Specific risk characteristics of long-term benzodiazepine users can be used to develop a risk profile for the management of benzodiazepines in general practice. We believe that (somatic) secondary care also contributes to benzodiazepine use. It may be worthwhile to coordinate care for benzodiazepine users between GPs and hospital specialists.