An evaluation of a computer based education program for the diagnosis and management of dementia in primary care. An international study of the transcultural adaptations necessary for European dissemination.

OBJECTIVES: The aim of this study is to make an inventory of the changes that are needed to make an interactive computer based training program (ICBT) with a specific educational content, acceptable to professional communities with different linguistic,cultural and health care backgrounds in different European countries. METHODS: Existing educational software, written in two languages was reviewed by GPs and primary care professionals in three different countries. Reviewers worked through the program using a structured critical reading grid. RESULTS: A 'simple' translation of the program is not sufficient. Minor changes are needed to take account of linguistic differences and medical semantics. Major changes are needed in respect of the existing clinical guidelines in every country related to differences in the existing health care systems. CONCLUSIONS: ICTB programs cannot easily be used in different countries and cultures. The development of a structured educational program needs collaboration between educationalists, domain experts, information technology advisers and software engineers. Simple validation of the content by local expert groups will not guarantee the program's exportability. It is essential to involve different national expert groups at every phase of the development process in order to disseminate it in other countries.

A combination of tests for the diagnosis of dementia had a significant diagnostic value.

OBJECTIVE: To study the diagnostic parameters of a number of instruments for a diagnosis of dementia in general practice and the added diagnostic value of these tests. STUDY DESIGN AND SETTING: Cross-sectional diagnostic research in general practice. PARTICIPANTS: 152 persons aged 65 plus. The Mini-Mental State Examination (MMSE), the Clock Drawing Test, the ADMP scale, the Timed Up and Go Test, the Extrapyramidal Sign Scale, the Behavior Observation Scale, the Poon-Baro-Wens computer battery, and the Cognitive Drug Research Computerized Assessment System were evaluated against the Dutch version of the Cambridge Examination for Mental Disorders of the Elderly (CAMDEX-N). Diagnostic characteristics were calculated with their 95% CI. Using forward stepwise logistic regression analysis, a model was built with CAMDEX-N as the dependent variable and the tests under study as independent variables. Area under the curve was the main parameter for the comparisons. RESULTS: The main diagnostic gain results from age and ADMP, followed by the Clock Drawing Test. Subsequent addition of the MMSE and computer tests results in modest additional gain only. The final model including five tests has an area under the curve of 0.95. CONCLUSION: Sophisticated neuropsychological computerized tests have little added value in the diagnostic work-up of dementia in general practice. Basic clinical tests used in an appropriate sequence can be very valuable in establishing the diagnosis of dementia.

Pseudomonads associated with midrib rot and soft rot of butterhead lettuce and endive.

During the past ten years, bacterial soft rot and midrib rot of glasshouse-grown butterhead lettuce (Lactuca sativa L. var. capitata) and field-grown endive (Cichorium endivia L.) has become increasingly common in the region of Flanders, Belgium. Severe losses and reduced market quality caused by bacterial rot represent an important economical threat for the production sector. Symptoms of midrib rot are a brownish rot along the midrib of one or more inner leaves, often accompanied by soft rot of the leaf blade. Twenty-five symptomatic lettuce and endive samples were collected from commercial growers at different locations in Flanders. Isolations of dominant bacterial colony types on dilution plates from macerated diseased tissue extracts yielded 282 isolates. All isolates were characterized by colony morphology and fluorescence on pseudomonas agar F medium, oxidase reaction, and soft rot ability on detached chicory leaves. Whole-cell fatty acid methyl esters profile analyses identified the majority of isolates (85%) as belonging to the Gammaproteobacteria, which included members of the family Enterobacteriaceae (14%) and of the genera Pseudomonas (73%), Stenotrophomonas (9%), and Acinetobacter (3%). Predominant bacteria were a diverse group of fluorescent Pseudomonas species. They were further differentiated based on the non-host hypersensitive reaction on tobacco and the ability to rot potato slices into 4 phenotypic groups: HR-/P- (57 isolates), HR-/P+ (54 isolates), HR+/P (16 isolates) and HR+/P+ (35 isolates). Artificial inoculation of suspensions of HR-, pectolytic fluorescent pseudomonads in the leaf midrib of lettuce plants produced various symptoms of soft rot, but they did not readily cause symptoms upon spray inoculation. Fluorescent pseudomonads with phenotype HR+ were consistently isolated from typical dark midrib rot symptoms, and selected isolates reproduced the typical midrib rot symptoms when spray-inoculated onto healthy lettuce plants.

Multidisciplinarity and multimedia in quality of care--education.

Quality of care and quality of life are patient-centred, whereas medical education tends to be disease-centred. More patient-centred models will be necessary to optimise the quality of care for cancer patients. This demands new priorities in medical education, new concepts for structuring and organising responsibilities in medical care, and new complementary task definitions for the players involved. Goal setting and functional care models are conceptual innovations that can help introduce the patient-centred approach into medical practice. In the care of patients with cancer, the goals of the physician, nurse, patient, and family may change and diverge as the disease progresses, necessitating open discussion and bargaining. Functional care models stress that the quality of care can be defined differently at the four different levels of care--medical, nursing, cleaning/providing, and support from family and friends. Instruments that maintain the focus of care on the patient's quality of life can help formalise the goal-setting process. Quality of life measuring instruments should be adapted to the priorities of the clinical situation and implemented in basic practice routines. There is no single objective quality of life level or score, and measuring instruments must take into account different quality of life options. Multidisciplinarity and multimedia education means the appropriate learning instruments at the appropriate time for all those concerned.

Cardiovascular risk factor distribution above the age of 75 years in a Belgian community.

An elderly Belgian population group anno 1986 consisting of 53 men and 110 women above the age of 75 years with a mean age of 80 and 81 years, respectively, is characterized by relative obesity and low diastolic blood pressure, both in men and women. The SBP/DBP ratio is 1.91 in men and 1.88 in women. HDL-cholesterol levels are relatively high in men. Women still have slightly higher HDL-cholesterol levels than men, the difference between women and men being 3.4 mg/dl. In both sexes HDL-cholesterol correlates negatively with body weight. The 24-hour urinary sodium/potassium ratio is 2.9 in men and 2.5 in women. Factors significantly related to diastolic blood pressure in a multiple regression analysis included being on a low-salt diet, the level of 24-hour urinary potassium excretion and of 24-hour urinary creatinine excretion in men, and body weight, heart rate and the level of 24-hour urinary calcium excretion in women. It may be concluded that significant differences exist between the distribution of cardiovascular risk factors in older compared to middle-aged subjects.

The use of fatty acid methyl ester analysis (FAME) for the identification of heterotrophic bacteria present on three mural paintings showing severe damage by microorganisms.

Mural paintings in Carmona (Spain), Herberstein (Austria) and Greene (Germany), showing visible deterioration by microorganisms, were sampled to investigate the biodiversity of the heterotrophic bacteria present. Four hundred twenty-eight bacterial strains were isolated from which 385 were characterized by fatty acid methyl ester analysis (FAME). The isolates were grouped into 41 clusters on the basis of their FAME profiles, 20 isolates remained ungrouped. The majority (94%) of the isolates comprised the gram-positive bacteria and the main clusters were identified as Bacillus sp., Paenibacillus sp., Micrococcus sp., Arthrobacter sp. and Staphylococcus sp. Other clusters contain nocardioform actinomycetes and gram-negative bacteria, respectively. A cluster of the latter contained extreme halotolerant bacteria isolated in Herberstein. The FAME profiles of this cluster showed a high similarity with Halomonas.

16S rDNA sequence analysis of bacterial isolates from biodeteriorated mural paintings in the Servilia tomb (Necropolis of carmona, Seville, Spain).

Bacteria were isolated from damaged mural paintings of the Servilia tomb (necropolis of Carmona, Seville, Spain). Selected strains, representative for different clusters of isolates with similar fatty acid profiles, were analysed by 16S rDNA sequence analysis. Bacillus is the dominant genus among the isolates: members of the rRNA species complexes of B. megaterium, B. pumilus and B. firmus were found as well as several other Bacillus species. One group of halotolerant isolates falls in the Bacillus sensu lato group, with closest relatedness to the genera Salibacillus and Virgibacillus. Other genera found are Artbrobacter, Micrococcus, Streptomyces, Sphingomonas, Paenibacillus, and a genus closely related to Paracraurococcus. Many isolates showed low 16S rDNA sequence similarities with the closest related database entries, a strong indication for the presence of several new species among the isolates.

Antihypertensive therapy in older patients with isolated systolic hypertension: the Syst-Eur experience in general practice

Background and objective. This interim report from the Syst-Eur trial investigated the level of blood pressure control achieved during the double-blind period in patients followed in general practices. Methods. In the Syst-Eur trial elderly patients (60 years or older) with isolated systolic hypertension were randomized to either active or placebo treatment. Active treatment consisted of nitrendipine combined with enalapril and/or hydrochlorothiazide to reduce systolic pressure to Results. This analysis was restricted to patients of general practitioners who had been followed for at least 12 months. The placebo (N = 204) and active treatment (N = 217) groups had similar characteristics at randomization. At one year, the difference in sitting pressure between the two treatment groups was 10 mmHg systolic and 4 mmHg diastolic. Fewer patients remained on monotherapy in the placebo than in the active treatment group and on placebo the second and third line medications were started earlier. Nitrendipine tablets were discontinued in 10 patients on placebo and in 21 patients assigned to active treatment (P Conclusions. A significant blood pressure reduction can be achieved and maintained in older patients with isolated systolic hypertension followed by general practitioners. Whether this blood pressure reduction results in a clinically meaningful decrease of cardiovascular complications is under investigation. Keywords. Antihypertensive treatment, general practice, isolated systolic hypertension, randomized clinical trial.

Dirithromycin versus amoxiclav in the treatment of acute exacerbations of chronic bronchitis.

A total of 334 patients with acute exacerbation of chronic bronchitis were treated with either dirithromycin for 5 days (n = 169) or amoxiclav for 7-10 days (n = 165) in an open randomized trial. The efficacy and tolerability of the two drugs were compared. There was no statistically significant difference in outcome between the two treatment arms. Clinical success (cure or improvement) was obtained in 94.5% and 93.1% of patients treated with dirithromycin and amoxiclav, respectively. Adverse events (mostly gastrointestinal) occurred in both groups, but led to discontinuation of treatment (in only seven patients). We conclude that the two drugs are equally efficacious and safe.

Type 2 diabetes in primary care in belgium: need for structured shared care.

OBJECTIVE: To picture the profile of type 2 diabetic patients in Belgium and to study the quality of care in the primary care setting, with regard, to multi-factorial approach of the disease. METHODS: Observational study of all known DM2-patients registered by 120 volunteer general practitioners. Quality of care was evaluated by the achievement of three major treatment targets: HbA1c<7%; Systolic Blood Pressure

Characterization of CMR5c and CMR12a, novel fluorescent Pseudomonas strains from the cocoyam rhizosphere with biocontrol activity.

AIM: To screen for novel antagonistic Pseudomonas strains producing both phenazines and biosurfactants that are as effective as Pseudomonas aeruginosa PNA1 in the biocontrol of cocoyam root rot caused by Pythium myriotylum. MATERIAL AND RESULTS: Forty pseudomonads were isolated from the rhizosphere of healthy white and red cocoyam plants appearing in natural, heavily infested fields in Cameroon. In vitro tests demonstrated that Py. myriotylum antagonists could be retrieved from the red cocoyam rhizosphere. Except for one isolate, all antagonistic isolates produced phenazines. Results from whole-cell protein profiling showed that the antagonistic isolates are different from other isolated pseudomonads, while BOX-PCR revealed high genomic similarity among them. 16S rDNA sequencing of two representative strains within this group of antagonists confirmed their relatively low similarity with validly described Pseudomonas species. These antagonists are thus provisionally labelled as unidentified Pseudomonas strains. Among the antagonists, Pseudomonas CMR5c and CMR12a were selected because of their combined production of phenazines and biosurfactants. For strain CMR5c also, production of pyrrolnitrin and pyoluteorin was demonstrated. Both CMR5c and CMR12a showed excellent in vivo biocontrol activity against Py. myriotylum to a similar level as Ps. aeruginosa PNA1. CONCLUSION: Pseudomonas CMR5c and CMR12a were identified as novel and promising biocontrol agents of Py. myriotylum on cocoyam, producing an arsenal of antagonistic metabolites. SIGNIFICANCE AND IMPACT OF THE STUDY: Present study reports the identification of two newly isolated fluorescent Pseudomonas strains that can replace the opportunistic human pathogen Ps. aeruginosa PNA1 in the biocontrol of cocoyam root rot and could be taken into account for the suppression of many plant pathogens.

Brevibacillus levickii sp. nov. and Aneurinibacillus terranovensis sp. nov., two novel thermoacidophiles isolated from geothermal soils of northern Victoria Land, Antarctica.

Thirteen strains of endospore-forming bacteria were isolated from geothermal soils at Cryptogam Ridge, the north-west slope of Mt Melbourne, and at the vents and summit of Mt Rittmann in northern Victoria Land, Antarctica. 16S rRNA gene sequencing, SDS-PAGE and routine phenotypic characterization tests indicated that the seven isolates from the north-west slope of Mt Melbourne represent a novel species of Brevibacillus and that the six isolates from Cryptogam Ridge and the vents and summit of Mt Rittmann represent a novel species of Aneurinibacillus. Brevibacillus strains were not isolated from the sites at Mt Rittmann or Cryptogam Ridge and Aneurinibacillus strains were not isolated from the north-west slope of Mt Melbourne. Preliminary metabolic studies revealed that L-glutamic acid, although not essential for growth, was utilized by both species. The Brevibacillus species possessed an uptake system specific for L-glutamic acid, whereas the Aneurinibacillus species possessed a more general uptake system capable of transporting other related amino acids. Both species utilized a K(+) antiport system and similar energy systems for the uptake of l-glutamic acid. The rate of uptake by the Brevibacillus species type strain was 20-fold greater than that shown by the Aneurinibacillus species type strain. The names Brevibacillus levickii sp. nov. and Aneurinibacillus terranovensis sp. nov. are proposed for the novel taxa; the type strains are Logan B-1657(T) (= LMG 22481(T) = CIP 108307(T)) and Logan B-1599(T) (LMG 22483(T) = CIP 108308(T)), respectively.

Diagnosis and management of dementia in primary care at an early stage: the need for a new concept and an adapted procedure.

Diagnosis of dementia in primary care is both difficult and important. The recommendations by several authors to improve the diagnosis of dementia by general practitioners are important, but insufficient. It is argued that perhaps the disease concept in itself is a cause of confusion for clinicians. Primary care physicians need an adapted procedure, gradually leading to the final diagnosis of dementia. It has to be a stepwise labelling strategy, using global descriptions and non-disease specific labels in the beginning, ending up with well-defined disease criteria. In this process, there is circularity: previous diagnoses have to be kept in mind because symptoms and signs may gradually change during the progression of the disease, leading to reconsideration of previous deleted options. To frame this properly, the primary care physician needs to adopt a broad "frail elderly" geriatric concept. Implementation of this concept not only helps the diagnostic process, but also stimulates the care for dementing patients and their caregivers. Relevant arguments for early diagnostic involvement of primary care physicians can be put forward on condition that a new concept, adapted procedures and adapted instruments are used.

How do general practitioners diagnose dementia?

By means of a qualitative study, we set out to generate hypotheses about the way general practitioners (GPs) diagnosed dementia. We looked for triggers for the diagnosis of dementia. Ten GPs were interviewed about four dementia cases taken from their own practices. GPs are more concerned with treatment than with the diagnosis of dementia as such, as diagnosis is performed in relation to treatment. The most important aid was the evolution of the clinical tables based on the information of caregivers. Important triggers were changes of activities of daily life function, behaviour and cognition. Acute illness and loss of the key caregiver were relevatory moments. Recommendations are made for the improvement of the diagnostic abilities of GPs.

Consequences of MRSA carriage in nursing home residents.

A prospective cohort study with 1 year follow-up evaluated the relation between MRSA carriage and mortality, likelihood of hospitalization and functional status in residents of a nursing home for the elderly. Included were all 447 residents living in the home in early June 1994. From all patients, swabs were taken from nose, throat and perineum. Additional swabs (sputum, urine or wounds) were taken when indicated. The relative risk (RR) of dying within 6 months in MRSA carriers compared to non-carriers was 2.29 (95% CI = 1.04-5.04). This RR remained stable (1.57-2.40) after adjustment for co-variables using Mantel-Haenszel stratified analysis. After I year, the RR was reduced to 1.30 (95% CI = 0.65-2.58). Univariate survival analysis confirmed a difference in survival between carriers and non-carriers after 6 months (log-rank P = 0.04) and no difference after 1 year. Cox regression analysis resulted in a hazard ratio for dying within 6 months of 1.73 (95% CI = 0.72-4.17). No relation was found between carriage and either likelihood of hospitalization or indicators of functional status. These results are compatible with a possible relation between 6 months mortality and MRSA carriage in nursing home patients. It calls for a large scale, multicentre cohort study in order to either confirm or refute these findings.

Systematic reviews of diagnostic research. Considerations about assessment and incorporation of methodological quality.

The aim of this paper is to provide a theoretical background for performing and reading systematic reviews of diagnostic studies. We first discuss items for assessment of methodological quality in diagnostic studies and then present methods on how to incorporate these quality measures in systematic reviews. The items of internal validity determine whether the presented results of the individual studies are unbiased and can be trusted. Items of external validity determine to what extent the results are applicable outside the population in which the study was performed. The issues concern the adequacy of the study population, the performance and interpretation of the diagnostic tests and the presentation of the results. Several methods exist for incorporation of issues of methodological quality into systematic reviews, such as subgroup analyses, meta-regression analysis, and methodological scores. Publications of diagnostic studies should provide sufficient information to enable assessment of the methodological quality. Furthermore, publication of results of subgroup analyses should be promoted. Methodological criteria lists might help to improve the quality of systematic reviews of diagnostic research. With the items of methodological quality in mind the general practitioner might be better equipped to critically read and interpret diagnostic reviews.

B-chromosomes and male-biased sex ratio with paternal inheritance in the fairy shrimp Branchipus schaefferi (Crustacea, Anostraca).

This study reports on male-biased sex ratios in west Mediterranean populations of the freshwater anostracan Branchipus schaefferi (Crustacea, Anostraca, Branchipodidae), in contrast to populations elsewhere. Crossing experiments over several generations indicate a clear paternal inheritance of the trait, possibly with a dosage effect. Various mechanisms which may underlie this phenomenon are discussed, the most plausible being the presence of one or more supernumerary ('B') chromosomes--as evidenced by karyological observations--interfering with sex determination and probably having an accumulation mechanism in male individuals.

Quality of life and effectiveness of diabetes care in three different settings in Leuven.

BACKGROUND: The new diabetes protocol, formulated in Belgium as a consensus between the National Institution of Health Insurance and diabetologists, implicitly assumes the care of type 1 diabetic patients to be more efficient at the specialist level (SP) in hospital, although GPs frequently are involved in diabetes care. OBJECTIVES: A study was carried out in order to highlight differences in diabetes care between three different treatment settings (SP alone, combined SP-GP and GP alone) METHODS: Out of a group of known diabetics, 325 patients were selected according to a stratified cluster sampling technique, in such a way that the three types of diabetes (formerly called type 1, type 2a and type 2b) occurred sufficiently in the three above-defined treatment settings. Outcome data on co-morbidity and diabetes health profile as well as output data on laboratory results were collected for each patient and compared between the different subgroups. RESULTS: On the basis of a response rate of 47.9%, equally distributed over the different levels, we demonstrated that GPs and SPs score equally low on the different measures and that a better follow-up is indicated in all settings. CONCLUSION: Diabetes care in Flanders can be upgraded significantly. There is no evidence that specialists are performing better. Therefore, one could argue for better follow-up of diabetes care in a primary health care setting.