Preoperative therapeutic programme for elderly patients scheduled for elective abdominal oncological surgery: a randomized controlled pilot study.

OBJECTIVE: Investigation of the feasibility and preliminary effect of a short-term intensive preoperative exercise programme for elderly patients scheduled for elective abdominal oncological surgery. DESIGN: Single-blind randomized controlled pilot study. SETTING: Ordinary hospital in the Netherlands. SUBJECTS: Forty-two elderly patients (>60 years). INTERVENTIONS: Patients were randomly assigned to receive a short-term intensive therapeutic exercise programme to improve muscle strength, aerobic capacity, and functional activities, given in the outpatient department (intervention group; n =22), or home-based exercise advice (control group; n=20). MAIN MEASURES: Parameters of feasibility, preoperative functional capacity and postoperative course. RESULTS: The intensive training programme was feasible, with a high compliance and no adverse events. Respiratory muscle endurance increased in the preoperative period from 259 +/- 273 to 404 +/- 349 J in the intervention group and differed significantly from that in the control group (350 +/- 299 to 305 +/- 323 J; P<0.01). Timed-Up-and-Go, chair rise time, LASA Physical Activity Questionnaire, Physical Work Capacity and Quality of Life (EORTC-C30) did not reveal significant differences between the two groups. There was no significant difference in postoperative complications and length of hospital stay between the two groups. CONCLUSION: The intensive therapeutic exercise programme was feasible and improved the respiratory function of patients due to undergo elective abdominal surgery compared with home-based exercise advice.

Once tired, always tired? Limitations in function over time of tired patients in Dutch general practice.

OBJECTIVE: To gain insight into limitations in function over time of general-practice patients who presented and were diagnosed with "tiredness". METHODS: In a routine family-practice electronic register based on use of the International Classification of Primary Care (ICPC), 684 patients were identified who presented (in 1997 or 1998) with the complaint tiredness, who were given the same symptom diagnosis, and who still had this diagnosis on 1 August 1999. A questionnaire (WONCA/COOP charts, HAD Scale, recent medical care, tiredness and attribution) was sent to these 684 "cases" and 858 controls. In a logistic regression analysis (16 dichotomous variables), we constructed five models for optimizing sensitivity and specificity for the detection of patients with an episode of care for "tiredness". RESULTS: We received 385 fully completed questionnaires of cases, on average 19 (7~31) months after the start of their episode of care for "tiredness". The results of the 1997 and 1998 cases were similar. Cases did considerably worse than did the 385 optimally matched controls: e.g., seriously limited by tiredness: 52% of cases vs 32% of controls; poor overall health: 35% of cases vs 20% of controls; HAD Scale scores indicating anxiety or depression: about 20% of cases vs about 10% of controls. Highest sensitivity (70%) was reached by including poor overall health, recent medical care and HAD Scale depression score >10 in the model; and highest specificity (65%) by including poor overall health and a HAD Scale anxiety score >7. CONCLUSION: Patients who present with tiredness and receive the same diagnosis have a high probability of suffering from substantial limitations in function in the years following diagnosis. Their limitations are more serious than those of controls, but no indication is found for a specific limitation. The indicators are strongly related and concentrate around "poor overall health".

[The clinical relationship between symptoms and the final diagnosis in general practice, determined by means of posterior probabilities calculated on the basis of the Transition Project]. / Het klinisch verband tussen klachten en uiteindelijke diagnosen in de huisartspraktijk, vastgesteld met achterafkansen berekend op grond van het Transitieproject.

OBJECTIVE: To determine how, with the aid of the database of the Transition Project (www.transitionproject.nl), one can calculate posterior probabilities for general practice that provide insight into the clinical significance of the simultaneous occurrence of two events (a symptom and a diagnosis, or two diseases) in general practice. DESIGN: Descriptive. METHOD: The use of the 'International classification of primary care' (ICPC) to code both the patient's reason for encounter and the diagnosis of the general practitioner in the Transition Project has resulted in a database for the period 1985-2002 with a total of 201,127 patient-years, in which the posterior probability of a diagnosis in the presence of a complaint or symptom is available in the form of an odds ratio. Also in the case of the simultaneous occurrence of 2 episodes of care (comorbidity) in a patient it is now possible to determine whether the ratio between the prior and the posterior probability indicates a clinically relevant relationship or that it is a chance finding. Such posterior probabilities have been calculated for the conditions otitis media, hypertension in diabetes mellitus, shortness of breath and heart failure. In the calculation ofthe prior and posterior probabilities, only 'certain' diagnoses were used. RESULTS: For the diagnosis 'otitis media' in the age group 0-4 years, otalgia had the highest posterior probability (odds ratio: 15.77), with discharge from the ear taking second place (odds ratio: 8.59). 'Fever' contributed almost nothing. The odds ratio for hypertension in 45-74-year-old women with diabetes mellitus was 3.42. When the symptom was 'shortness of breath', the prior probability of heart failure in the age group 45-64 years was relatively low (2.0) but the posterior probability was relatively high (24.2). In this way, the combination of prior and posterior probabilities can provide support for the clinical work of the general practitioner. As a predictive variable for heart failure in the age group 65-74 years, 'ankle oedema' played an important role while 'fatigue' contributed nothing to the diagnosis. It was apparent from the database that the care for patients with heart failure often coincided with that for chronic diseases such as diabetes mellitus, hypertension, ischaemic heart disease, chronic obstructive pulmonary disease and atrial fibrillation. But the question whether there is a clinically relevant relationship could only be answered on the basis of the posterior probabilities: the highest odds ratio's were found for 'atrial fibrillation/atrial flutter' (32.5), 'chronic obstructive pulmonary disease' (22.5) and 'chronic skin ulcer' (20.2). CONCLUSION: The calculation of prior and posterior probabilities on the basis of the database of the Transition Project makes it possible for general practitioners to determine the clinical relevance of their observations.

Isomer-dependent cytostatic activity of bis(1-aziridinyl)cyclophosphazenes.

A number of recently synthesized mono- and bis(1-aziridinyl) derivatives of the inorganic ring systems (NPCl2)3 and (NPCl2)4 was tested for their cytostatic activity in vitro (L1210 and L5178Y cells) and in vivo (intraperitoneal leukemia L1210 in CDF1 mice). Generally, the nongeminal bis(1-aziridinyl) isomers (either trans or cis) appear to be potent tumor growth inhibitors in contrast to their geminally substituted and mono(1-aziridinyl)-substituted analogues. A relationship between the biological activity and the number of alkylating centers (i.e., P atoms carrying one or two aziridinyl groups) is proposed.

Surface antigens on cultured malignant melanoma cells as detected by a membrane immunofluorescence method with human sera. Lack of tumor-specific reactions on melanoma lines.

Surface antigens on melanoma cells were studied with an MIF method applied for monolayers of cultured cells. Human sera were used with indirect immunofluorescence. Preparations were fixed in methanol after staining. Reactions of sera with antibodies against trasplantation antigens displayed a fine granular fluorescence. This appearance was abolished by absorptions with pooled tonsilar lymphocytes. Melanoma patients' sera free from antibodies against transplantation antigens exhibited a coarse patchy fluorescence reaction. Melanoma patients' sera with antibodies against transplantation antigens yielded the second type of MIF reaction after absorptions with normal lymphocytes whereas further absorptions with melanoma line suspensions effectively removed all antibody reactivity...

Philadelphia-positive T-acute lymphoblastic leukemia.

A case of typical T-acute lymphoblastic leukemia (T-ALL) is reported in which, at diagnosis, 100% of bone marrow metaphases showed a Philadelphia (Ph) translocation, t(9;22). These cells completely disappeared following chemotherapy. The significance of the Ph chromosome in T and B leukemic cells is discussed.

Do our patients receive maximum benefit from preventive care? A North American perspective.

Politicians, their constituents and family physicians believe that preventive medicine is essential if health care is to be improved. Family physicians believe that the majority of their patients are well cared for with preventive health care services but in reality preventive services are provided to less than half the population and some to fewer than 10%. Barriers to providing preventive care include the selection of procedures of unproven effectiveness, public unawareness of the benefits of the procedure and practical obstacles for physicians providing the services. Assessment of each of these barriers indicates how preventive care can be improved. Narrowing the gap between what we believe about preventive care and the level of preventive services we are providing could improve the health of our nations. However, the concept of primum non nocere must dominate the assessment of currently advocated preventive procedures and the consideration of new procedures.

Classification of reasons why persons seek primary care: pilot study of a new system.

In 1978, the World Health Organization formed a group to begin work on the Reason for Encounter Classification (RFEC), which is designed to classify the reasons why patients seek care at the primary level. The relatively simple classification is based on two axes--chapters and components--and uses a three-character alpha-numeric code. Chapters, which are named by body systems or more general terms, are the reasons that health care was sought. Five of the seven components, or subdivisions of chapters, contain rubrics identified by the same two-digit numerical code. A pilot study with a training exercise was carried out in The Netherlands by nine family physicians to confirm the feasibility of using the new classification system in primary care settings. Training consisted of viewing videotapes of encounters and an exercise of coding 76 vignettes by the RFEC. Within 2 months, the physicians in the subsequent pilot study had collected and coded 7,503 reasons for encounters. Results of the pilot study confirm that the RFEC is feasible, easy to use in practice, and different from disease-oriented classifications in its system of classifying the reasons for encounter. The pilot study results have been used to modify the RFEC in preparation for a field trial in ambulatory care settings worldwide.

Advantages of long observation in episode-oriented electronic patient records in family practice.

From 1985-2000, 58 Dutch family physicians (FPs) of the Transition Project collected ICPC-coded data on 47, 2451 episodes of care, first in paper records for direct encounters only, later with a complete electronic patient record (EPR) for all (direct and indirect) encounters. Based on these data, the effects of a long observation period and the inclusion of all encounters (both direct and indirect) in the EPR were studied. Long observation periods in EPRs appear to have important advantages for patient documentation and the assessment of the content of family practice. Comparison of data from a one-year versus a four-year observation period showed a shift in utilization rates. In a long observation period, visiting patients appeared to make less demand on care, while the content of the FP's care for selected chronic diseases was reflected more realistically. The inclusion of all indirect encounters in an EPR (as compared to the previous inclusion of direct encounters only) resulted in more than twice the number of coded entries per listed patient, and thus led to a major shift in perspective on the FP's involvement in patient care.

Rationale for a community strategy in the field of information and communications technologies applied to health care.

The challenge for Europe in the field of information and communications technologies applied to health care is that of addressing positively the problem of the widening gap between the expectations of the citizens of the type of care that can be made available and the limited resources to provide that care. If the expectations of the population are to be fulfilled, it will be necessary to find innovative ways of delivering health services and to do it more efficiently than has yet been the case. Advanced information and communications technologies will be important tools for Member States to achieve the levels of efficiency required. Based on the results of the Community AIM Exploratory Action, further collaborative work is required at EEC level to create an Integrated Health Information Environment (IHE) allowing essentially for integration, modularity and security.

Results of the international field trial with the Reason for Encounter Classification.

The Reason for Encounter Classification (RFEC) was designed by a WHO Working Party to classify the reasons why patients seek care at the primary care level. It is designed along two axes: Chapters and Components. Each chapter carries an alpha-code which is the first character of the basic 3-character alphanumeric code. Each chapter is subdivided into seven "components" carrying 2-digit numeric codes. The field trial was undertaken by family physicians and nurses in: Australia, Barbados, Brazil, Hungary, Malaysia, the Netherlands, Norway and the US. 90497 RFE's were analysed. Their distribution over the chapters and components characterize the content of international primary care. Listings with the most common RFE's in the participating countries reflect the cultural differences. It is concluded that the RFEC is not only feasible to classify reasons why patients seek care but also to classify the diagnosis and the process of primary care. As a result of this, the International Classification of Primary Care (ICPC) succeeds the RFEC.

Use of symptoms and signs to diagnose maxillary sinusitis in general practice: comparison with ultrasonography.

OBJECTIVE: To establish the incidence of maxillary sinusitis in general practice and the predictive value of symptoms and signs. DESIGN: Population based study. SETTING: 9 general practices with 15,220 patients aged 15 years and older on the list. PATIENTS: 400 patients with 441 episodes in whom practitioners intended to confirm or to exclude sinusitis. MAIN OUTCOME MEASURES: Results of ultrasonography and signs and symptoms associated with positive results. RESULTS: 212 of the 441 episodes were confirmed by ultrasonography. 15.7 episodes occurred per 1000 adults per year. The five symptoms beginning with common cold (beta coefficient = 1.035), purulent rhinorrhoea (0.996), pain at bending (0.950), unilateral maxillary pain (0.640), and pain in teeth (0.606) were associated with positive results on ultrasonography. General practitioners' clinical diagnoses were correct in 177 episodes, false positive in 88, false negative in 22, and uncertain in 154. With an algorithm using the five weighted symptoms 243 of the diagnoses would have been correct, but 110 would remain uncertain and 44 cases would have been missed. CONCLUSION: The five symptoms algorithm would improve diagnostic accuracy of general practitioners, but incorrect and uncertain diagnoses cannot be avoided.

[Meticulous handling of electronic patient records in general practice]. / Zorgvuldig omgaan met het elektronisch patiëntendossier in de huisartspraktijk.

A 41-year-old woman visited her general practitioner because she wished to receive her medical records and those of her two children. She had decided to move pending divorce and wanted to transfer her medical information to another physician. The information was handed to her on a floppy disk. The next day her husband came and demanded that his own information be deleted from the records. Many Dutch physicians have electronic patient records, which will replace paper records presently. Patients may decide to have their medical information selectively transferred to another physician. This may interfere with adequate information of the treating physician. Electronic episode-related patient records may facilitate transfer of information and will have an important role in regulating physician-patient contact according to the Wet Bescherming Persoonsgegevens (Act on the protection of personal data), the Wet op de Geneeskundige Behandelingsovereenkomst (Act on agreement concerning medical treatment), and the Wet op de Beroepen in de Individuele Gezondheidszorg (Individual health care professionals act). Patients' rights to control the transfer of their information must be ensured.

[Variable rates of diseases in health survey and family practitioners' registries]. / Verschillende frequentiecijfers van aandoeningen bij gezondheidsenquête en huisartsregistraties.

OBJECTIVE: To compare the data from the health survey of the Central Bureau for Statistics (CBS: about episodes of chronic diseases experienced by those questioned) and from general practice registration projects (regarding episodes of care). DESIGN: Descriptive. SETTING: Department of General Practice, Academic Medical Centre, Amsterdam, the Netherlands. METHOD: Frequency figures from the CBS health survey regarding chronic diseases for 1992 were compared with data from three large continuous general practice registration projects: the Amsterdam Transition Project, the Nijmegen Continuous Morbidity Registration and the fourth British National Morbidity Study. From the Transition Project not only one-year data were used but also data referring to a four-year period (1989/'93). RESULTS: Incidence and prevalence figures concerning illness and care were in good agreement regarding cardiovascular diseases, uterine prolapse, diabetes mellitus, thyroid disorders, epilepsy and cancer. The health survey had higher frequencies than the GP registration for respiratory disorders, hypertension (both mostly in the age group 25-44 years) gastrointestinal disorders, articular disorders and migraine. With regard to a number of diseases, the four-year registration was in better agreement with the health survey than the one-year registration (e.g. joint disorders): with other disorders the reverse was true (e.g. stroke). CONCLUSION: There were similarities as well as differences between the frequencies from the health survey and the general practice registration projects. Regarding a number of these differences interpretation was possible by using not only one-year data from the GP practice but also data concerning a longer period (4 years) and by comparing the information for different age groups.

Episode of care: a core concept in family practice.

The new Institute of Medicine definition of primary care requires that primary care clinicians address the large majority of personal health care needs of their patients. The unit of assessment for this is the episode of care, defined as a health problem from its first encounter with a health care provider through the completion of the last encounter. An episode of care is distinct from an episode of disease or illness. In this article, episode-of-care date from Dutch family practice, classified with the International Classification of Primary Care, illustrate this approach. Data on women 25 to 44 years of age are presented. The top 20 new reasons for encounter and new episodes of care as well as the relations between a reason for encounter (headache) and disease (sinusitis) support the potential of episode-oriented epidemiology and some important clinical considerations in family practice.

Values and roles in primary care.

Discussions about research priorities and criteria for quality assessment in primary care are confusing when the differences in the underlying models and value systems are unclear. This article presents a simple grid that can facilitate discussions involving the roles of primary care physicians. One axis of the grid includes three value systems that are important to the understanding of different goals in primary care. The second axis includes three practice roles that are important to the evaluation of the actual delivery of primary care. Examples are used to illustrate how the grid can be used in discussion about the mission of primary care.

[Post-traditional medicine. Negotiating about the complaint, diagnosis and therapy]. / Posttraditionele geneeskunde. Onderhandelen over klacht, diagnose en therapie.

Dutch health care is developing in the direction of posttraditional medicine: a dynamic system of demand and supply, in which the media, information technology and a more active attitude of the patient play a part. The nature of the complaint/diagnosis combination affects the degree to which therapy is or is not evidence-based and can be medically justified. Randomized studies and guidelines in itself do not lead to a more purposeful application of treatment. Patients persistently request interventions that are not medically justified, but rather have various non-medical aims. Physicians can regard demands of this nature as an encroachment on their authenticity and find it difficult to decide whether or not to comply with them.

[Mood disorders in daily practice; the North American consensus statement on the undertreatment of depression]. / Stemmingsstoornissen in de dagelijkse praktijk; de Noord-Amerikaanse consensusverklaring over de onderbehandeling van depressie.

The American National Depressive and Manic-Depressive Association consensus statement on the undertreatment of depression may have consequences for the treatment of patients in the Netherlands. It is concluded that Dutch clinicians, also, can be expected to play a more active role in cases of mood disorders than formerly. A comparison of the definitions of depressive disorder in the available classification system results in the recommendation to be strict about the distinction between severe and moderate depressive disorders on the one hand and subthreshold or mild conditions on the other. It is expected that this will limit the anticipated shift towards a more general willingness to use pharmacotherapy for mood disorders in patients in whom this can be expected to be efficacious.

Defensive testing in Dutch family practice. Is the grass greener on the other side of the ocean?

BACKGROUND: Ordering laboratory tests and diagnostic imaging can be part of the defensive behavior of the physician. How often does this occur in family practice in the Netherlands? Defensive behavior is defined as a clear deviation from the family physician's usual behavior and from what is considered to be good practice in order to prevent complaints or criticism by the patient or the patient's family. METHODS: Over a 1-year period, 1989-1990, 16 family physicians in 11 practices with 31,343 patients recorded all episodes of care involving an order for laboratory tests or diagnostic imaging or both (n = 8897). The physicians selected one or more reasons to order each test from a fixed list of clinical considerations. In addition, they recorded whether they acted defensively for every test order. RESULTS: The participating physicians reported that some degree of defensive medicine was associated with 27% of all test orders. Defensive testing varied with the clinical reasons to order a test: the wish to exclude a disease or to reassure the patient was a much stronger motive for defensive testing than the intention to confirm a diagnosis or to screen. Defensive tests generally resulted in fewer abnormal findings. CONCLUSIONS: Defensive testing is an important phenomenon in Dutch family practice: it forms a well-defined element of practice despite the variations implicit in the different clinical reasons to order a test. Defensive testing is associated with a lower probability of finding an abnormal test result. The analysis of family physicians' clinical reasons for ordering tests becomes more meaningful when defensive testing is included.

[Scratching for the itch in eczema; a psychodermatologic approach]. / Krabben tegen de jeuk bij eczeem; een psychodermatologische benadering.

Atopic dermatitis patients often complain of intense itching and excessive scratching. Apart from standard therapies of antihistamines with sedative side effects, there are patients who appear not to respond satisfactorily to standard medical treatments. As itching can be a skin manifestation of psychological disturbance, these patients may benefit from behaviour treatment of scratch behaviour which can have a beneficial effect on the course of atopic eczema. The scratch response is considered a classical conditioned habit and special attention was given to the function of behaviour. Two patients, a man of 27 and a girl of 11, were suffering from intractable atopic eczema. The first patient was required to record his own scratching in a diary which is part of awareness training regarding scratch situations. In the second patient impaired parent-child relationships were the main discriminative stimuli to provoke scratch behaviour. It was shown that behaviour therapy helps patients who scratch repeatedly to exercise voluntary control over it.