How to use polarity thinkingTM to manage tensions between accountability and learner agency when using a multipurpose portfolio?

Portfolios are often implemented to target multiple purposes, e.g. assessment, accountability and/or self-regulated learning. However, in educational practice, it appears to be difficult to combine different purposes in one portfolio, as interdependencies between the purposes can cause tensions. This paper explored directions to manage tensions that are inextricably linked to multipurpose portfolio use. We used a systems thinking methodology, that was based on the polarity thinkingTM framework. This framework provides a step-by-step approach to chart a polarity map® that can help to balance the tensions present in specific settings. We followed the steps of the framework to chart a polarity map for multipurpose portfolio use. Based on literature and our prior research, we selected one overarching polarity: accountability and learner agency. This polarity seems responsible for multiple tensions related to multipurpose portfolio use. We formulated values (potential benefits) and fears (tensions that can arise) of the two poles of this polarity. Then, we organised a session with stakeholders who work with the portfolio of the Dutch General Practice speciality programme. Together we formulated action steps and early warnings that can help to balance accountability and learner agency during multipurpose portfolio use. In addition to previous recommendations concerning portfolio use, we advocate that it is important to create a shared frame of reference between all involved with the multipurpose portfolio. During this process, the acknowledgement and discussion of tensions related to multipurpose portfolio use are vital.

It Is Smart to Set Treatment Goals, But Are Set Treatment Goals SMART? A Qualitative Assessment of Goals Described in the Assessment of the Burden of COPD Tool.

The Assessment of the Burden of COPD (ABC) tool facilitates shared decision-making and goal setting to develop a personalized care plan. In a previous trial (RCT), the ABC tool was found to have a significant effect on patients' Health-related Quality of Life (HRQoL). In this exploratory study we used data from the intervention group of the RCT to investigate if patients with health-related goals had an improved HRQoL compared to those without goals, and if the quality and types of goals differed for those who have a clinically meaningful improvement in HRQoL. We hypothesized that the quality and the type of the goal described in the ABC tool, relates to an improved HRQoL. We assessed the quality of the goals according to the Specificity, Measurability, Achievability, Relevance and Timeliness (SMART) criteria, and coded and counted each type of goal. We found that having a goal or not, did not differ significantly for those who had a clinically meaningful improved HRQoL versus those who had not, nor was the quality or type of goal significantly different. The most common types of goals were exercise more, smoke less, and improve weight. Based on the results, we speculate that when a clinically meaningful improvement in HRQoL is achieved, it is not related to a single component (i.e. goal setting as part of shared decision-making) but that the different components of the ABC tool (visualization of burden, shared decision making, utilization of tailored evidence based interventions, and regular monitoring of progress) may have a synergistic effect on disease cognition and/or behavior change. Noteworthy, the sample size was small while the calculated effect size was moderate, making it unlikely to find a significant effect.

European Society of ColoProctology: guideline for haemorrhoidal disease.

AIM: The goal of this European Society of ColoProctology project was to establish a multidisciplinary, international guideline for haemorrhoidal disease (HD) and to provide guidance on the most effective (surgical) treatment for patients with HD. METHODS: The development process consisted of six phases. In phase one we defined the scope of the guideline. The patient population included patients with all stages of haemorrhoids. The target group for the guideline was all practitioners treating patients with haemorrhoids and, in addition, healthcare workers and patients who desired information regarding the treatment management of HD. The guideline needed to address both the diagnosis of and the therapeutic modalities for HD. Phase two consisted of the compilation of the guideline development group (GDG). All clinical members needed to have affinity with the diagnosis and treatment of haemorrhoids. Further, attention was paid to the geographical distribution of the clinicians. Each GDG member identified at least one patient in their country who could read English to comment on the draft guideline. In phase three review questions were formulated, using a reversed process, starting with possible recommendations based on the GDG's knowledge. In phase four a literature search was performed in MEDLINE (Ovid), PubMed, Embase (Ovid) and the Cochrane Database of Systematic Reviews. The search was focused on existing systematic reviews addressing each review question, supplemented by other studies published after the time frame covered by the systematic reviews. In phase five data of the included papers were extracted by the surgical resident (RT) and checked by the methodologist (JK) and the GDG. If needed, meta-analysis of the systematic reviews was updated by the surgical resident and the methodologist using Review Manager. During phase six the GDG members decided what recommendations could be made based on the evidence found in the literature using GRADE. RESULTS: There were six sections: (i) symptoms, diagnosis and classification; (ii) basic treatment; (iii) outpatient procedures; (iv) surgical interventions; (v) special situations; (vi) other surgical techniques. Thirty-four recommendations were formulated. CONCLUSION: This international, multidisciplinary guideline provides an up to date and evidence based summary of the current knowledge of the management of HD and may serve as a useful guide for patients and clinicians.

Interprofessional Pulmocheck care pathway: An innovative approach to managing pediatric asthma care in the Netherlands.

OBJECTIVES: Under-diagnosis and suboptimal asthma control in children persists. An innovative care pathway was developed by a hospital department of pediatrics with the aim to detect pulmonary problems in children and provide appropriate treatment possibilities through systematic feedback towards the referring primary care physician. Primary care physicians can use this pathway to refer children with asthma-like symptoms for a one-day assessment. Goals are to measure the usage of the pathway by primary care general practitioners (GPs), the outcomes in terms of new diagnoses of asthma, the reduction in regular referrals, generated recommendations/therapy and the adequacy of asthma follow-up. METHODS: We collected all feedback letters sent to the GP concerning children who underwent the Pulmocheck in 2010, 2011 and 2012. Furthermore, all GPs, who had referred a child to the Pulmocheck in this period and that subsequently was diagnosed with asthma and was further managed in primary care, were sent a follow-up questionnaire in 2014. RESULTS: There were 121 referrals from 51 GPs in 3 years to this pathway. In 59.5% of these referrals a new diagnosis of asthma was established. In 90.9% one or more changes in clinical management were advised. The response rate to the follow-up questionnaires was 65.7% of which 4.8% of the children with new established asthma were reviewed four times or more in the follow-up period, 17.4% two times, 65.2% once, and in 8.7% were not followed. CONCLUSIONS: The specialty pediatric asthma care pathway revealed a high number of children with newly diagnosed asthma, but was also helpful to exclude this diagnosis. However, the referral rate of GPs to this pathway was low, but in the children, that were referred several changes in the clinical management were advised and the frequency of monitoring of the children with diagnosed asthma was not in accordance with the asthma guidelines.

Effectiveness of video- versus text-based computer-tailored smoking cessation interventions among smokers after one year.

BACKGROUND: In western countries, smoking prevalence rates are high among smokers unmotivated to quit and those with a lower socioeconomic status (LSES). Multiple computer tailoring and the use of audio-visual aids may improve such interventions and increase cessation in LSES smokers. This study assessed the 12-month effectiveness of a video- and text-based computer-tailored intervention. METHODS: A randomized controlled trial in the Netherlands was used in which smokers were allocated to the video-based condition (VC) (N=670), the text-based condition (TC) (N=708) or the control condition (CC) (brief generic text advice) (N=721). After 12months, self-reported prolonged abstinence was assessed and biochemically verified in respondents indicating to have quit smoking. Three analysis strategies were used to assess the effects: (1) multiple imputation (MI); (2) intention-to-treat (ITT); (3) complete case analysis (CC). RESULTS: VC was more effective in prolonged abstinence compared to CC (odds ratio (OR)=1.90, p=.005) and the text-based condition (OR=1.71, p=.01). VC was furthermore more effective than TC. No differences were found for SES and motivational levels. Results were similar when using ITT and CC. For our secondary outcome seven-day point prevalence abstinence; however, neither VC (OR=1.17, p=.34) or TC (OR=0.91, p=.52) outperformed the CC. CONCLUSION: The video-based computer-tailored intervention was effective in obtaining substantial long-term abstinence compared to the text-based version and a brief generic text advice.

How to encourage smokers to participate in web-based computer-tailored smoking cessation programs: a comparison of different recruitment strategies.

The reach, retention and costs of four strategies aimed to recruit smokers for participation in a computer-tailored smoking cessation intervention was explored. The study was part of a randomized controlled trial whereby 832 respondents were randomized to three conditions. Smokers were invited by general practitioners (GPs), newspapers, Internet and other strategies (i.e. mailing organizations) to take part. ANOVA's/Chi-square tests explored sample differences. Logistic regression analyses investigated differences between the samples regarding retention and smoking behaviour. Smokers recruited via GPs (N = 144) had a lower educational level and suffered more from chronic obstructive pulmonary disease compared with respondents recruited via Internet (N = 307) (χ(2) = 11.554, df = 3, P = 0.009). Less motivated respondents recruited by GPs were more likely to return to study compared with the less motivated respondents recruited by 'other recruitment' strategies (χ(2) = 6.416, df = 3, P = 0.093). Highly addicted respondents recruited from newspapers (N = 213) were less likely to make a quit attempt compared with highly addicted respondents recruited by GPs (OR = 0.334, P = 0.035). Females from newspapers were less likely to remain abstinent compared with the GP sample (OR = 0.337, P = 0.005). Recruitment via GPs showed highest costs. Recruitment strategy influenced the type of smokers. Group differences were associated with different patterns of quitting.

Learning from complex elderly care: a qualitative study on motivating residents in family medicine.

BACKGROUND: More and more patients need complex care, especially the elderly. For various reasons, this is becoming increasingly difficult. The onus is essentially on family physicians to provide this care and family medicine residency programs should therefore prepare their residents for this task. We know from self-determination theory (SDT) that motivation plays a key role in learning and that in order to boost motivation, fulfillment of 3 basic psychological needs - for autonomy, competence, and relatedness - is crucial. As residents often lack motivation, residency programs face the important challenge to motivate them to learn about and engage in complex elderly care. How to do so, however, is not yet sufficiently understood. METHODS: We conducted a qualitative multi-institutional case study across four universities in Belgium and the Netherlands. In the period between June, 2015, and May, 2019, we triangulated information from semi-structured interviews, document analysis, and observations of educational moments. Guided by SDT concepts, the analysis was performed iteratively by a multidisciplinary team, using ATLAS.ti, version 8. In this process, we gained more insights into residents' motivation to learn complex elderly care. RESULTS: We scrutinized 1,369 document pages and 4 films, observed 34 educational moments, and held 41 semi-structured interviews. Although we found all the 3 basic psychological needs postulated by SDT, each seemed to have its own challenges. First, a tension between the need to guide residents and to encourage their independent learning complicated fulfillment of the need for autonomy. Second, the unpredictability of complex care led to reduced feelings of competence. Yet, guidelines and models could help residents to capture and apprehend its complexity. And third, family medicine practice, patients, and educational practice, by either satisfying or thwarting the need for relatedness, were identified as key mediators of motivation. By setting the right example and encouraging residents to discuss authentic dilemmas and switch their health care approach from cure to care, educators can boost their motivation. CONCLUSION: Our study has demonstrated that the degree of perceived autonomy, guidance by the education program, use of authentic dilemmas, as well as involvement of group facilitators can aid the process of motivation. TRIAL REGISTRATION: NVMO, ERB number 482.

COPD screening in general practice using a telephone questionnaire.

Chronic obstructive pulmonary disease (COPD) is a growing health problem, and an underestimated and underdiagnosed disease in primary care. The aim of this survey was to study the feasibility of detecting undiagnosed COPD patients in the general practice population with the aid of a telephone questionnaire. The study was held in 2 general practices in the Netherlands. During 2 weeks, all patients registered with these 2 practices and aged between 40 and 75 years were contacted through a call center. Persons known with a previous history or diagnosis of COPD or asthma or comorbidity were excluded from the telephone list. The telephone interview used the Respiratory Health Screening Questionnaire (DB Price, 2006). Based on the score on this instrument, respondents were classified as having a low, moderate or high risk of having COPD. Smoking behaviour and BMI were also recorded. Patients with medium and high risk for COPD were invited for spirometry, performed by 2 experienced registered nurses. The results of the telephone interview and spirometric findings were assessed by the attending GP, who established the final diagnosis. The call center reached 1032 persons, 813 of whom answered the questions. The percentage of smokers was 49.2%, with an average number of pack-years of 17.9 (SD = 17); mean BMI was 26.1. Spirometry and analysis by the GP showed that 15.7% of the medium-risk group had previously undiagnosed COPD, versus 39.6% of the high-risk group. The number of undiagnosed COPD patients in the general practice population is considerable. Case finding can focus on moderate- and high-risk groups after telephone risk assessment.

[Nausea; article for education and training purposes]. / Misselijkheid.

Nausea is a common presenting symptom in medical care with a broad differential diagnosis. In this teaching article we provide practical information on many aspects of nausea including pathophysiology and differential diagnosis, history and physical examination, and diagnostic tests and treatment. This was done by means of answering several questions from the daily practice of general practitioners, specialists in internal medicine and surgeons. In a patient with nausea a provisional diagnosis can be made based on medical history, careful history-taking and age. Diagnostic testing is only performed on clinical suspicion and depends on the provisional diagnosis and presence of alarm symptoms. Tailored medical treatment of nausea is based on the provisional diagnosis and on the mechanism of action of the intended antiemetic agent.

A TASMAN Expedition: Development of a Questionnaire to Assess Specific Self-Management Abilities.

Introduction: Self-management (SM) is a core component of well-being and perceived health for patients with chronic obstructive pulmonary disease (COPD). Most theories on SM share that self-efficacy, illness-perception and coping are determinants of SM behavior. Optimal support to improve SM should be tailored to the individual patient's level of these determinants as SM abilities vary between patients. To tailor SM support, it is therefore necessary to assess the scores on these determinants. Unfortunately, no such instrument exists for clinical use. Therefore, the first goal of this study was to verify presumed correlations between SM and the determinants thereof. The second goal was to develop an instrument to assess the SM abilities. Methods: In this cross-sectional, observational study, COPD patients completed the General Self-Efficacy Scale (GSES), Brief Illness Perception Questionnaire (B-IPQ) and the Utrecht Proactive Coping Competence measure (UPCC) as well as the Self-Management Ability Scale (SMAS-30). Correlations between the questionnaires were assessed and a principal component analysis (PCA) was performed to identify the best-fitting items in the three independent variables related to SM. These items were used to create an instrument to assess SM abilities. Results: Hundred COPD patients (58 males, 41 females, 1 unknown) were included. The correlation between SM and self-efficacy, illness perception on concerns and proactive coping was moderate and significant (r=0.318, p<0.01; r=-.230, p<0.05; r=.426, p<0.01, respectively). PCA identified six UPCC items and nine GSES items that met the predefined criteria. These items were supplemented with the B-IPQ concerns item to establish the new instrument to assess SM abilities.

Rome III vs Rome IV criteria for irritable bowel syndrome: A comparison of clinical characteristics in a large cohort study.

BACKGROUND: The Rome criteria for irritable bowel syndrome (IBS) have been revised and are expected to apply only to the subset of Rome III IBS subjects with abdominal pain as predominant symptom, occurring at least once a week. The aim of this study was to determine the percentage of Rome III IBS subjects that fulfills Rome IV criteria and to evaluate differences between Rome IV-positive and Rome IV-negative subjects. METHODS: Four hundred and four Rome III IBS subjects completed a 14-day end-of-day symptom diary, the Gastrointestinal Symptom Rating Scale (GSRS), Hospital Anxiety and Depression Scale, and RAND 36-item Short-Form Health Survey (SF-36). Diary-based surrogate Rome IV criteria were defined as occurrence of abdominal pain at least 1 day each week with a severity of ≥2 (mild; definition 1) or ≥3 (considerable; definition 2). KEY RESULTS: Using surrogate Rome IV criteria, 353 (87.4%, definition 1) and 249 (61.6%, definition 2) subjects were defined as Rome IV positive. These patients were more often female, younger, and recruited from secondary/tertiary care compared with Rome IV-negative subjects. They also presented with higher abdominal pain scores and gastrointestinal (GI) symptom severity on both end-of-day diary and GSRS, higher psychological symptom scores, and lower quality of life compared with Rome IV-negative subjects. CONCLUSIONS AND INFERENCES: The Rome IV IBS population likely reflects a subgroup of Rome III IBS patients with more severe GI symptomatology, psychological comorbidities, and lower quality of life. This implies that results from Rome III IBS studies may not be directly comparable to those from Rome IV IBS populations.

The contribution of an asthma diagnostic consultation service in obtaining an accurate asthma diagnosis for primary care patients: results of a real-life study.

Previous studies showed that general practitioners have problems in diagnosing asthma accurately, resulting in both under and overdiagnosis. To support general practitioners in their diagnostic process, an asthma diagnostic consultation service was set up. We evaluated the performance of this asthma diagnostic consultation service by analysing the (dis)concordance between the general practitioners working hypotheses and the asthma diagnostic consultation service diagnoses and possible consequences this had on the patients' pharmacotherapy. In total 659 patients were included in this study. At this service the patients' medical history was taken and a physical examination and a histamine challenge test were carried out. We compared the general practitioners working hypotheses with the asthma diagnostic consultation service diagnoses and the change in medication that was incurred. In 52% (n = 340) an asthma diagnosis was excluded. The diagnosis was confirmed in 42% (n = 275). Furthermore, chronic rhinitis was diagnosed in 40% (n = 261) of the patients whereas this was noted in 25% (n = 163) by their general practitioner. The adjusted diagnosis resulted in a change of medication for more than half of all patients. In 10% (n = 63) medication was started because of a new asthma diagnosis. The 'one-stop-shop' principle was met with 53% of patients and 91% (n = 599) were referred back to their general practitioner, mostly within 6 months. Only 6% (n = 41) remained under control of the asthma diagnostic consultation service because of severe unstable asthma. In conclusion, the asthma diagnostic consultation service helped general practitioners significantly in setting accurate diagnoses for their patients with an asthma hypothesis. This may contribute to diminish the problem of over and underdiagnosis and may result in more appropriate treatment regimens. ASTHMA: SERVICE HELPS GENERAL PRACTITIONERS MAKE ACCURATE DIAGNOSES: A consultation service can help general practitioners more accurately diagnose asthma and select the appropriate treatments for their patients. Researchers in The Netherlands, led by Frank Smeenk from Catharina Hospital in Eindhoven, describe an asthma diagnostic consultation service they created to support GPs in their diagnostic process for patients suspected of having asthma. Over a four-year period, the service received a total of 659 referrals and only confirmed the diagnosis of asthma in 275 cases. Another 20 patients had asthma overlapping with chronic obstructive pulmonary syndrome. The service also picked up other diseases, such as rhinitis, that general practitioners had missed. Overall, because of the consultation service and its revised diagnoses, more than half of all patients adjusted their medications. Most patients required only a single consultation and could then be referred back to their physicians.

Association between exhaled inflammatory markers and asthma control in children.

The relationship between exhaled inflammatory markers and asthma control in children is unclear. To explore the association between inflammatory markers in exhaled breath (fractional nitric oxide (FeNO), volatile organic compounds (VOCs), cytokines/chemokines) and asthma control. To assess whether exhaled inflammatory markers are able to discriminate between children with persistently controlled/uncontrolled asthma. 96 asthmatic children were followed-up in a one-year observational study. Every 2 months, the following parameters were assessed: asthma control, FeNO, lung function (forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC), exhaled VOCs, and cytokines/chemokines in exhaled breath condensate (EBC). Random Forest was used to analyse the relationship between exhaled inflammatory markers and asthma control. For each model, patients were randomly selected for a training set and validation set. To assess the accuracy of the classification models, receiver operating characteristic-curves (ROC-curves) were generated. No significant association was found between the exhaled inflammatory markers (FeNO, markers in EBC, VOCs) and asthma control (area under the ROC-curve 49%). However, 15 exhaled VOCs could discriminate between subgroups of children with persistently controlled and uncontrolled asthma during all clinical visits (area under the ROC-curve 86%). Adding FeNO and markers in EBC to this model, did not lead to a more accurate classification (area under the ROC-curve 87%). There was no association between exhaled inflammatory markers and asthma control in children. However, children with persistently controlled or uncontrolled asthma during the 12 month study period could be discriminated by a set of VOCs.

Clinical items not helpful in differentiating viral from bacterial lower respiratory tract infections in general practice.

OBJECTIVE: Incorrect and unnecessary antibiotic prescribing enhancing bacterial resistance rates might be reduced if viral and bacterial lower respiratory tract infections (LRTI) could be differentiated clinically. Whether this is possible is often doubted but has rarely been studied in general practice. STUDY DESIGN AND SETTING: This was an observational cohort study in 15 general practice surgeries in the Netherlands. RESULTS: Etiologic diagnoses were obtained in 112 of 234 patients with complete data (48%). Viral pathogens were found as often as bacterial pathogens. Haemophilus (para-) influenzae was most frequently found. None of the symptoms and signs correlated statistically significantly with viral or bacterial LRTI. Erythrocyte sedimentation rate >50 (odds ratio [OR] 2.3-3.3) and C-reactive protein (CRP) >20 (OR 2.1-4.6) were independent predictors for viral LRTI and bacterial LRTI when compared with microbiologically unexplained LRTI. CONCLUSION: Extensive history-taking and physical examination did not provide items that predict viral or bacterial LRTI in adult patients in daily general practice. We could not confirm CRP to differentiate between viral and bacterial LRTI.

Irritable bowel syndrome: an integrated explanatory model for clinical practice.

BACKGROUND: Although irritable bowel syndrome (IBS) is a symptom-based diagnosis, clinicians' management of and communication about the disorder is often hampered by an unclear conceptual understanding of the nature of the problem. We aimed to elucidate an integrated explanatory model (EM) for IBS from the existing literature for pragmatic use in the clinical setting. METHODS: Systematic and exploratory literature searches were performed in PubMed to identify publications on IBS and EMs. KEY RESULTS: The searches did not identify a single, integrated EM for IBS. However, three main hypotheses were elucidated that could provide components with which to develop an IBS EM: (i) altered peripheral regulation of gut function (including sensory and secretory mechanisms); (ii) altered brain-gut signaling (including visceral hypersensitivity); and (iii) psychological distress. Genetic polymorphisms and epigenetic changes may, to some degree, underlie the etiology and pathophysiology of IBS and could increase the susceptibility to developing the disorder. The three model components also fit into one integrated explanation for abdominal symptoms and changes in stool habit. Additionally, IBS may share a common pathophysiological mechanism with other associated functional syndromes. CONCLUSIONS & INFERENCES: It was possible to elucidate an integrated, three-component EM as a basis for clinicians to conceptualize the nature of IBS, with the potential to contribute to better diagnosis and management, and dialog with sufferers.

Meta-analysis: the diagnostic value of alarm symptoms for upper gastrointestinal malignancy.

BACKGROUND: With the advent of empirical treatment strategies for patients with dyspeptic symptoms, it becomes increasingly important to select patients with a high risk of having cancer for immediate endoscopy. Usually alarming symptoms are used for this matter, but their diagnostic value is by no means clear. AIM: To investigate the diagnostic value of alarm symptoms for upper gastrointestinal malignancy. METHODS: Meta-analysis of studies describing prevalence of alarm symptoms in patients with and without endoscopically verified upper gastrointestinal malignancy were identified through a Medline search. The prevalence, pooled sensitivity, specificity, positive and negative predictive values were calculated. RESULTS: About 17 case studies and nine cohort studies were selected. The mean prevalence of gastrointestinal malignancies in the cohort studies was 2.8% of 16,161 patients. Five cohort studies indicated that 25% of the patients diagnosed with upper gastrointestinal malignancy had no alarm symptoms. The pooled sensitivities of individual alarm symptoms varied from 9 to 41%, the pooled positive predictive value ranged from 4.6 to 7.9%, and was 5.9% for 'having any alarm symptom'. The pooled negative predictive value was 99.4% for 'having any alarm symptom'. CONCLUSION: The risk of upper gastrointestinal malignancy in any individual without alarm symptoms is very low, but approximately one in four patients with upper gastrointestinal cancer have no alarm symptoms at the time of diagnosis.

Systematic review: the role of different types of fibre in the treatment of irritable bowel syndrome.

BACKGROUND: Both high-fibre dietary advice and the prescription of fibre as a bulking agent are very common in primary and secondary care management of irritable bowel syndrome. Irritable bowel syndrome patients with constipation may have delayed intestinal transit. Therefore, fibres that accelerate intestinal transit may be beneficial in these patients. The uncertain benefits reported in several clinical studies, however, have led us to reappraise the value of fibre in irritable bowel syndrome management. AIM: To quantify the effect of different types of fibre on global and symptom relief from irritable bowel syndrome. METHODS: Using a structured literature search in MEDLINE (1966-2002), we selected randomized controlled trials involving irritable bowel syndrome patients treated with fibre. Analyses were performed for the total group and for trials using soluble and insoluble fibre separately. RESULTS: Seventeen studies were included in the analysis. None investigated primary care irritable bowel syndrome patients. Fibre, in general, was effective in the relief of global irritable bowel syndrome symptoms [relative risk, 1.33; 95% confidence interval (CI), 1.19-1.50]. Irritable bowel syndrome patients with constipation may receive benefit from fibre treatment (relative risk, 1.56; 95% CI, 1.21-2.02), but there was no evidence that fibre was effective in the relief of abdominal pain in irritable bowel syndrome. Soluble and insoluble fibre, separately, had different effects on global irritable bowel syndrome symptoms. Soluble fibre (psyllium, ispaghula, calcium polycarbophil) showed significant improvement (relative risk, 1.55; 95% CI, 1.35-1.78), whereas insoluble fibre (corn, wheat bran), in some cases, worsened the clinical outcome, but there was no significant difference compared with placebo (relative risk, 0.89; 95% CI, 0.72-1.11). CONCLUSIONS: The benefits of fibre in the treatment of irritable bowel syndrome are marginal for global irritable bowel syndrome symptom improvement and irritable bowel syndrome-related constipation. Soluble and insoluble fibres have different effects on global irritable bowel syndrome symptoms. Indeed, in some cases, insoluble fibres may worsen the clinical outcome. Future clinical studies evaluating the effect and tolerability of fibre therapy are needed in primary care.

Patient-directed strategy to reduce prescribing for patients with dyspepsia in general practice: a randomized trial.

BACKGROUND: The percentage of patients receiving long-term treatment with acid suppressive drugs, mainly proton pump inhibitors, is higher than the prevalence of diseases that are commonly accepted as the proper indication for long-term proton pump inhibitor use. AIM: To evaluate whether a patient-directed intervention (direct mail) reduced the prescription of antisecretory medication for dyspepsia in general practice. METHODS: A cluster-randomized trial was performed. One hundred and thirteen chronic users of proton pump inhibitors were recruited by 20 general practitioners. An unsolicited information leaflet was sent to patients that suggested stopping or reducing the use of proton pump inhibitors. The number of patients who stopped or reduced proton pump inhibitor use was measured at 12 and 20 weeks after the intervention. Secondary outcome measures were dyspepsia symptom severity and perceived quality of life measured at 12 weeks after the intervention. RESULTS: Fourteen of the 59 (24%) intervention group patients stopped or reduced their use of proton pump inhibitors, compared with three of the 45 (7%) control group patients (relative risk ratio 3.56; CI 95%: 1.088-11.642). Dyspepsia symptom severity and quality of life did not change. CONCLUSIONS: A simple patient-directed intervention reduced the volume of long-term prescriptions of proton pump inhibitors in patients with dyspepsia.

Assessment of the accuracy of diagnostic tests: the cross-sectional study.

In diagnostic accuracy studies, the contrast of interest can be one of the following: one single test contrast; comparing two or more single tests; further testing in addition to previous diagnostics; and comparing alternative diagnostic strategies. The clinical diagnostic problem under study must be specified. Studies of "extreme contrasts" (as early phase evaluations) and studies in "clinical practice" settings (assessing clinical value) should be distinguished. Design options are (1) survey of the total study population, (2) case-referent approach, or (3) test-based enrollment. Data collection should generally be prospective, but ambispective and retrospective approaches are sometimes appropriate. In addition to determinants of primary interest [the test(s) under study] possible modifiers of test accuracy and confounding variables must be specified. The reference standard procedure should be independent from the test results. Applying a reference standard can be difficult in case of classification errors, lack of a clear pathophysiologic concept, incorporation bias, or invasive or complex investigations. Possible solutions are: an independent expert panel, and the delayed type cross-sectional study (clinical follow-up). Also, a prognostic criterion can be chosen. For studies to be relevant for practice, inclusion criteria must be based on "intention to diagnose" or "intention to screen." The recruitment procedure is preferably a consecutive series of presenting patients or a target population screening, respectively. Sample size estimation should be routine. Analysis has to be focused on the contrast of interest. Estimating test accuracy and prediction of outcome need different approaches. External (clinical) validation requires repeated studies in other, similar populations. Also, systematic reviews and meta-analysis have a role. To enable readers of diagnostic research reports to evaluate whether methodological key issues were addressed, authors are advised to follow the STARD guidelines.

Modern life' in the epidemiology of inflammatory bowel disease: a case-control study with special emphasis on nutritional factors.

OBJECTIVE: The rising incidence of inflammatory bowel disease (IBD) since the Second World War coincides with profound changes of the dietary pattern. The aim of the study was to investigate the possible pathogenic role of some characteristic 'modern life' dietary factors in IBD. DESIGN: Case-control, studying risk factors in recently diagnosed cases, 290 with Crohn's disease and 398 with ulcerative colitis, compared with 616 population controls. Smoking, age, gender and education were taken into account by using logistic regression analysis. SETTING: Hospital cases and population controls. INTERVENTIONS: Questionnaires. MAIN OUTCOME MEASURES: Logistic regression-derived odds ratios. RESULTS: A positive association with cola drinks [OR: 2.2 (95% CI 1.5-3.1)], chewing gum [OR: 1.5 (95% CI: 1.1-2.1)] and chocolate consumption [OR: 2.5 (95% CI: 1.8-3.5)] and a negative association with citrus fruit consumption [OR: 0.5 (95% CI 0.3-0.7)] and the development of Crohn's disease were found. Consumption of cola drinks [OR: 1.6 (95% CI 1.1-2.3)] and chocolate consumption [OR: 2.5 (95% CI 1.8-3.5)] were positively associated with developing ulcerative colitis. There was a negative association between the intake of citrus fruits [OR: 0.5 (95% CI 0.4-0.8)] and 'having a stuffed pet' for a period longer than 5 years [OR: 0.6 (95% CI 0.4-0.9)] and developing the disorder. No association with the frequency of tooth brushing and developing IBD was found. CONCLUSION: All the nutritional items mentioned may be true risk factors or they just might be the expression of a modern life-style also involving other risk factors for the development of IBD which at the present are still unknown.