[Prevalence of and health care consumption for asthma and COPD in relation to ethnicity]. / Prevalentie en zorgconsumptie bij astma en COPD in relatie tot etniciteit.

OBJECTIVE: To determine whether there are differences in prevalence of and health care consumption for asthma and COPD between Dutch people of Turkish, Moroccan and Surinamese origin and indigenous Dutch people. DESIGN: Retrospective. METHOD: Based on data from the 'Second Dutch national study into morbidity and interventions in general practice', we compared the prevalence of asthma and COPD in the different ethnic groups. In addition, we compared the use of various airway medications and the number of general practice contacts between these ethnic groups. RESULTS: We analysed data of 240,067 indigenous Dutch, 2,942 Turkish, 2,416 Moroccan and 3,320 Surinamese subjects. Asthma is more prevalent among Surinamese and seems less prevalent among Moroccans. COPD seems less prevalent among immigrants than among the indigenous Dutch population. Immigrants tend to have less prescriptions of prophylactic maintenance airway medication and they also tend to have less airway-related general practice contacts than indigenous Dutch patients. CONCLUSION: Differences exist in the prevalence of and health care consumption for asthma and COPD between the different ethnic groups in the Netherlands. There seems to be underdiagnosis of COPD in immigrants. Moreover, immigrant asthma and COPD patients are probably undertreated.

Prevalence of physical symptoms of itch, pain and fatigue in patients with skin diseases in general practice.

BACKGROUND: Physical symptoms of skin diseases have been shown to negatively affect patients' wellbeing. Although insight into physical symptoms accompanying skin diseases is relevant for the management and treatment of skin diseases, the prevalence of physical symptoms among patients with skin diseases is a rather unexplored territory. OBJECTIVES: The goal of the present study was to examine the prevalence of physical symptoms of itch, pain and fatigue in patients with skin diseases. METHODS: On the basis of a systematic morbidity registration system in primary care, questionnaires were sent to 826 patients with skin diseases. Eventually, questionnaires from 492 patients were suitable for our analyses. RESULTS: Results indicated that patients with skin diseases particularly experience symptoms of itch and fatigue. Approximately 50% of all patients report experiencing these symptoms and about 25% experience these symptoms as relatively severe. Pain was relatively less frequently reported by 23% of all patients, and was on average somewhat less intense. The physical symptoms showed relatively strong correlations with disease-related quality of life and self-reported disease severity. In contrast, only moderate correlations were found with comorbidity and demographic variables, which suggests that the physical symptoms of itch, pain and fatigue are consequences of the skin diseases. CONCLUSIONS: Itch and fatigue and, to a somewhat lesser extent, pain have a high prevalence among patients with skin diseases. Clinicians should be encouraged to carefully assess itch, pain and fatigue in patients with skin diseases, and where appropriate focus treatment to these symptoms.

Psychosocial well-being of patients with skin diseases in general practice.

BACKGROUND: Skin diseases are a substantial part of the problems dealt with by general practitioners. Although the psychosocial consequences of skin diseases in secondary care has been extensively studied, little is known about the psychosocial well-being of patients with skin diseases in primary care. OBJECTIVE: To investigate the psychosocial well-being of patients with skin diseases in primary care. PATIENTS/METHODS: Questionnaires about the psychosocial consequences of skin diseases were sent to patients with a skin disease who were registered within a research network (continuous morbidity registration) of general practices that continuously have recorded morbidity data since 1971. Questionnaires completed by 532 patients were eventually suitable for analyses. RESULTS: Compared with the general population, patients with skin diseases reported significantly lower scores for psychosocial well-being. Furthermore, a lower psychosocial wellbeing was significantly related with higher levels of disease-severity, lower disease-related quality of life, longer disease duration, more comorbidity and more physical symptoms of itch, pain and fatigue. After demographic variables and comorbidity were controlled for, sequential regression analyses showed that disease duration, disease severity and physical symptoms (itch, pain and fatigue) were significant predictors of psychosocial well-being. CONCLUSION: The psychosocial well-being of patients with skin diseases in primary care is lower than that of the general population. Special attention has to be directed to those patients with lowered psychosocial well-being who might be at risk of developing severe psychosocial impairments such as clinical depression.

[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.

[Prevalence of urinary and faecal incontinence among community-dwelling elderly patients in Nijmegen, The Netherlands, January 1999-July 2001]. / Prevalentie van incontinentie voor urine en ontlasting bij zelfstandig wonende ouderen in Nijmegen, januari 1999-juli 2001.

OBJECTIVE: To evaluate the prevalence of urinary, faecal and double incontinence in community-dwelling elderly patients. DESIGN: Cross-sectional population-based survey. METHOD: By means of a postal questionnaire, data were collected in the period January 1999-July 2001 from patients aged 60 and over from 9 general practices associated with the academic general practitioner registration network of the St Radboud University Medical Centre (the Nijmegen Monitoring Project). Excluded were patients living in a home for the elderly, as well as patients with dementia, patients who were too ill to participate and patients with a catheter. RESULTS: Of the 5278 patients who received a questionnaire, 4650 (88%) returned it. 885 (19%) respondents had involuntary loss of urine twice a month or more, 299 (6%) had involuntary loss of faeces and 153 (3%) had both. The prevalence of urinary, faecal and double incontinence increased with age in both men and women, in men especially in the age group > 80 years. Urinary incontinence was more prevalent in women (29%) than in men (9%). The prevalence of faecal incontinence showed no sex differences (women: 6%; men: 7%), but the loss of slimy faeces occurred twice as often in men as in women (60% versus 29%). Double incontinence was also more or less equally prevalent in men and women (men: 2%; women: 4%), except in the age group 65-74 years (men: 1%; women: 4%). CONCLUSION: Especially urinary, but also faecal incontinence was common in the community-dwelling elderly. The prevalence increased with age. Because of ageing of the population and the increasing life expectancy in the next decennia, the prevalence of incontinence can be expected to increase considerably.

Eating behaviour and adherence to diet in patients with Type 2 diabetes mellitus.

AIM: To assess restrained, emotional and external eating behaviour in patients newly diagnosed with Type 2 diabetes compared with the general population, and to assess the relationship of eating behaviour to changes in fat and energy. METHODS: We assessed emotional, external, and restrained eating behaviour and measured fat and energy intake in a cohort of patients with newly diagnosed Type 2 diabetes. Data from a comparable sample of the general population served as reference figures. We calculated correlation coefficients of the three different types of eating behaviour at diagnosis between: (i) energy and fat intake at diagnosis and (ii) changes in energy and fat intake between diagnosis and both 8 weeks and 4 years later. In addition, we used a stepwise multiple regression model with energy and fat intake or changes in energy and fat intake as dependent variables. RESULTS: The distribution of the three types of eating behaviour was similar in patients with Type 2 diabetes and the general population. Emotional and external eating was associated with increased intake of energy and fat. Conversely, restrained eating showed an inverse correlation with energy and fat intake. External eating, but not emotional eating, showed a statistically significant relation with a decrease in energy intake in women. We found no statistically significant correlations between eating behaviour (measured at diagnosis) and changes in energy and fat intake between diagnosis and 4 years. CONCLUSIONS: Patients newly diagnosed with Type 2 diabetes have similar eating behaviour compared with the general population. At diagnosis, external eating behaviour and emotional eating behaviour are associated with high-energy intake and restrained eating behaviour with low-energy intake. Women with high scores for emotional eating behaviour seem to be less able to make initial dietary changes after being diagnosed and having received dietary advice.

Predictors of discontinuation of benzodiazepine prescription after sending a letter to long-term benzodiazepine users in family practice.

BACKGROUND: Predictors of benzodiazepine discontinuation after sending a discontinuation letter by the family practitioner have not been established sufficiently. OBJECTIVE: To identify predictors of short- and long-term discontinuation of benzodiazepine use and relapse in use after a minimal intervention with a discontinuation letter followed by an offer for an evaluation consultation. METHODS: Predictors of benzodiazepine discontinuation and relapse in use were studied by logistic regression analysis and survival analysis within a family practice population of long-term benzodiazepine users (n = 1707) addressed by a discontinuation letter and followed for 21 months. RESULTS: A lower baseline prescription, a shorter duration of use, male gender and use of an agent with a half-life time <24 hours were predictive of complete discontinuation in the short (6 months) and long term (21 months). Multiple agent use at baseline, use of antidepressants at 6 months and benzodiazepine type (anxiolytic/hypnotic) at baseline predicted relapse. Attendance at an evaluation consultation 3 months after the letter was sent was not predictive of discontinuation or relapse. CONCLUSIONS: Amount of baseline use and duration of use are the main determinative characteristics of successful discontinuation. The discontinuation letter intervention is suitable for use with a broad group of long-term benzodiazepine users in family practice and can be used as a first step within a stepped care approach to decrease long-term benzodiazepine use.

Gout, not induced by diuretics? A case-control study from primary care.

BACKGROUND: It is taken for granted that diuretics may induce gout, but there is a general lack of evidence on this topic. OBJECTIVES: To determine the incidence of gout in patients who use diuretics, taking into account concurrent hypertension and cardiovascular diseases. METHODS: A case-control study was designed. From a primary care population all patients with a first gout registration (59 men, 11 women; mean (SD) age 55.1 (13.5)) were identified as cases. To relate the occurrence of gout to diuretic use a matched reference series of three controls for each case was compiled. Conditional logistic regression analyses were applied to estimate incidence rate ratios (IRRs) of gout, and 95% confidence intervals (CIs), in subjects with and without diuretic treatment, hypertension, and cardiovascular diseases. Additional stratification analyses were made, particularly in the subjects not using diuretics. RESULTS: The IRRs of gout in subjects with v those without diuretic treatment, hypertension, heart failure, and myocardial infarction were 2.8 (95% CI 1.2 to 6.6), 2.6 (95% CI 1.2 to 5.6), 20.9 (95% CI 2.5 to 173.8), and 1.9 (95% CI 0.7 to 4.7), respectively. After adjustment, the IRR of gout for diuretic use dropped to 0.6 (95% CI 0.2 to 2.0), while the IRRs of gout for hypertension, heart failure, and myocardial infarction were still >1. This was also the case for subjects with hypertension or myocardial infarction, who had not used diuretics. CONCLUSION: The results suggest that diuretics do not actually increase the risk of gout. Cardiovascular indications for treatment may have confounded previous inferences.

Prevalence of urinary, fecal and double incontinence in the elderly living at home.

The aim of this study was to evaluate the prevalence of urinary, fecal and double incontinence in the elderly, through a population-based cross-sectional survey. The study included all patients aged 60 and over of nine general practices in the Nijmegen Monitoring Project. Patients living in a home for the elderly were excluded, as well as patients with dementia, patients who were too ill to participate and patients with a catheter. There were 5278 selected patients who received a postal questionnaire. Of these, 88% returned it. Nineteen percent of the respondents had involuntary loss of urine twice a month or more, 6% loss of feces and 3% both. The prevalence of urinary, fecal and double incontinence increased with age in both men and women, and especially in men in the oldest age group. Urinary incontinence was more prevalent in women than in men. The prevalence of fecal incontinence showed no sex differences, but the type of fecal incontinence did differ between men and women. In men loss of mucus was twice as common as in women. Double incontinence was also equally prevalent in men and women, except in the age group 65-74 years. In conclusion, urinary, fecal and double incontinence are common conditions in the community-dwelling population. The prevalence rates increase with age. Urinary incontinence is more prevalent in women. There were no sex differences in the prevalence of fecal incontinence but the type of fecal incontinence was different in men and women.

Gout, just a nasty event or a cardiovascular signal? A study from primary care.

OBJECTIVE: Our aim was to examine the relationship between gout on the one hand and cardiovascular diseases and cardiovascular risk indicators on the other. METHODS: A case-control study was carried out in an aggregate primary care population of approximately 12 000 patients from four Dutch general practices, with follow-up of the cases free of cardiovascular diseases at the time of the first registered episode of gout. The subjects comprised 261 patients with a first episode of gout, 170 of whom were without prevalent cardiovascular diseases, and two control patients for each case matched for age, sex and practice. In the case-control study, the main outcome measures were the prevalence of cardiovascular morbidity (angina pectoris, myocardial infarction, heart failure, cerebrovascular accident, transient ischaemic attack, peripheral vascular disease), hypertension, diabetes mellitus, obesity and hypercholesterolaemia; in the follow-up study, the main outcome measure was the incidence of cardiovascular morbidity. RESULTS: Thirty-five percent of 261 gout patients and 26% of 522 controls had one or more prevalent cardiovascular diseases. Compared with controls, patients had a higher prevalence of hypertension (43% versus 18%), hypercholesterolaemia (14% versus 6%) and obesity (56% versus 30%). A total of 170 gout patients without prevalent cardiovascular diseases (compared with 340 controls) had a higher prevalence of hypertension (39% versus 14%), hypercholesterolaemia (8% versus 4%), diabetes mellitus (5% versus 1%) and obesity (52% versus 27%). The first occurrence of a cardiovascular disease (real end-point) was seen in 26% of the patients free of cardiovascular morbidity and in 21% of the controls. This difference was not significant. In a Cox proportional hazard model, controlling for the cardiovascular risk indicators, gout did not prove to be an independent determinant for the development of cardiovascular disease. CONCLUSION: Gout was found to be associated with cardiovascular diseases and with cardiovascular risk indicators, without evidence of it being an independent risk indicator itself. A gout attack should be an incentive to assess the cardiovascular risk profile, when a patient seeks medical help.

Tapering off long-term benzodiazepine use with or without group cognitive-behavioural therapy: three-condition, randomised controlled trial.

BACKGROUND: Benzodiazepine withdrawal programmes have never been experimentally compared with a nonintervention control condition. AIMS: To evaluate the efficacy and feasibility of tapering off long-term benzodiazepine use in general practice, and to evaluate the value of additional group cognitive-behavioural therapy (CBT). METHOD: A 3-month randomised, 3-month controlled trial was conducted in which 180 people attempting to discontinue long-term benzodiazepine use were assigned to tapering off plus group CBT, tapering off alone or usual care. RESULTS: Tapering off led to a significantly higher proportion of successful discontinuations than usual care (62% nu. 21%). Adding group CBT did not increase the success rate (58% v. 62%). Neither successful discontinuation nor intervention type affected psychological functioning. Both tapering strategies showed good feasibilityin general practice. CONCLUSIONS: Tapering off is a feasible and effective way of discontinuing long-term benzodiazepine use in general practice. The addition of group CBT is of limited value.

[Relationship between te general practice guidelines for the diagnosis of hypertension and the indication for treatment and practice in the Nijmegen region, the Netherlands, 1983-2001]. / Samenhang tussen de huisartsrichtlijnen voor diagnostiek van hypertensie en indicatie tot behandeling en de praktijk in de regio Nijmegen, 1983-2001.

OBJECTIVE: To determine whether patients with hypertension in general practice are diagnosed and treated according to the criteria of the Dutch College of General Practitioners guidelines. DESIGN: Retrospective, descriptive. METHOD: Using data from 9 general practices belonging to the general practice research network of the Academic Medical Centre St Radboud, Nijmegen, the Netherlands, all intake data of newly diagnosed hypertensive patients were collected. Three periods (1983-1991, 1992-1996 and 1997-2001) were studied and compared to the 1991 and 1997 versions of the guidelines. RESULTS: During the study period, 1959 patients with hypertension were registered. In 4% of the men and 3% of the women the hypertension criteria of the time were not met. These figures decreased during the course of the research period. Mean blood pressure at diagnosis was above 160/100 mmHg, even in patients with diabetes. The additional risk factors were recorded increasingly frequently (cholesterol level, smoking behaviour, body-mass index). In 1991, 63% were treated with medication (the other 37% only received lifestyle advice). During the last period, 86% received medication, while the indication to prescribe medication according to the guidelines increased from 40% to 81%. The increase may be ascribed to the new guideline recommendation of one risk factor as an indication to treat patients with mild hypertension instead of two. CONCLUSION: Almost all patients in whom the participating general practitioners diagnosed hypertension fulfilled the criteria. The difference in threshold values for diagnostic measurements and medicinal treatment means that people with mild hypertension are not always registered and consequently risk being forgotten by their general practitioner.

Cardiovascular risk factors and disease in general practice: results of the Nijmegen Cohort Study.

The relationship between risk factors and cardiovascular disease (CVD) was determined using data from the Nijmegen Cohort study, an 18-year prospective study. In 1977, cardiovascular risk factors were measured in 7092 Caucasian males and females from six general practices: age, smoking, serum cholesterol, blood pressure, body mass index and a family history of CVD were related to subsequent CVD mortality and morbidity. Most patients had more than one risk factor in particular among men. A significant relationship between risk factors and CVD was demonstrated. In men, a relative risk (RR) of 1.8 was found for both high blood pressure and smokers. A positive family history yielded a RR of 1.8. The risk increased gradually with the number of risk factors; 38% of the group with all risk factors suffered a CVD within 18 years. In women, comparable RRs were found but the low absolute risk of CVD should indicate against the treatment of cardiovascular risk factors.