Patients' evaluation of quality of care in general practice: what are the cultural and linguistic barriers?

OBJECTIVE: Increased migration implies increased contacts for physicians with patients from diverse cultural backgrounds who have different expectations about healthcare. How satisfied are immigrant patients, and how do they perceive the quality of care? This study investigated which patient characteristics (such as cultural views and language proficiency) are related to patients' satisfaction and perceived quality of care. METHODS: Patients (n=663) from 38 general practices in Rotterdam (The Netherlands) were interviewed. General satisfaction with the general practitioner (GP) was measured by a report mark. Perceived quality of care was measured using the 'Quote-mi' scale (quality of care through the patient's eyes-for migrants), which contains an ethnic-specific subscale and a communication process subscale. Using multilevel regression techniques, the relation between patient characteristics (ethnicity, age, education, Dutch language proficiency, cultural views) and satisfaction and perceived quality of care was analysed. RESULTS: In general, patients seemed fairly satisfied. Non-Western patients perceived less quality of care and were less satisfied than Dutch-born patients. The older the patients and the more modern cultural views they had, the more satisfied they were about the GP in general, as well as about the communication process. However, non-Western patients holding more modern views were the most critical regarding the ethnic-specific quality items. The poorer patients' Dutch language proficiency, the more negative they were about the communication process. CONCLUSION: It is concluded that next to communication aspects, especially when the patient's proficiency in Dutch is poor, physician awareness about the patient's cultural views is very important during the consultation. This holds especially true when the immigrant patient seems to be more or less acculturated. PRACTICE IMPLICATIONS: Medical students and physicians should be trained to become aware of the relevance of patients' different cultural backgrounds. It is also recommended to offer facilities to bridge the language barrier, by making use of interpreters or cultural mediators.

[The practice guideline 'Viral hepatitis and other liver diseases' (second revision) from the Dutch College of General Practitioners; a response from the perspective of general practice]. / De standaard 'Virushepatitis en andere leveraandoeningen' (tweede herziening) van het Nederlands Huisartsen Genootschap; reactie vanuit de huisartsgeneeskunde.

This revised practice guideline appears to concern a relatively arbitrarily chosen group of liver diseases. Why not choose for hepatitis alone or for a complete liver practice guideline? The approach to non-alcoholic fatty liver disease and non-alcoholic steatohepatitis does not differ from that of other lifestyle diseases. The elaboration on hepatitis misses the importance of the ethnic risk factor even though there is much literature evidence to support this association. This is not in accordance with the new policy of the Dutch College of General Practitioners to pay more attention to ethnic factors in practice guideline development. Apart from these criticisms, the practice guideline is well structured and well written, notably with respect to the strategy for hepatitis A, B and C.

Theory and application of landfarming to remediate polycyclic aromatic hydrocarbons and mineral oil-contaminated sediments; beneficial reuse.

When applying landfarming for the remediation of contaminated soil and sediment, a fraction of the soil-bound contaminant is rapidly degraded; however, a residual concentration may remain, which slowly degrades. Degradation of polycyclic aromatic hydrocarbons (PAHs) and mineral oil can be described using a multi-compartment model and first-order kinetics, in which three degradable fractions are distinguished; (1) rapid, (2) slowly, and (3) very slowly degradable. Using this model populated with data from long-term experiments (initiated in 1990), it is shown that time frames from years to decades can be necessary to clean the soil or sediment to obtain a target below regulatory guidelines. In passive landfarms without active management, three principal potentially limiting factors can be identified: (1) availability of appropriate microorganisms, (2) supply of oxygen for the biodegradation process, and (3) bioavailability of the pollutants to the microorganisms. Bioavailable PAHs and mineral oil are readily biodegradable contaminants under aerobic conditions, and presence and activity of microorganisms are not problems. The other two factors can be limiting and are theoretically described. Using these descriptions, which are in agreement with field experiments of 10 to 15 yr, it is shown if and when optimization of the biodegradation process is an option. Because a long time period is necessary to degrade the slowly and very slowly degradable fractions, passive landfarming should be combined with beneficial use of the land area. Examples include the development of natural environments, use in constructions, growing of biomass for energy production, including biofuels, and use as cover for landfills.

Assessment of mutual understanding of physician patient encounters: development and validation of a Mutual Understanding Scale (MUS) in a multicultural general practice setting.

Mutual understanding between physician and patient is essential for good quality of care; however, both parties have different views on health complaints and treatment. This study aimed to develop and validate a measure of mutual understanding (MU) in a multicultural setting. The study included 986 patients from 38 general practices. GPs completed a questionnaire and patients were interviewed after the consultation. To assess mutual understanding the answers from GP and patient to questions about different consultation aspects were compared. An expert panel, using nominal group technique, developed criteria for mutual understanding on consultation aspects and secondly, established a ranking to combine all aspects into an overall consultation judgement. Regarding construct validity, patients' ethnicity, age and language proficiency were the most important predictors for MU. Regarding criterion validity, all GP-related criteria (the GPs perception of his ability to explain to the patient, the patient's ability to explain to the GP, and the patient's understanding of consultation aspects), were well-related to MU. The same can be said of patient's consultation satisfaction and feeling that the GP was considerate. We conclude that the Mutual Understanding Scale is regarded a reliable and valid measure to be used in large-scale quantitative studies.

Isolation and structure of the pectin lyase D-encoding gene from Aspergillus niger.

The filamentous fungus, Aspergillus niger, produces a number of extracellular pectin-degrading enzymes. We present here the isolation and the complete nucleotide sequence of the gene, pelD, coding for a pectin lyase D (PLD), which was previously described as pectin lyase I (Van Houdenhoven, Ph.D. Thesis, Wageningen, 1975). The deduced amino acid (aa) sequence corresponds to 373 aa residues including a signal peptide of 19 aa. The coding region is interrupted by four short introns (57-65 bp). The nucleotide sequence of the 5'- and 3'-flanking regions is also presented and shows no unusual features. By comparing the deduced aa sequences of the A. niger PLD and a number of bacterial pectate lyases, short regions of homology were found despite the different substrate specificities (high methoxyl-pectin versus low methoxyl-pectin or polygalacturonate) of these enzymes.

[General practitioner's workload: objective increase in 9 practices in Rotterdam and surroundings, 1992-1997 and an extrapolation to 2005]. / Werkbelasting van huisartsen: objectieve toename in 9 praktijken in Rotterdam en omgeving, 1992-1997 en een extrapolatie naar 2005.

OBJECTIVE: To assess the change in general practitioners' (GPs') workload during the period 1992-1997, calculated as consult frequency and GP-patient contact time, and to estimate the workload in 2005. DESIGN: Descriptive. METHOD: During the period 1992 to 1997, data from all GP-patient contacts from nine general practices in and around Rotterdam, the Netherlands, were registered and stored in a central database. The yearly GP-patient contact time in 1992 and 1997 was calculated using the measured contact frequencies and known figures from the medical literature on the distribution and average duration of the different contact types (consultation, home visit, telephonic consultation, other). The contact time in 2005 was estimated by extrapolating the contact time for the period 1992 to 1997, whilst bearing in mind the expected population composition in 2005. RESULTS: The number of GP consultations increased from 4.26 in 1992 to 5.16 in 1997 (+21%). Compared with 1992, the yearly GP-patient contact time in 1997 was at least 90 hours higher. Extrapolation to 2005, revealed a further increase in this contact time of 667 (+36%) hours compared to 1997. This predicted increase in the workload could mostly be attributed to an increase in the number of elderly patients and the number of contacts with these patients. CONCLUSION: The number of hours worked by GPs increased by 20% over a six year period and is expected to increase by about a third over the next few years.

In situ remediation of contaminated sediments using carbonaceous materials.

Carbonaceous materials (CM), such as activated carbons or biochars, have been shown to significantly reduce porewater concentrations and risks by binding hydrophobic organic compounds (HOCs) present in aquatic sediments. In the present study, the authors review the current state-of-the-art use of CM as an extensive method for sediment remediation, covering both technical and ecological angles. The review addresses how factors such as CM type, particle size and dosage, sediment characteristics, and properties of contaminants affect the effectiveness of CM amendment to immobilize HOCs in aquatic sediments. The authors also review the extent to which CM may reduce bioaccumulation and toxicity of HOCs and whether CM itself has negative effects on benthic species and communities. The review is based on literature and datasets from laboratory as well as field trials with CM amendments. The presence of phases such as natural black carbon, oil, or organic matter in the sediment reduces the effectiveness of CM amendments. Carbonaceous material additions appear to improve the habitat quality for benthic organisms by reducing bioavailable HOC concentrations and toxicity in sediment. The negative effects of CM itself on benthic species, if any, have been shown to be mild. The beneficial effects of reducing toxicity at low CM concentrations most probably outweigh the mild negative effects observed at higher CM concentrations.

Seasonal variation of total and biochemically available concentrations of PAHs in a floodplain lake sediment has no effect on the benthic invertebrate community.

Floodplain areas in the Netherlands are moderately to heavily contaminated with trace metals and organic contaminants. The impact of this sediment pollution on benthic invertebrates is best described with so-called 'bioavailable' concentrations instead of total concentrations. Studies into the effect of contaminants on biota are usually a snapshot in time, with one or two samples in a year. In such studies, effect of seasonal variation cannot be detected. Objective of this study was to investigate the temporal variation of sediment PAH contamination in one floodplain lake, and possible consequences for the benthic invertebrate community. This was done by sampling biota, abiotic variables and sediment contaminants every four weeks during one year. We observed a limited seasonal variation in total and bioavailable concentrations of PAHs. Multivariate analysis revealed that the PAH contamination is not a significant factor for the benthic invertebrate community in this floodplain lake. Bioavailable concentrations of PAHs were low and no effects could be expected based on the measured values. No increase of available PAHs was observed in periods where conditions for degradation were absent (low temperature, anaerobic). These results also indicate that in such floodplain lake systems, with historical pollution, the timing of sampling to assess sediment contamination with organic pollutants is of limited importance. This can be useful for planning sampling in risk assessment studies.

Cultural dissimilarities in general practice: development and validation of a patient's cultural background scale.

Due to increased migration physicians encounter more communication difficulties due to poor language proficiency and different culturally defined views about illness. This study aimed to develop and validate a 'patient's cultural background scale' in order to classify patients based on culturally conditioned norms instead of on ethnicity. A total of 986 patients from 38 multi-ethnic general practices were included. From a list of 36 questions, non-contributing and non-consistent questions were deleted and from the remaining questions the scale was constructed by principal component analysis. Comparing the scale with two other methods of construction assessed internal validity. Comparing the found dimensions with known dimensions from literature assessed the construct validity. Criterion validity was determined by comparing the patient's score with criteria assumed or known to have relationship with cultural background. Criterion validity was reasonably good but poor for income. A valid patient's cultural background scale was developed, for use in large-scale quantitative studies.

Measurement of helicity-dependent photoabsorption cross sections on the neutron from 815 to 1825 MeV.

Helicity-dependent total photoabsorption cross sections on the deuteron have been measured for the first time at ELSA (Bonn) in the photon energy range from 815 to 1825 MeV. Circularly polarized tagged photons impinging on a longitudinally polarized LiD target have been used together with a highly efficient 4pi detector system. The data around 1 GeV are not compatible with predictions from existing multipole analyses. From the measured energy range an experimental contribution to the GDH integral on the neutron of [33.9 +/- 5.5(stat) +/- 4.5(syst)] microb is extracted.

Structure of the Aspergillus niger pelA gene and its expression in Aspergillus niger and Aspergillus nidulans.

Aspergillus niger pectin lyases are encoded by a multigene family. The complete nucleotide sequence of the pectin lyase PLA-encoding gene pelA has been determined. Comparison of the deduced amino acid sequence with the deduced amino acid sequence of the other characterized pectin lyase, PLD, shows that the proteins share 69% amino acid identity. When grown on media with pectin as the sole carbon source, A. niger transformants containing multiple copies of the pelA gene show raised mRNA levels and overexpression of the gene product PLA compared with the wild-type strain. PLA was purified and characterized. In A. nidulans transformants PLA is also produced in medium containing a high concentration of glucose and no pectin.

Cloning and expression of a second Aspergillus niger pectin lyase gene (pelA): indications of a pectin lyase gene family in A. niger.

Using the previously cloned Aspergillus niger N756 pectin lyase D gene as a probe, the corresponding pelD gene has been isolated from a genomic library of the laboratory strain A. niger N400. This gene encodes PLD, previously described as PLI, which is one of the two major pectin lyases isolated from the commercial pectinase preparation Ultrazym. Heterologous hybridization of the A. niger N400 genomic library with the pelD gene led to the isolation of another five genes: pelA, B, C, E, and F. These genes differ in their hybridization patterns with probes containing either the entire pelD gene, or 5' or 3' parts thereof. By partial sequencing, and expression in an A. niger transformant containing multiple copies of the pelA gene, we show that this gene, which hybridizes strongest with the pelD gene, encodes the other major pectin lyase from Ultrazym, PLII.

Primary structure and gene organization of the middle-component RNA of cowpea mosaic virus.

Middle component RNA (M RNA) of cowpea mosaic virus (CPMV) was transcribed into cDNA and double-stranded cDNA was inserted into the EcoRI site of plasmid pBRH2. The nucleotide sequence of inserts was determined, after subcloning in bacteriophages M13mp7, M13mp8 or M13mp9, by the dideoxy chain termination method. The complete sequence of CPMV M RNA, up to the poly(A) tail, is 3481 nucleotides long. The sequence contains a long open reading frame starting at nucleotide 161 from the 5' terminus and continuing to 180 nucleotides from the 3' terminus. The sequence does not contain a polyadenylation signal for the poly(A) tail at the 3' end of CPMV RNA. The initiation site at position 161 together with AUG codons in the same reading frame at positions 512 and/or 524 account for the two large colinear precursor polypeptides translated in vitro from M RNA. The amino acid sequence deduced from the nucleotide sequence suggests that both precursor polypeptides are proteolytically cleaved at glutaminyl-methionine and glutaminyl-glycine, respectively, to produce the two viral capsid proteins.

Using a high-resolution magnetic sector mass spectrometer for fast analysis of transient reaction processes in automotive catalytic converters.

A high-resolution magnetic sector mass spectrometer has been developed and used for transient kinetic measurements on reactions that are important for automotive exhaust gas catalysis. This instrument allows separation of the isobaric masses of CO and N2 as well as CO2 and N2O, which are separately monitored in time at a sampling rate of 48 Hz. The time resolution is sufficient to determine individual kinetic rate parameters for reactions under transient conditions. A description of the experimental set-up as well as the software used is given. The results are illustrated by the catalytic reduction of NO by CO. To the best knowledge of the authors, this is the first application of a magnetic sector mass spectrometer for kinetic research under dynamic operation conditions.

Measurement of spin-transfer observables in p p-->Lambda Lambda at 1.637 GeV/c.

Spin-transfer observables for p p-->Lambda Lambda have been measured using a transversely polarized frozen-spin target and a beam momentum of 1.637 GeV/c. Current models of the reaction near threshold are in good agreement with existing measurements performed with unpolarized particles in the initial state but produce conflicting predictions for the spin-transfer observables Dnn and Knn (the normal-to-normal depolarization and polarization transfer), which are measurable only with polarized target or beam. Measurements of Dnn and Knn presented here are found to be in disagreement with predictions from these models.

Helicity dependence of gammap --> Npi below 450 MeV and contribution to the Gerasimov-Drell-Hearn sum rule.

The helicity dependence of the single pion photoproduction on the proton has been measured in the energy range from 200 to 450 MeV for the first time. The experiment, performed at the Mainz microtron MAMI, used a 4pi-detector system, a circularly polarized, tagged photon beam, and a frozen-spin target. The data obtained provide new information for multipole analyses of pion photoproduction and determine the main contributions to the Gerasimov-Drell-Hearn sum rule and the forward spin polarizability gamma(0).

Helicity amplitudes A1/2 and A3/2 for the D13(1520) resonance obtained from the gamma-->p-->-->ppi(0) Reaction.

The helicity dependence of the gamma-->p-->-->ppi(0) reaction has been measured for the first time in the photon-energy range from 550 to 790 MeV. The experiment, performed at the Mainz microtron MAMI, used a 4pi-detector system, a circularly polarized, tagged photon beam, and a longitudinally polarized frozen-spin target. These data are predominantly sensitive to the D13(1520) resonance and are used to determine its helicity amplitudes.

First Measurement of the Gerasimov-Drell-Hearn Sum Rule for 1H from 0.7 to 1.8 GeV at ELSA.

To verify the fundamental Gerasimov-Drell-Hearn (GDH) sum rule for the first time experimentally, we measured the helicity dependent total photoabsorption cross section with circularly polarized real photons and longitudinally polarized nucleons in the photon energy range 0.68-1.82 GeV with the tagged photon facility at ELSA. The experiment was carried out with a 4pi detection system, a circularly polarized tagged photon beam, and a frozen spin polarized proton target. The contribution to the GDH sum rule in this photon energy range is [49.9+/-2.4(stat)+/-2.2(syst)] microb.