The clinical course and prognostic determinants of non-ulcer dyspepsia: a literature review.
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Dyspepsia↗
Biomedical subjects
J W Muris
Publications and source records attributed to J W Muris.
Can small group education and peer review improve care for patients with asthma/chronic obstructive pulmonary disease?
OBJECTIVE: To study the effectiveness of an intensive small group education and peer review programme aimed at implementing national guidelines on asthma/chronic obstructive pulmonary disease (COPD) on care provision by general practitioners (GPs) and on patient outcomes. DESIGN: A randomised experimental study with pre-measurement and post-measurement (after one year) in an experimental group and a control group in Dutch general practice. SUBJECTS AND INTERVENTION: Two groups of GPs were formed and randomised. The education and peer review group (17 GPs with 210 patients) had an intervention consisting of an interactive group education and peer review programme (four sessions each lasting two hours). The control group consisted of 17 GPs with 223 patients (no intervention). MAIN OUTCOME MEASURES: Knowledge, skills, opinion about asthma and COPD care, presence of equipment in practice; actual performance about peakflow measurement, non-pharmacological and pharmacological treatment; asthma symptoms (Dutch Medical Research Council), smoking habits, exacerbation ratio, and disease specific quality of life (QOL-RIQ). Data were collected by a written questionnaire for GPs, by self recording of consultations by GPs, and by a written self administered questionnaire for adult patients with asthma/COPD. RESULTS: Data from 34 GP questionnaires, 433 patient questionnaires, and recordings from 934 consultations/visits and 350 repeat prescriptions were available. Compared with the control group there were only significant changes for self estimated skills (+16%, 95% confidence interval 4% to 26%) and presence of peakflow meters in practice (+18%, p < 0.05). No significant changes were found for provided care and patient outcomes compared with the control group. In the subgroup of more severe patients, the group of older patients, and in the group of patients not using anti-inflammatory medication at baseline, no significant changes compared with the control group were seen in patient outcomes. CONCLUSION: Except for two aspects, intensive small group education and peer review in asthma and COPD care do not seem to be effective in changing relevant aspects of the provided care by GPs in accordance with guidelines, nor in changing patients' health status.
Adult↗
[Discrepancy between the guidelines and practice by family physicians in treating adults with an exacerbation of asthma or chronic obstructive pulmonary disease].
OBJECTIVE: To analyse to what extent current management of exacerbation in adult asthmatics and patients with asthma or chronic obstructive pulmonary disease (COPD) in general practice is consistent with the guidelines from the standard 'asthma/COPD in adults' of the Dutch College of General Physicians (NHG). DESIGN: Cross-sectional, prospective. SETTING: Centre for Quality of Care Research, University of Nijmegen, the Netherlands. PATIENTS AND METHODS: Fifty-two GPs in 1992 during an average of 3.5 months in adult patients with exacerbation of asthma or COPD prospectively registered the severity of the dyspnoea, productiveness of coughing, colour of phlegm, fever, auscultatory findings, patients' age and sex and use of medication. Current management (peak flow measurement, prescriptions) was related to all these data and compared with that recommended in the current NHG standard. RESULTS: Data were available on 383 exacerbations. Peak flow measurement was used diagnostically in 27% of the exacerbations. Inhalation steroids were prescribed in 26% of the cases (new or step-up), oral steroids were prescribed in 24%, more often in exacerbations with severe dyspnoea (48%; p < 0.0005), in patients who prior to the exacerbations had been using two or more different COPD drugs (37%; p < 0.0005) and in patients over 55 years of age (35%; p < 0.0005). Antibiotics were prescribed in 60% of the cases, and more often in case of coloured phlegm (83%; p < 0.0005) and of fever (91%; p < 0.0005). CONCLUSION: Objectivation of the bronchial obstruction by peak flow measurement was done less often than recommended in the standard; antibiotics were prescribed more often and steroids less often. In order to reduce the substantial discrepancy between the guidelines and the actual management, implementation should be aimed at changing GPs' routines, with special attention for barriers to change.
Adult↗
High incidence of inflammatory bowel disease in The Netherlands: results of a prospective study. The South Limburg IBD Study Group.
PURPOSE: To gain recent epidemiologic information about inflammatory bowel disease in The Netherlands, a prospective study over four years (1991-1995) was performed. METHODS: The incidence of inflammatory bowel disease and its subgroups was examined using standardized reports of newly diagnosed patients. A separate study compared the Inflammatory Bowel Disease Registration and computerized diagnostic files of a subgroup of general practitioners with the aim of estimating completeness of case ascertainment. RESULTS: The following mean incidence rates (per 100,000 inhabitants and year) were found: 6.9 (95 percent confidence interval, 5.9-7.9) for Crohn's disease, 10 (95 percent confidence interval, 8.7-11.2) for ulcerative colitis (23 percent of these with ulcerative proctitis), and 1.1 (95 percent confidence interval, 0.7-1.5) for indeterminate colitis. In the age category 20 to 29 years, the incidence rate of Crohn's disease with small-bowel involvement was higher in females than in males. In extended ulcerative colitis, a male preponderance was observed in the older age groups. Estimated case ascertainment was 78 percent. CONCLUSIONS: Compared with recent studies in neighboring countries, the observed age and gender standardized incidence rates are high in the south of The Netherlands. Completeness of case ascertainment might have contributed to this observation; however, case ascertainment was low in ulcerative proctitis. In the study area, differences in age and gender standardized incidence rates and in disease localizations could be compatible with an influence of environmental risk factors.
Adolescent↗
The clinical course and prognostic determinants of the irritable bowel syndrome: a literature review.
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Adult↗
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.
Adult↗
Appendectomy and the risk of developing ulcerative colitis or Crohn's disease: results of a large case-control study. South Limburg Inflammatory Bowel Disease Study Group.
BACKGROUND & AIMS: Appendectomy has been pointed out as a protective factor for ulcerative colitis (UC). The aim of this study was to elucidate the role of appendectomy in inflammatory bowel disease (IBD). METHODS: Prevalent as well as incident cases with IBD were studied separately using a pairwise age- and sex-matched case-control study design. RESULTS: In 232 prevalent UC cases, the risk of developing UC was significantly lower after previous appendectomy (odds ratio [OR], 0.36; 95% confidence interval [CI], 0.15-0.80); subgroup analysis found a protective effect only in pancolitis (OR, 0.2; 95% CI, 0.02-0.7). In 208 patients with Crohn's disease (CD), the OR was not significantly increased but a positive association with appendectomy was observed in ileocecal disease. A significant larger proportion of appendectomies was performed close to the time of diagnosis. Smoking was not a confounding factor. No statistically significant associations were observed in incident IBD patients. Prevalent and incident patients taken together resulted in ORs of 0.44 (95% CI, 0.24-0.78) in UC and 1.65 (95% CI, 0.96-2.91) in CD. CONCLUSIONS: An overall protective role of appendectomy for UC was observed. The observations in CD suggest that appendectomy in some cases was a result of still undiagnosed CD.
Adolescent↗
Familial aggregation of inflammatory bowel disease: a population-based study in South Limburg, The Netherlands. The South Limburg IBD Study Group.
BACKGROUND: The aim of our study was to investigate the prevalence of Crohn's disease (CD) and ulcerative colitis (UC) in first-degree relatives of IBD patients living in a well-defined area. METHODS: IBD patients known at the IBD Registration South Limburg as well as population controls were asked about the occurrence of IBD in their first-degree relatives. RESULTS: IBD was reported and confirmed in 16 (out of 1554) relatives by 11 (out of 245) patients. Prevalence of IBD was highest for siblings (1.5%) and children (1.3%), while only 0.2% of the parents were affected with IBD. Among relatives of the control subjects, IBD was observed in 0.8% (versus 4.5% in IBD patients), resulting in an odds ratio of 5.7 (95% CI: 2.0-16.7). CONCLUSIONS: The observed risk of IBD for first-degree relatives of IBD patients was higher than in controls. However, the risk in our population is lower than has been reported by other centres, possibly because of the population-based character of our study.
Adolescent↗
[Quality improvement project 'laboratory diagnosis by family physicians' leads to considerable decrease in number of laboratory tests].
OBJECTIVE: Quality improvement of laboratory diagnostics by general practitioners (GPs) through introduction of a simplified, problem-oriented application form, supported by information and feedback. DESIGN: Prospective descriptive study. SETTING: Laboratory of Clinical Chemistry and Haematology of St. Maartens Gasthuis, Venlo, the Netherlands and the GPs in the region. METHODS: The effects of the intervention were measured by counting the analyses requested by all GPs in the region in 1992, 1993 and 1994. Furthermore requests by every GP for fifteen selected analyses in the first 6 months of 1992, 1993 and 1994 were counted and reported together with the anonymous data of all colleagues. RESULTS: After the intervention a 23% reduction of the total number of analyses request by GPs was noticed. Blood sampling increased by 8% and the mean number of laboratory test requests per patient decreased from 5.9 to 4.2. The largest request reductions were noticed for analyses not listed on the application form. Measurements in the first 6 months of 1992, 1993 and 1994 showed continuation of the trend and a fadeaway of 'redundant' analyses. CONCLUSION: The introduction of a simplified problem-oriented application form for GPs supported by feedback caused a marked decrease of the number of (redundant) laboratory requests.
Clinical Laboratory Techniques↗
One-year prognosis of abdominal complaints in general practice: a prospective study of patients in whom no organic cause is found.
BACKGROUND: Data on the one-year prognosis of patients with non-organic, non-acute abdominal complaints in primary care are lacking. Knowledge of prognostic determinants could be helpful in management and health education. AIM: To describe the prognosis after one year of non-organic abdominal complaints in general practice, and to show how this relates to socio-demographic factors, medical history and psychological problems. METHODS: The one-year prognosis of patients with non-organic abdominal complaints in a primary care setting was analysed in a prospective study (n = 756). Clinical and psychological factors were measured and their relative risks regarding unfavourable prognosis were calculated one year after the first consultation. RESULTS: In 68% of the patients examined, the abdominal complaints had either improved or disappeared by the end of the first year. Female sex and depressive mental state were associated with an unfavourable prognosis. Clinical symptoms that were significantly associated with persisting complaints were a combination of abdominal pain, flatulence and bowel irregularities; a specific description of the character of the pain by the patient; looser stools at the onset of the pain; long duration or recurrence, pyrosis; absence of visible distension; and epigastric localization of the pain or tenderness. CONCLUSIONS: The prognosis after one year of non-acute abdominal pain in general practice is better than that reported from studies of outpatient populations. Female sex, depressive mood and some clinical parameters are associated with persistent complaints one year after presentation.
Abdominal Pain↗
Predictive value of signs and symptoms for colorectal cancer in patients with rectal bleeding in general practice.
The aim of the study is to determine the diagnostic value of (combinations of) signs, symptoms and simple laboratory test results for colorectal cancer in patients with rectal bleeding presenting in general practice. Initial complaints and findings were compared with the final diagnoses based on clinical follow-up after at least 1 year. Patients studied were those presenting overt rectal bleeding to the general practitioner (83 GPs in the South of the Netherlands). Outcome measures are sensitivity, specificity, predictive values, odds ratios and a prediction model derived from multiple logistic regression analysis. Age, change in bowel habit and blood mixed with or on stool show a statistically significant independent value in the discrimination between patients with a low and those with a high probability of colorectal cancer. Many other variables did not show predictive value. The prediction model has a sensitivitiy of 100% and a specificity of 90%. Although the number of patients with colorectal cancer is small (n = 9) it was possible to identify three characteristics which can be helpful in the prediction of presence or absence of colorectal cancer in general practice. Application of the model presented might prevent 90% of 'unnecessary' invasive diagnostic procedures for patients with rectal bleeding who do not have colorectal cancer (true negative). Testing the performance of the model in other general practice populations is recommended.
Adolescent↗
Non-acute abdominal complaints in general practice: diagnostic value of signs and symptoms.
BACKGROUND: Although many patients are evaluated initially by their general practitioner, clinicians' accuracy at diagnosing organic gastrointestinal disease has not been studied in a primary care setting. Different spectra of severity of disease in general practice and hospital populations may lead to different values for diagnostic tests in these two populations. AIM: This study set out to determine the diagnostic value of history and physical and laboratory items for organic and neoplastic disease in general practice patients with nonacute abdominal complaints. METHOD: The one-year prospective, observational study was carried out in 1989 in 80 general practices in Limburg, the Netherlands. The study subjects were 933 patients (aged 18-75 years) presenting to their general practitioner with new non-acute abdominal complaints of minimum duration two weeks, and with whom the doctor had a diagnostic problem. Patients were physically examined by their general practitioner and asked to complete pre-structured questionnaires. Basic laboratory tests were carried out. Patients were followed up for at least one year by researchers and then a diagnosis was determined by an independent panel of three general practitioners using patient records, blinded for the results of the questionnaires. Sensitivity, specificity and odds ratios were calculated for clinical items. Stepwise forward logistic regression analysis was undertaken to identify independent predictors of organic gastrointestinal disease. RESULTS: Of the 933 patients 14% had organic gastrointestinal disease. No clinical item had both high sensitivity and specificity. Logistic regression analysis showed only eight independent predictors of organic disease: male sex, greater age, epigastric pain, no specific character to pain, pain affecting sleep, history of blood in stool, no pain relief after defecation and abnormal white blood cell count. When the model was programmed to predict neoplasms five items were found: male sex, greater age, no specific character to pain, weight loss and erythrocyte sedimentation rate greater than 20 mm hour-1. CONCLUSION: In a general practice population with non-acute abdominal complaints some clinical findings can be used as predictors for organic and neoplastic gastrointestinal disease.
Adolescent↗
Discriminant value of symptoms in patients with dyspepsia.
BACKGROUND: Family physicians encounter many pitfalls in managing and treating dyspeptic patients, most of whom are treated in family practice based solely on their signs and symptoms. METHODS: A computer literature search followed by a systematic methodological appraisal was performed to identify studies that evaluated clinical symptomatology in dyspeptic patients. RESULTS: Ten studies, none of which took place in a family practice, fulfilled our inclusion criteria. The main conclusion drawn from outpatient populations and patients referred for open-access endoscopy was that certain clusters of symptoms have a negative predictive value for organic causes of dyspepsia. Higher age, male sex, pain at night, relief by antacids or food, and previous history of peptic ulcer disease were identified as predictors of organic causes for abdominal symptoms. CONCLUSIONS: These findings can be helpful to family physicians in determining the need for endoscopy referral. However, since the diagnostic values of tests in family practice may differ from those in referred populations, there is a need for prospective studies in primary care.
Dyspepsia↗
The diagnostic value of rectal examination.
The rectal examination is a much advocated procedure for assessing abdominal and urinary symptoms. A Medline literature search yielded only a few studies, not one of them in a general practice setting. The sensitivity of the rectal examination to rectal carcinoma and appendicitis is low, while it is high for prostate carcinoma. When reviewing the likelihood ratios of normal and abnormal findings of rectal examinations it was concluded that it may be a useful procedure in the case of abnormal findings in patients presenting rectal problems and in assessing men with prostate problems, although it does not seem useful in diagnosing appendicitis. However, since the diagnostic values in general practice and in referred populations may be different, there is a need for further prospective studies in settings of general medical practice.
Appendicitis↗
The incidence and outcome of rectal bleeding in general practice.
The objective of the studies reported in this paper was to determine the incidence as well as the final diagnostic outcome of rectal bleeding presenting in general practice. Because of the wide variety observed in incidence rates among 83 general practitioners (GPs) in the first study (A) an additional study (B) was undertaken. In study B with 10 GPs special efforts were made to maximize the catchment rate. The mean 'consultation incidence rate' was 7 per 1000 people per year. A follow-up period of at least 1 year was applied to establish the final diagnostic conclusion. Occurrence of colorectal cancer was found in 3% of patients with rectal bleeding. This may represent an overestimation of the prior probability since there was a selection in favour of patients with clinically relevant rectal bleeding. In about 90% of patients rectal bleeding was related to minor ailments or self-limiting disorders. Further study on predictive values of (combinations of) other signs and symptoms is necessary to develop clinical recommendations.
Adolescent↗
Abdominal pain in general practice.
Five hundred and seventy-eight consecutive cases of non-acute abdominal pain presenting to 11 general practices were included in a descriptive study and were followed during 15 months. Females predominated in the younger age groups. Eighty per cent of these patients visited their GP not more than three times for abdominal complaints during the follow-up period. Eighty-three per cent were managed entirely in the practice and 64% received a prescription. Only 20% of patients were additionally investigated in any way by the GP. There were hardly any differences in final diagnoses between patients who had complaints less than 1 week or more than 1 week before presenting to the GP. Non-acute abdominal pain is a condition that is seen and managed mainly in general practice.
Abdominal Pain↗
Morbidity among unemployed and work-incapacitated men in The Netherlands.
As yet, the relationship between unemployment and physical health has not sufficiently been clarified. With a longitudinal approach a representative Dutch panel study and a study on a health center population were carried out. They involved work-incapacitated and unemployed men between 21 and 65 years of age. Men incapacitated for work were in poorer health than matched working men; the same was true in a three-year follow-up. Unemployed and working men were shown to be equally healthy. The physical health of the incapacitated men decreased with time but that of the unemployed men did not. This finding implies that unemployment per se does not lead to poorer health. Differences in social security systems seem to interfere with an international comparison of the consequences of unemployment on health. International research should distinguish more explicitly between those who are unemployed for economic reasons or incapacitated for work for medical reasons.
Adult↗
The diagnostic value of symptoms for the identification of patients with an increased risk of colorectal disease. A criteria-based analysis.
In most textbooks of gastroenterology, diseases with their symptoms are discussed. The exact diagnostic value of these symptoms, however, regarding the differentiation between organic and functional disease, is not mentioned. A criteria-based meta-analysis of the few existing studies in this field was done. From the 14 identified studies, there were two that did not find any significant symptoms. In the other studies the diagnostic value of colonic symptoms showed great variability. Methodological deficiencies in these studies are probably responsible for the latter. The generalization of these results into general practice is not straightforward and needs research in general practice patients.
Colonic Diseases↗