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Biomedical subjects

W Devillé

Publications and source records attributed to W Devillé.

At least 19 recordsLinked to original sources
PubMed2002

Rapid evaluation of FDG imaging alternatives using head-to-head comparisons of full ring and gamma camera based PET scanners--a systematic review.

AIM: While FDG full ring PET (FRPET) has been gradually accepted in oncology, the role of the cheaper gamma camera based alternatives (GCPET) is less clear. Since technology is evolving rapidly, "tracker trials" would be most helpful to provide a first approximation of the relative merits of these alternatives. As difference in scanner sensitivity is the key variable, head-to-head comparison with FRPET is an attractive study design. This systematic review summarises such studies. METHODS: Nine studies were identified until July 1, 2000. Two observers assessed the methodological quality (Cochrane criteria), and extracted data. RESULTS: The studies comprised a variety of tumours and indications. The reported GC- and FRPET agreement for detection of malignant lesions ranged from 55 to 100%, but with methodological limitations (blinding, standardisation, limited patient spectrum). Mean lesion diameter was 2.9 cm (SD 1.8), with only about 20% < 1.5 cm. The 3 studies with the highest quality reported concordances of 74-79%, for the studied lesion spectrum. Contrast at GCPET was lower than that of FRPET, contrast and detection agreement were positively related. Logistic regression analysis suggested that pre-test indicators might be used to predict FRPET-GCPET concordance. CONCLUSION: In spite of methodological limitations, "first generation" GCPET devices detected sufficient FRPET positive lesions to allow prospective evaluation in clinical situations where the impact of FRPET is not confined to detection of small lesions (< 1.5 cm). The efficiency of head-to-head comparative studies would benefit from application in a clinically relevant patient spectrum, with proper blinding and standardisation of acquisition procedures.

Equipment Design↗
PubMed2001

Risk factors of HIV infection and needle sharing among injecting drug users in Ho Chi Minh City, Vietnam.

OBJECTIVE: We sought to identify risk factors for needle sharing and HIV infection among injecting drug users (IDUs) in Ho Chi Minh City (HCMC), Vietnam. METHODS: Three cross-sectional surveys among IDUs, both on the street (in 11 urban districts) and in the rehabilitation center for IDUs in HCMC, were carried out in April of 1995, 1997, and 1998. Outreach workers interviewed IDUs about socio-demographic characteristics, drug use and sexual practices, and HIV knowledge and perceptions. The IDUs were also tested for seropositivity to HIV. Independent predictors for HIV positivity and needle sharing were determined by univariate and multivariate logistic regression for the study sample within the rehabilitation center in 1997 and for that on the street in 1998. RESULTS: The HIV prevalence in 1998 among IDUs was 44% for those on the street and 38.5% for those in the rehabilitation center. Independent predictors for HIV infection in IDUs were being injected by drug dealers (for the 1997 sample), injecting on the street, and sharing the drug pots (for the 1998 sample). The reported rate of needle sharing was low and decreased significantly from 20% in 1995 to 12% in 1998 for the sample of IDUs at the street. In the multivariate analysis, predictors for needle sharing for both study samples were injecting on the street, injecting at shooting galleries, and having shared needles in the past. Adequate and easy access to sterile needles and syringes, and a supportive environment of behavior change, especially in street and shooting gallery could reduce risks of virus transmission in the Vietnamese IDU community.

Adult↗
PubMed2001

Diagnostic accuracy of 18F-fluorodeoxyglucose positron emission tomography in the follow-up of papillary or follicular thyroid cancer.

Positron emission tomography with 18F-fluorodeoxyglucose is a relatively new nuclear imaging technique in oncology. We conducted a systematic review to determine the diagnostic accuracy of 18F-fluorodeoxyglucose positron emission tomography in patients suspected of recurrent papillary or follicular thyroid carcinoma. Two reviewers independently selected, extracted, and assessed data from relevant literature found in computerized databases and by reference tracking. Prospective and retrospective studies with 10 human subjects, or more, that evaluated the accuracy of ring positron emission tomography, using 18F-fluorodeoxyglucose in follicular and papillary thyroid cancer, were included. Studies on 18F-fluorodeoxyglucose imaging using gamma cameras, reviews, case reports, editorials, letters, and comments were excluded. The methodological quality was assessed by applying the criteria for diagnostic tests recommended by the Cochrane Methods Group on Screening and Diagnostic Tests. A rating system was used for qualitative analysis consisting of four levels of evidence (1 = highest level; 4 = lowest level). Fourteen studies met the inclusion criteria. All studies claimed a positive role for positron emission tomography but, at evidence levels 3 or 4, precluding quantitative analysis. Methodological problems included poor validity of reference tests and a lack of blinding of test performance and interpretation. The reviewed material was heterogeneous with respect to patient variation and validation methodology. The most consistent data were found on the ability of 18F-fluorodeoxyglucose positron emission tomography to provide an anatomical substrate in patients with elevated serum Tg and negative iodine-131 scans. In conclusion, the results seem to support the potential of 18F-fluorodeoxyglucose positron emission tomography to identify and localize foci of recurrent cancer in the latter patient subset. However, implementation of positron emission tomography in a routine diagnostic algorithm requires additional evidence.

Adenocarcinoma, Follicular↗
PubMed2000

Disappointing performance of literature-derived selective screening criteria for asymptomatic Chlamydia trachomatis infection in an inner-city population.

BACKGROUND: In an inner-city population with a low prevalence of Chlamydia trachomatis infection, selective screening may be indicated to increase the efficiency of screening. GOAL: To evaluate the performance of sets of selective screening criteria for asymptomatic Chlamydia trachomatis infection in an inner-city population. The criteria were derived from reports of studies carried out in various settings. STUDY DESIGN: A total of 5714 women age 15 to 40 years living in Amsterdam were invited for a screening based on home-obtained urine specimens. Criteria identified from the literature were applied to the screening population. A calculated area under the receiver-operator characteristic curve (AUC) of greater than 0.75 was considered a good measure of diagnostic accuracy. RESULTS: Of the four sets of criteria, selection based on the following determinants showed the highest diagnostic accuracy: younger than 25 years, being unmarried, number of partners during the previous 6 months, Surinam or Antillean origin (black), and vaginal douching (AUC, 0.67; 95% CI, 0.65-0.69). Selection based on age alone showed an AUC of 0.57 (95% CI, 0.55-0.69). CONCLUSION: The performance of selective screening criteria for asymptomatic C trachomatis infection in an inner-city population in Amsterdam was insufficient to recommend its implementation in practice.

Adolescent↗
PubMed2000

A randomized controlled trial of rubber band ligation versus infra-red coagulation in the treatment of internal haemorrhoids.

OBJECTIVE: Despite the presence of numerous non-surgical therapies for the treatment of haemorrhoids, none of these therapies has clearly been proven to be superior. The effectiveness and patient tolerance of rubber band ligation (RBL) and infra-red coagulation (IRC) in the treatment of haemorrhoids was assessed. DESIGN: Prospective randomized trial. SETTING: Academic hospital (tertiary care). PARTICIPANTS: A total of 133 consecutive patients (73 males, 60 females, mean age 48 years (range 19-82)) with internal haemorrhoids, and without concomitant anorectal disease, were randomized to rubber band ligation (RBL, n = 65) or infra-red coagulation (IRC, n = 68). INTERVENTIONS: Rubber band ligation or infra-red coagulation was performed in one or more sessions with four-week intervals until symptoms had resolved. Treatment outcome and side-effects were assessed after each treatment session and one month after the last treatment by proctological examination and a questionnaire, including a pain score (visual analogue scale from 0 to 10). Recurrence of complaints was assessed by telephone questionnaire [mean follow-up of 19.2 months (SD 7.8)]. RESULTS: Treatment outcome was assessed in 124 patients (60 RBL, 64 IRC). The mean number of treatment sessions was 1.6 (SD 0.9) for both therapies. For RBL, 58 patients (97%), and for IRC, 59 patients (92%) were symptom-free or had satisfactorily improved. Only third-degree haemorrhoids seemed to respond better to RBL (five of five patients symptom-free) than to IRC (two of four patients symptom-free). Pain following treatment was more common and more severe after RBL (VAS 5.5 +/- 3.7) than after IRC (VAS 3.3 +/- 3.3, P= 0.018). The telephone questionnaire was answered by 105 patients. Nine of 50 patients (18%) treated with RBL and 11 of 55 patients (20%, P= 0.81) treated with IRC had experienced symptomatic relapse to pre-treatment levels. CONCLUSIONS: Infra-red coagulation and rubber band ligation are equally effective in the treatment of haemorrhoids. The rate and severity of pain is higher after rubber band ligation. Infra-red coagulation should be the first-line treatment for haemorrhoids.

Adult↗
PubMed2000

Low diagnostic accuracy of selective screening criteria for asymptomatic Chlamydia trachomatis infections in the general population.

OBJECTIVES: To develop and validate selective screening criteria for asymptomatic Chlamydia trachomatis infections in the general population. METHODS: 11,505 people, aged 15-40 years, registered in 16 general practices in Amsterdam were invited to return by mail a home obtained first void urine sample and a questionnaire. Participants were randomly allocated into a development group (75%) or a validation group (25%). C trachomatis infection was determined by the ligase chain reaction. In the development group a set of criteria was identified by means of stepwise logistic regression analysis. The diagnostic accuracy (area under the ROC curve; AUC) and sensitivity, and the corresponding percentage of people selected for screening were calculated. The criteria developed in this study were applied to the validation group. RESULTS: The prevalence of asymptomatic C trachomatis infections among men was found to be 2.4% (1.7-3.0), and among women 2.8% (2.2-3.4). Screening men, based on Surinam/Antillean origin and painful micturition, yielded an AUC of 0.58 (0.55-0.60). Screening women, based on Surinam/Antillean origin, new sex partner in the previous 2 months, and unmarried/not cohabiting, yielded an AUC of 0.67 (0.65-0.69). Application of the criteria for men to the validation group yielded an AUC of 0.53 (0.48-0.57); by screening 10% of the men, 15% of the cases were detected. The AUC of the criteria for women in the validation group was 0.58 (0.54-0.61); by screening 51% of the women, 63% of the cases were detected. CONCLUSION: The prevalence of asymptomatic C trachomatis infections in Amsterdam is less than 3%. No suitable selective screening criteria for the general population could be identified.

Adolescent↗
PubMed1999

Variability of fasting and post-methionine plasma homocysteine levels in normo- and hyperhomocysteinaemic individuals.

To assess the variability of plasma homocysteine levels, fasting and post-methionine homocysteine levels were measured twice, at baseline and after follow-up of 1-4 months, in 16 individuals with normal and 26 with elevated homocysteine levels after methionine loading. The intra-individual coefficients of variation varied from 15 to 23% for fasting and post-methionine homocysteine levels, whether these levels were within the normal range or not. As a result, test-retest agreement was poor when subjects were dichotomized as having 'normal' or 'abnormal' homocysteine levels (itself a questionable concept). There was a relation between the average post-methionine homocysteine levels (at the first and second measurement) and the difference between both measurements (r = 0.37, P = 0.016). In normohomocysteinaemic individuals, delta (i.e., the difference between baseline and follow-up) fasting homocysteine and delta post-methionine homocysteine were correlated negatively with delta folate serum levels: r = -0.64, P = 0.007 and r = -0.50, P = 0.05, respectively. Individuals homozygous for the 677 C-->T mutation in the 5,10-methylenetetrahydrofolate reductase gene showed a greater variation of fasting homocysteine levels than those homozygous for the wild type (P = 0.017). In summary, we suggest that there is a substantial intra-individual variability in plasma homocysteine levels over time and that this variability is significantly related to the variability in serum folate levels, especially in normohomocysteinaemic individuals.

5,10-Methylenetetrahydrofolate Reductase (FADH2)↗
PubMed1999

Diagnostic classification of shoulder disorders: interobserver agreement and determinants of disagreement.

OBJECTIVES: To assess the interobserver agreement on the diagnostic classification of shoulder disorders, based on history taking and physical examination, and to identify the determinants of diagnostic disagreement. METHODS: Consecutive eligible patients with shoulder pain were recruited in various health care settings in the Netherlands. After history taking, two physiotherapists independently performed a physical examination and subsequently the shoulder complaints were classified into one of six diagnostic categories: capsular syndrome (for example, capsulitis, arthritis), acute bursitis, acromioclavicular syndrome, subacromial syndrome (for example, tendinitis, chronic bursitis), rest group (for example, unclear clinical picture, extrinsic causes) and mixed clinical picture. To quantify the interobserver agreement Cohen's kappa was calculated. Multivariate logistic regression analysis was applied to determine which clinical characteristics were determinants of diagnostic disagreement. RESULTS: The study population consisted of 201 patients with varying severity and duration of complaints. The kappa for the classification of shoulder disorders was 0.45 (95% confidence intervals (CI) 0.37, 0.54). Diagnostic disagreement was associated with bilateral involvement (odds ratio (OR) 1.9; 95% CI 1.0, 3.7), chronic complaints (OR 2.0; 95% CI 1.1, 3.7), and severe pain (OR 2.7; 95% CI 1.3, 5.3). CONCLUSIONS: Only moderate agreement was found on the classification of shoulder disorders, which implies that differentiation between the various categories of shoulder disorders is complicated. Especially patients with high pain severity, chronic complaints and bilateral involvement represent a diagnostic challenge for clinicians. As diagnostic classification is a guide for treatment decisions, unsatisfactory reproducibility might affect treatment outcome. To improve the reproducibility, more insight into the reproducibility of clinical findings and the value of additional diagnostic procedures is needed.

Acromioclavicular Joint↗
PubMed1999

Estimation of serial interval and incubation period of tuberculosis using DNA fingerprinting.

OBJECTIVE: To determine the frequency distributions of serial interval and incubation period of tuberculosis within 4 years of transmission, and to identify correlates of serial intervals and incubation periods. METHODS: DNA fingerprints were obtained for all isolates from all culture-positive patients notified in The Netherlands from 1993 to 1996. Patient information was obtained from the National Tuberculosis Register. Results from contact investigations were provided by public health services. Source cases and secondary cases of tuberculosis were identified, based on 1) identical DNA fingerprints, and 2) epidemiological confirmation of contact. Under-representation of long intervals were corrected for by weighting cases. RESULTS: A total of 69 source-secondary case couples were identified. The geometric mean serial interval was 29.5 weeks (95% confidence interval [CI] 22.8-38.2 weeks) and the geometric mean incubation period 20.8 weeks (95% CI 15.5-27.8 weeks). Serial intervals and incubation periods tended to increase with age (P > 0.05). Three secondary cases with human immunodeficiency virus infection showed very short incubation periods (P > 0.05). CONCLUSION: Using a new methodology, the distribution of incubation periods of tuberculosis gave results consistent with earlier studies.

Adolescent↗
PubMed1998

Effectiveness of corticosteroid injections versus physiotherapy for treatment of painful stiff shoulder in primary care: randomised trial.

OBJECTIVE: To compare the effectiveness of corticosteroid injections with physiotherapy for the treatment of painful stiff shoulder. DESIGN: Randomised trial. SETTING: 40 general practices. SUBJECTS: 109 patients consulting general practitioners for shoulder pain were enrolled in the trial. INTERVENTIONS: Patients were randomly allocated to 6 weeks of treatment either with corticosteroid injections (53) or physiotherapy (56). MAIN OUTCOME MEASURES: Outcome assessments were carried out 3, 7, 13, 26, and 52 weeks after randomisation; some of the assessments were done by an observer blind to treatment allocation. Primary outcome measures were the success of treatment as measured by scores on scales measuring improvement in the main complaint and pain, and improvement in scores on a scale measuring shoulder disability. RESULTS: At 7 weeks 40 (77%) out of 52 patients treated with injections were considered to be treatment successes compared with 26 (46%) out of 56 treated with physiotherapy (difference between groups 31%, 95% confidence interval 14% to 48%). The difference in improvement favoured those treated with corticosteroids in nearly all outcome measures; these differences were statistically significant. At 26 and 52 weeks differences between the groups were comparatively small. Adverse reactions were generally mild. However, among women receiving treatment with corticosteroids adverse reactions were more troublesome: facial flushing was reported by 9 women and irregular menstrual bleeding by 6, 2 of whom were postmenopausal. CONCLUSIONS: The beneficial effects of corticosteroid injections administered by general practitioners for treatment of painful stiff shoulder are superior to those of physiotherapy. The differences between the intervention groups were mainly the result of the comparatively faster relief of symptoms that occurred in patients treated with injections. Adverse reactions were generally mild but doctors should be aware of the potential side effects of injections of triamcinolone, particularly in women.

Adult↗
PubMed1998

Risk factors for back pain incidence in industry: a prospective study.

The objective of this study was to examine the relationship between physical and psychological risk factors on the one hand, and the occurrence of new episodes of back pain on the other hand. A prospective study was conducted with 12 months follow-up by means of self-administered questionnaires. The study took place in the Cargo Department of a major Dutch airline company. The subjects for this study were 270 workers involved in heavy physical work. Only workers without back pain at baseline were included. Self-reported back pain and sick leave due to back pain during the follow-up period were measured. Of the 238 workers included in the analysis, 73 (31%) developed a new episode of back pain during the follow-up period, and 27 (11%) subjects reported sick leave due to back pain. Multiple logistic regression analysis showed that the history of back pain was the best predictor for the occurrence of a new episode of back pain during follow-up (OR 9.8; 95% CI 2.8-34.4 for subjects who had back pain more than twice in the past year). Low job satisfaction was also associated with an increased risk for the occurrence of back pain during follow-up (OR 1.2; 95% CI 1.01-1.4). Riding a forklift truck appeared to be a protective factor for the occurrence of back pain (OR 0.7; 95% CI 0.5-0.99). In this study the best predictors for the occurrence of back pain were the history of back complaints and low job satisfaction. Although it needs to be confirmed by future intervention studies, the results indicate that increasing job satisfaction may be a successful (co-)intervention for the prevention of back pain at the workplace.

Adult↗
PubMed1998

On the course of low back pain in general practice: a one year follow up study.

OBJECTIVES: Knowledge on the clinical course of low back pain presented in general practice is poor. Preceding studies offer a fragmentary view only, whereas further knowledge is important to enable the assessment of the prognosis. The object of this study is to investigate the course of low back pain presented in general practice to enable the assessment of the prognosis. METHODS: A one year follow up study on the clinical course of low back pain in consecutive cases receiving usual care in general practice. During a period of two years 15 general practitioners from Amsterdam and surrounding areas included consecutive patients with both chronic and recent onset low back pain. After the initial visit, each patient was monitored for a period of 12 months. The follow up consisted of monthly postal questionnaires on the course of the low back pain and the related disability. RESULTS: A total of 443 of 605 patients identified were included in the follow up, which was fully completed by 269 patients. In general, patients with less serious low back pain participated less often or did not complete the follow up. At 12 weeks 35% and at the end of the follow up 10% of the population, respectively, still suffered from low back pain. Both the pain and the disability seemed to diminish quickly after the initial visit, and both seemed to stabilise at a lower level if the low back pain did not disappear completely. About three of four patients, whose pain disappeared before the end of the follow up, endured one or more relapses within a year. The median time to a relapse was about seven weeks, and its median duration about six weeks. Both the pain and the disability turned out to be less severe during relapses. The median time to recovery for patients whose low back pain developed more than seven weeks before the initial visit, was four weeks longer than for patients with more recently developed low back pain at the initial visit. CONCLUSIONS: The clinical course of low back pain presented in general practice, for the most patients, clearly is less favourable than expected. It takes more than just a few weeks to recover, and relapses occur within a year in most cases. Fortunately, both the pain and the disability quickly diminish, even if the low back pain does not resolve within a few weeks.

Acute Disease↗
PubMed1998

The responsiveness of the Shoulder Disability Questionnaire.

OBJECTIVE: To evaluate the responsiveness of the Shoulder Disability Questionnaire (SDQ). METHODS: The study was conducted within the framework of an observational study on shoulder disorders in primary care. After first presentation of their complaints to the general practitioner and after one and six months, participants completed the SDQ, a single question on functional status (FSQ), and an ordinal 11 point scale for the severity of pain (PSS). Responsiveness of the SDQ was evaluated compared with that of the FSQ and PSS, by calculating responsiveness ratios and by plotting receiver operating characteristic (ROC) curves. Recovery according to the patient was used as an external criterion for clinically relevant improvement (complete recovery or much improved on a six point Likert scale was denoted as clinically relevant improvement). RESULTS: A total of 349 consecutive patients with shoulder disorders were enrolled in the observational study. Response rates ranged between 96% and 89%. Responsiveness ratios were slightly higher for the PSS compared with the SDQ (2.53 versus 2.22 at one month, 2.24 versus 1.89 at six months). The area under the ROC curve was 0.84 for both the SDQ and the PSS, and 0.72 for the FSQ. CONCLUSION: The results of this study confirm the responsiveness of the SDQ, making it a useful instrument to assess functional disability in longitudinal studies.

Activities of Daily Living↗
PubMed1998

Well-being and symptoms in relation to insulin therapy in type 2 diabetes.

OBJECTIVE: To determine the influence of insulin therapy on physical symptoms, emotional and general well-being, and treatment satisfaction in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: A descriptive prospective 2-year cohort study was performed. The study population consisted of 272 eligible NIDDM patients of Dutch origin > or = 40 years of age who had a known diabetes duration > or = 3 months and who were treated with diet and/or oral hypoglycemic agents. Dependent variables in the logistic regression analysis were scores on the Type 2 Diabetes Symptom Checklist, the Profile of Mood States, and questions regarding general well-being and treatment satisfaction. Potential determinants under study were age, sex, known diabetes duration, insulin dose, duration of insulin therapy, comorbidity, baseline and change in metabolic parameters and cardiovascular risk factors. RESULTS: A baseline and 2-year questionnaire were available for 157 patients (58%). During follow-up, 39 of them (24.8%) were treated with insulin. Initiation of insulin therapy was significantly associated with improved glycemic control (mean HbA1c 8.2 +/- 1.4 [SD] to 7.4 +/- 0.9%, P = 0.001) and weight gain (BMI 27.1 +/- 3.9 to 28.6 +/- 4.3 kg/m2, P = 0.000). Of all symptom and well-being scores, only feelings of emotional fatigue worsened significantly, although modestly (0.4-1.7 on a scale of 0.0-10.0, P = 0.02). Although diabetes management with insulin was experienced as more demanding (P = 0.04), treatment satisfaction scores were not adversely influenced (2.5-1.9, P = 0.39). High insulin doses were significantly and independently associated with high symptom scores (total score, hypoglycemic score) and with low mood (displeasure score, anger, tension, emotional fatigue) and perceived state of health. CONCLUSIONS: Initiation of insulin therapy in type 2 diabetes improves glycemic control effectively, has little influence on physical and psychological well-being dimensions, and does not affect treatment satisfaction.

Adult↗
PubMed1997

The prognosis of low back pain in general practice.

STUDY DESIGN: A prospective cohort study on low back pain in consecutive patients in general practice, in which potential prognostic indicators at baseline and at the 1-year follow-up examination were assessed by means of four weekly questionnaires. OBJECTIVES: To identify prognostic indicators of the duration of low back pain in general practice and the occurrence of a relapse. BACKGROUND: Little is known about the prognosis of low back pain in general practice. Different designs and different results of preceding studies make drawing conclusions about the prognostic indicators, in any, of the course of low back pain in general practice difficult. METHODS: For a period of 2 years, 15 general practitioners from Amsterdam and surrounding areas studied consecutive patients with chronic low back pain and those with a recent onset of low back pain. A large number of potential prognostic indicators were assessed at the initial visit. After the initial visit, each patient was monitored for a period of 12 months. The follow-up assessment was conducted with four weekly postal questionnaires. The associations among the potential prognostic indicators, the duration of the index episode, and the occurrence of a relapse were analyzed using multivariate Cox regression and logistic regression analysis, respectively. RESULTS: Of the 605 patients identified, 443 were included in the follow-up period of assessment; the questionnaires were completed by 269 patients. In general, patients with less severe low back pain participated less often or did not complete the follow-up study. Thirty-five percent of the population still experienced low back pain after 12 weeks, and 10% still experienced it after 1 year. Approximately three of every four patients whose index episode ended before the end of the follow-up period had one or more relapses within a year. The analysis resulted in a model with four variables predicting the duration of the low back pain, including "the duration of the low back pain preceding the initial visit," "receiving physical therapy," "pain intensity", and "history of back surgery." Daily functioning appeared to be the only variable that was significantly associated with the occurrence of a relapse. CONCLUSIONS: Only a few variables appear to be related to the clinical course of low back pain seen in general practice. In particular, the duration preceding the initial visit and, unexpectedly, receiving physical therapy were both associated with a longer duration of low back pain.

Adult↗
PubMed1997

Sustained good glycaemic control in NIDDM patients by implementation of structured care in general practice: 2-year follow-up study.

In primary care it is difficult to treat the growing number of non-insulin-dependent diabetic (NIDDM) patients according to (inter)national guidelines. A prospective, controlled cohort study was designed to assess the intermediate term (2 years) effect of structured NIDDM care in general practice with and without 'diabetes service' support on glycaemic control, cardiovascular risk factors, general well-being and treatment satisfaction. The 'diabetes service', supervised by a diabetologist, included a patient registration system, consultation facilities of a dietitian and diabetes nurse educator, and protocolized blood glucose lowering therapy advice which included home blood glucose monitoring and insulin therapy. In the study group (SG; 22 general practices), 350 known NIDDM patients over 40 years of age (206 women; mean age 65.3 +/- SD 11.9; diabetes duration 5.9 +/- 5.4 years) were followed for 2 years. The control group (CG; 6 general practices) consisted of 68 patients (28 women; age 64.6 +/- 10.3; diabetes duration 6.3 +/- 6.4 years). Mean HbA1c (reference 4.3-6.1%) fell from 7.4 to 7.0% in SG and rose from 7.4 to 7.6% in CG during follow-up (p = 0.004). The percentage of patients with poor control (HbA1c > 8.5%) shifted from 21.4 to 11.7% in SG, but from 23.5 to 27.9% in CG (p = 0.008). Good control (HbA1c < 7.0%) was achieved in 54.3% (SG; at entry 43.4%) and 44.1% (CG; at entry 54.4%) (p = 0.013). Insulin therapy was started in 29.7% (SG) and 8.8% (CG) of the patients (p = 0.000) with low risk of severe hypoglycaemia (0.019/patient year). Mean levels of total and HDL-cholesterol (SG), triglycerides (SG) and diastolic blood pressure (SG + CG) and the percentage of smokers (SG) declined significantly, but the prevalence of these risk factors remained high. General well-being (SG) did not change during intensified therapy. Treatment satisfaction (SG) tended to improve. Implementation of structured care, including education and therapeutic advice, results in sustained good glycaemic control in the majority of NIDDM patients in primary care, with low risk of hypoglycaemia. Lowering cardiovascular risk requires more than reporting results and referral to guidelines.

Aged↗
PubMed1997

Diet or diuretic? Treatment of newly diagnosed mild to moderate hypertension in the elderly.

The aim of this study was to assess the effectivity of dietary measures in the treatment of hypertension. Therefore, a single-blind randomised clinical trial was carried out in elderly persons with recently diagnosed hypertension. Patients were recruited from a general practice (6555 persons) during visits or after written invitation or invitation by phone. New hypertensive patients (with measurements taken on three different occasions >159 mm Hg systolic and/or >94 mm Hg diastolic), aged 60-80 years, without target-organ damage, dementia, diabetes mellitus or malignant disease entered a 3-month intervention programme of either intensive dietary counselling, receiving a sodium-reduced (<100 mmol/24h), potassium-enriched (>75 mmol/24h), and weight-reducing diet (BMI <25), or only 25 mg chlorthalidone a day. Forty-two newly diagnosed hypertensive subjects met the inclusion criteria. Two dropped out from the chlorthalidone group, one with side effects and another after a myocardial infarction. Although blood pressure (BP) in the diet group decreased less than in the drug group, of the patients in the diet group 45% fell back to a normal systolic and 50% to a normal diastolic BP (drug treatment group, systolic 75% and diastolic 85%). In contrast with the diet group, lipid spectrum and blood glucose concentration in the diuretic group, however, deteriorated slightly. The dietary intervention was effective in elderly patients with a systolic or diastolic BP in the range of 160-180 and 95-100 mm Hg, respectively. Reduction in weight should be the primary aim. It is argued that sodium reduction can be achieved better by collective measures. In patients with a BP of more than 180 mm Hg systolic or 100 mm Hg diastolic, dietary advice and drug treatment should be combined.

Aged↗