Biomedical subjects

W J van den Bosch

Publications and source records attributed to W J van den Bosch.

At least 19 recordsLinked to original sources

PubMed2004

[The practice guideline 'Acute cough' from the Dutch College of General Practitioners; a response from the perspective of general practice].

The practice guideline 'Acute cough' from the Dutch College of General Practitioners stresses the fact that a cough of less than 3 weeks' duration seldom heralds serious pathology. However, for sound reassurance of patients presenting with a cough of short duration, the general practitioner needs to know much about the signs and symptoms connected to low-prevalence serious pathology in these patients. The practice guideline distinguishes upper and lower respiratory tract infections and defines serious lower respiratory tract infection. The diagnostic value of symptoms and laboratory findings like a sedimentation rate or C-reactive protein in order to make such distinctions, is not explained in detail. Antibiotics are reserved for serious lower respiratory tract infection with the exception of acute bronchitis, croup and bronchiolitis, which can be treated without antibiotics. Recommendations for treatment of acute bronchiolitis with bronchodilators or corticosteroids, and croup with corticosteroids are based on consensus. This practice guideline can be considered as a clear and valuable piece of work for all physicians in primary and secondary care.

Acute Disease↗

PubMed2004

[Summary of the practice guideline 'Rheumatoid arthritis' (first revision) from the Dutch College of General Practitioners].

The guideline covers the evaluation of patients with one or more painful joints without previous injury and focuses on the distinction between rheumatoid arthritis and other joint complaints. In the case of rheumatoid arthritis, the arthritis is based on aseptic synovitis and is nearly always associated with tenderness, warmth, swelling, and impaired function. Redness is not present in most cases. The diagnosis is primarily made on the basis of the case history and physical examination. Laboratory tests and X-ray are only of secondary importance. NSAIDs are recommended as the initial treatment for patients with rheumatoid arthritis or serious indications for this. If the arthritis does not settle within a period of 6 to 12 weeks after the onset of the complaints, the patient should be referred to a rheumatologist to start treatment with one or more disease-modifying antirheumatic drugs (DMARDs). DMARDs suppress the activity of the disease and can prevent joint damage. However, which combination of DMARDs gives the best results is still unclear.

Anti-Inflammatory Agents, Non-Steroidal↗

PubMed2003

[Depression: longer-lasting episode not an automatic indication for referral].

During episodes of depression, patients exhibit a low mood and a number of other emotional and/or physical symptoms for a certain period of time. Regarding depression as just the defined episode when patients meet the criteria for diagnosis, ignores the fluctuating character of the illness and the role of the patient. The patient is, after all, the one who decides if and when the symptoms experienced are important enough to seek medical assistance. How a patient with depression should be treated, and whether or not and to whom the patient should be referred, depends on more than just the severity of the depression. This is because severity involves more than just the number of symptoms when the depression was first diagnosed. Ineffective coping behaviour and lack of social support both negatively influence the course of depression and if the initial treatment is not effective enough, the episode will be prolonged. The interest and skills of the general practitioners as well as the expectations and former experiences of the patient play a major role in deciding whether to refer a patient to secondary care.

Depression↗

PubMed2003

[The practice guideline 'Anemia' from the Dutch College of General Practitioners; a response from the perspective of general practice medicine].

The practice guideline 'Anaemia' from the Dutch College of General Practitioners will certainly be a support for the Dutch general practitioner. The inclusion of an algorithm to make a more precise diagnosis is an experiment that needs to be evaluated in the near future. However, many general practitioners will regard it as too complex for use in daily practice and specialists will find it to be of limited use, as it does not cover all cases. Consultation between the general practitioner and the specialist will give the best answer in complicated cases. Patients who complain about tiredness or dizziness will expect their general practitioner to take a blood sample for a haemoglobin test. The general practitioner will consider the risk of false-positive test results in interpreting the patient's haemoglobin level. A few concrete remarks: the guideline does not mention that vegetarianism and a low meat intake can increase the risk of vitamin B12 deficiency, and iron suppletion is advised in premenopausal women with profuse vaginal blood loss, whereas there are several treatable disorders that may cause menorrhagia.

Algorithms↗

PubMed2001

[Penicillin for acute throat infections. Are there arguments for modifying the guidelines of the Dutch College of General Practitioners?].

A recent study concludes that a 7-day penicillin treatment for a sore throat is superior to a 3-day treatment or a placebo, because the symptoms are resolved two days earlier. Prior to this study, the difference--based on the conclusions of a Cochrane review--was thought to be just 8 hours. The total number of patients included was too small to conclude that penicillin could reduce the number of short-term and long-term complications. In the guidelines of the Dutch College of General Practitioners, a 7-day penicillin treatment for a sore throat is only recommended in severe cases. It is still quite acceptable for Dutch GPs to discuss the treatment options for a sore throat with their patients. A change to the current guidelines is not necessary.

Acute Disease↗

PubMed2000

['Cholesterol' guideline (first revision) of the Dutch College of Family Physicians; response from the family practice].

The revised guidelines of the Dutch College of General Practitioners on cholesterol are more in accordance with the consensus guidelines of the Dutch Institute for Health Care Improvement. The number of people with a history of cardiovascular disease who will receive medication is probably underestimated. The guidelines attach little value to diet measurements; however, in individual cases a diet can be a realistic possibility for treatment. Screening for hypercholesterolaemia is now focused more on other risk factors. This and stopping medication in people who have been told in the past they have a treatable disease can turn out to be a problem, for which a national campaign of the public might be helpful.

Anticholesteremic Agents↗

PubMed2000

Changes in serum total cholesterol levels over 18 years in a cohort of men and women: The Nijmegen Cohort Study.

BACKGROUND: This study aimed to investigate to what extent cholesterol levels change in individuals in different age groups over an 18-year period. Factors that contribute to the changes, with respect to prevention of cardiovascular disease, were taken into account. METHODS: In 1977 serum cholesterol, systolic and diastolic blood pressures, body mass index, and smoking habits were measured in a cohort of 7,092 patients (men and women from 20 to 50 years of age) from six general practices in The Netherlands. In 1995, a sample of 2,600 of these same patients were invited to take part in a similar screening program; 2,335 patients, consisting of 1,171 men and 1,164 women, agreed to participate. Patients were derived from both high-risk and low- to normal-risk category in 1977. The differences in cholesterol between 1977 and 1995 were calculated and cholesterol levels were tracked over the study period by determining Pearson correlation coefficients. A multiple linear regression analysis was performed to investigate the determinants influencing the changes in cholesterol level. RESULTS: The mean cholesterol levels rose during the study period in all age groups. The highest mean increase in men was 1.23 mmol/L, or 20%, in the youngest age group (20-24 years), and in women the maximum mean increase was 1.12 mmol/L, or 17%, in the age group 40-44 years. Correlation coefficients between the 1977 and 1995 readings varied from 0.63 in the youngest age group to 0.41 in the oldest. Body weight change during the study period, more than initial body weight, was found to have influenced the rise in serum cholesterol. At basic screening, 19.2% of the men and 12.4% of the women had cholesterol levels of 6. 5 mmol/L or higher, as against 35.8 and 36.8%, respectively, in 1995. CONCLUSIONS: Over an 18-year period cholesterol level increased in most subjects, at a younger age in men than in women. The highest increase in women took place during the menopausal period. Weight gain, more than baseline weight, had a positive influence on the increase in cholesterol.

Adult↗

PubMed2000

Treatment of depression related to recurrence: 10-year follow-up in general practice.

OBJECTIVES: To study outcomes related to long-term treatment of depression and differences in treatments for first episodes of depression in patients with and without recurrences. METHODS: A historic cohort design study with 222 general practice patients who had been followed up for 10 years after being diagnosed of depression. Prescriptions for antidepressants, psychotropics and referrals over the period of 10 years following the first diagnosis of depression were studied. RESULTS: Over the 10-year period, the length of treatment with antidepressants and the doses prescribed were low compared to what is known to be efficacious in depression. This was also true for treatment during the first episode. Patients with a recurrent type of illness were more often treated with antidepressants and other psychotropics during their first episode than patients with only one episode of depression, but they were not referred any more often. CONCLUSION: Even though treatment was not as recommended for depression, the majority of the patients did not have recurrences. Future prospective research is needed to study causal relationships between treatment of depression and long-term outcome.

Adult↗

PubMed2000

The validity of the diagnosis of depression in general practice: is using criteria for diagnosis as a routine the answer?

BACKGROUND: In general practice, making a diagnosis does not follow the same lines as in secondary care because every new diagnosis is made against 'foreknowledge' and could be coloured by it. This could explain low accordance and differences in diagnoses between primary and secondary care, in particular when mental illness such as depression is concerned. When criteria are used for diagnosis there should be no differences. AIM: To establish the accordance with the Diagnostic and Statistical Manual of mental disorders, 4th edition (DSM-IV) criteria of major depressive disorder when the diagnosis of depression has been made by general practitioners (GPs) for whom coding and using criteria for diagnosis is a daily routine (ICHPPC-2 criteria). METHOD: Ninety-nine general practice patients from four general practices belonging to the Continuous Morbidity Registry (CMR) of the University of Nijmegen in The Netherlands were interviewed using the Composite International Diagnostic Interview (auto) 12-month version (DSM-IV criteria). Thirty-three patients had a code for depression; 33 patients a code for chronic nervous functional complaints (CNFC); and 33 had no code for mental illness (the depression and CNFC codes were given in the 12 months prior to the interview). Specificity and accordance with the DSM-IV criteria of major depressive disorder (MDD) were calculated with the results from the interviews. RESULTS: Of the 33 general practice depression cases (all matching ICHPPC-2 criteria), 28 matched DSM-IV criteria: 26 for MDD and 2 for dysthymia. No cases of DSM-IV MDD were found in the control group without a code for a mental disorder, and seven out of 33 were found in the control group with the code for CNFC. CONCLUSION: The specificity of diagnosis of depression made by GPs in a continuous morbidity registry and the accordance with DSM-IV criteria are high. Using criteria for diagnosis, which is a trend, could be one of the solutions towards a better diagnosis. As far as the sensitivity is concerned, GPs should not be distracted from using criteria for the diagnosis of depression when a large variety of complaints is presented.

Adult↗

PubMed2000

Long-term follow-up of depression among patients in the community and in family practice settings. A systematic review.

BACKGROUND: Current knowledge about the long-term outcome of depression is largely based on the results of studies performed with the small selection of patients who are referred to psychiatric professionals. However, because of the high prevalence of depression in the community and in primary care, information about the longterm outcome in these populations is indispensable if physicians are to offer the best possible care in these settings. METHODS: We performed a literature search to identify relevant papers published between 1970 and 1999 on original long-term follow-up studies of depression in community and primary care populations. The included studies were of adult populations with depression based on diagnostic criteria and a follow-up of at least 5 years. Data about recurrences, relapses, psychopathology, disability, or quality of life at follow-up were examined. RESULTS: We found 8 studies that fulfilled our criteria. The reported rates of recurrence or depression at follow-up were between 30% and 40%. Higher rates were found in the younger and older age groups. Data about other predictors of outcome, health status, and the relation between treatment and outcome did not justify any hard conclusions. CONCLUSIONS: The long-term outcome of depression in the community and in primary care is rarely studied. The results of available studies are difficult to compare because of the large differences in populations and methods. Nevertheless, these studies suggest that the longterm prognosis of depression in the community and in primary care is not as poor as in psychiatry.

Adolescent↗

PubMed1999

[The 'Diabetes mellitus type 2' guideline (first revision) of the Dutch College of General Practitioners: response from family practice].

The first revision of the guidelines of the Dutch College of General Practitioners on diabetes mellitus type 2 has been prepared by experts from primary and secondary care. This might be a big improvement, since the guidelines will be welcomed by general practitioners as well as by specialists. One item that will cause debate is that the threshold to make the diagnosis of diabetes is decreased to 6.1 mmol/l. This will increase the number of diabetes patients and the GP's workload. Another controversy is made by the advice to screen for unknown diabetics in risk groups using case-finding. There are many questions about the feasibility of this advice while conclusive evidence that it will lead to better prognosis is not yet established.

Blood Glucose↗

PubMed1999

Development of blood pressure and the incidence of hypertension in men and women over an 18-year period: results of the Nijmegen Cohort Study.

The objective of this study was to determine the factors that influence diastolic blood pressure (DBP) and the incidence of hypertension. In 1977, DBP and cardiovascular risk factors were measured in 7092 men and women. In 1995, 2335 subjects participated at a second screening. Those patients already under hypertension treatment in 1977 were excluded. The DBP tracking was studied in subjects not under hypertension treatment during the study. Hypertension was defined on two ways in the analysis: under current hypertension treatment or a DBP > 95 mmHg measured at rescreening in 1995. Forty-seven percent of the subjects with a DBP < 75 mmHg in 1977 remained in the same category of DBP in 1995, and 7% had become hypertensive. Of the 75-84 mmHg group in 1977, 40% stayed in the same category in 1995 and 15% became hypertensive. Of the 85-94 mmHg category, 30% stayed in the same category and 30% became hypertensive in 1995. Of the highest category in 1977 (> 95 mmHg), 64% were still in that category in 1995. Baseline DBP in 1977 had the highest predictive value for future DBP. Weight gain over the years increased the risk for future hypertension: in contrast, there was no risk at a low DBP without weight gain. There is no need for regular check-ups for those patients with a low DBP who experience no weight gain. Borderline DBP (85-95 mmHg), together with weight gain, increases the risk of development of hypertension. The risk was especially high for men in the lower socioeconomic class.

Adult↗

PubMed1999

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↗

PubMed1999

Practice visits as a tool in quality improvement: mutual visits and feedback by peers compared with visits and feedback by non-physician observers.

OBJECTIVE: To evaluate and compare the effects of two programmes of assessment of practice management in a practice visit: mutual visits and feedback by peers compared with visits and feedback by non-physician observers. DESIGN: Prospective, randomised intervention study, with follow up after one year. SETTING: General practices in the Netherlands in 1993 and 1994. SUBJECTS: A total of 90 general practitioners (GPs) in 68 practices; follow up after one year comprised 81 GPs in 62 practices. MAIN MEASURES: Scores on indicators and dimensions of practice management in the visit instrument to assess practice management and organisation (a validated Dutch method to assess practice management in a practice visit). Change was defined as the difference in score between the first visit and the visit after one year on 208 indicators and on 33 dimensions of practice management. RESULTS: Data of 44 mutual visits by peers were compared with data of 46 visits by non-physician observers. After a year both programmes showed improvements on many aspects of practice management, but different aspects changed in each of the two programmes. After mutual practice visits, GPs scored significantly higher on content of the doctor's bag, on collaboration with colleagues, on collaboration with other care providers, and on accessibility of patient information than after a visit by a non-physician observer. The visits by non-physician observers resulted in a higher score on extent of use of records and on assessment on outcome and year report. CONCLUSION: Change after mutual practice visits and feedback by peers is more marked than after a visit and feedback by a non-physician observer.

Family Practice↗

PubMed1999

Practice visits as a tool in quality improvement: acceptance and feasibility.

OBJECTIVE: To evaluate the feasibility and acceptance of (a) two programmes of assessment of practice management in a practice visit: mutual practice visits and feedback by peers versus visits and feedback by non-physician observers and (2) the practice visit method used in these programmes (the visit instrument to assess practice management and organisation (VIP)--a validated Dutch tool). DESIGN: Prospective, randomised intervention study with the two programmes, follow up after one year. General practitioners (GPs) were visited after each programme and after the revisits by non-physician observers a year later. SETTING: General practices in the Netherlands in 1993 and 1994. SUBJECTS: A total of 90 GPs in 68 practices. At follow up after 1 year there were 81 GPs in 62 practices. MAIN MEASURES: Scores (mainly five point scales) for questions on appreciation and acceptance; after the follow up visit a year later, scores for questions on feasibility and practicality of the improved procedure and feedback report. RESULTS: Data of 44 mutual visits by peers were compared with data of 46 visits by non-physician observers. A visit by a non-physician observer was appreciated significantly more. After the practice visit at one year follow up, the participants reported to have appreciated the visit and the feedback report and to prefer feedback of a non-physician observer to that of a peer. Participants' reports on the procedure and the presentation of the feedback provided clues for the improvement of visit procedures. CONCLUSIONS: A practice visit and feedback by a non-physician observer is more appreciated than a visit and feedback by a colleague. A practice visit with the VIP by a non-physician observer is a simple, easy, and well accepted method for assessing practice management.

Family Practice↗

PubMed1998

[Clinical diagnosis and decision in practice. A young woman with back pain].

A woman aged 23 visited the GP because of nagging back pain at the level of L.2-L.3. In spite of the atypical symptom, the GP made the diagnosis of 'back pain of myogenic origin', possibly the result of camping in inclement weather. When the pain was still present after one week, the patient coughed, produced greyish-green mucus, was dyspnoeic, had 38.5 degrees C fever, while crepitations and reduced breathing sounds were heard in the right lower lung fields, the working diagnosis of 'pneumonia' was made. No laboratory studies were done; X-ray diagnostics and a good response to antibiotic treatment confirmed the diagnosis. After the symptoms recurred and patient's use of an oral contraceptive was established, she was examined for 'pulmonary embolism'. After this condition was shown to be likely, anticoagulant treatment was instituted, which led to rapid recovery.

Adult↗

PubMed1998

Assessment of management in general practice: validation of a practice visit method.

BACKGROUND: Practice management (PM) in general practice is as yet ill-defined; a systematic description of its domain, as well as a valid method to assess it, are necessary for research and assessment. AIM: To develop and validate a method to assess PM of general practitioners (GPs) and practices. METHOD: Relevant and potentially discriminating indicators were selected from a systematic framework of 2410 elements of PM to be used in an assessment method (VIP = visit instrument PM). The method was first tested in a pilot study and, after revision, was evaluated in order to select discriminating indicators and to determine validity of dimensions (factor and reliability analysis, linear regression). RESULTS: One hundred and ten GPs were assessed with the practice visit method using 249 indicators; 208 of these discriminated sufficiently at practice level or at GP level. Factor analysis resulted in 34 dimensions and in a taxonomy of PM. Dimensions and indicators showed marked variation between GPs and practices. Training practices scored higher on five dimensions; single-handed and dispensing practices scored lower on delegated tasks, but higher on accessibility and availability. CONCLUSION: A visit method to assess PM has been developed and its validity studied systematically. The taxonomy and dimensions of PM were in line with other classifications. Selection of a balanced number of useful and relevant indicators was nevertheless difficult. The dimensions could discriminate between groups of GPs and practices, establishing the value of the method for assessment. The VIP method could be an important contribution to the introduction of continuous quality improvement in the profession.

Family Practice↗

PubMed1997

The effect of the family physician on improving follow-up after an abnormal PAP smear.

OBJECTIVE: The aim of this study was to assess the effect of the family physician on improving compliance with follow-up of abnormal smears in cervical cancer screening. DESIGN: Observational study. SETTING: Two Regional Health Authority districts in the east of The Netherlands. STUDY PARTICIPANTS: Family practices with a national call system for cervical cancer screening and family practices with a family-practice-based call system. In a number of practices the family physicians had introduced a fail-safe system for follow-up. MAIN OUTCOME MEASURES: Follow-up of women who participated in the first screening round and in whom a cytological abnormality had been diagnosed in the first smear. Criteria for adequate follow-up were defined with regard to the severity of the cytological abnormality. RESULTS: The overall compliance with follow-up in the study-group was 88%. The study showed a strong relationship between involvement of the family physician and compliance with follow-up. The compliance in practices that had a fail-safe system for follow-up was 93% compared to 82% in the practices without a fail-safe system. The highest follow-up was found in practices involved in the family-practice-based system.

Adult↗