Treatment by a nurse practitioner in primary care improves the severity and impact of urinary incontinence in women. An observational study.

BACKGROUND: Urinary Incontinence (UI) is a common problem in women. The management of UI in primary care is time consuming and suboptimal. Shift of incontinence-care from General Practitioners (GP's) to a nurse practitioner maybe improves the quality of care. The purpose of this observational (pre/post) study is to determine the effectiveness of introducing a nurse practitioner in UI care and to explore women's reasons for not completing treatment. METHODS: Sixteen trained nurse practitioners treated female patients with UI. All patients were examined and referred by the GP to the nurse practitioner working in the same practice. At baseline the severity of the UI (Sandvik-score), the impact on the quality of life (IIQ) and the impressed severity (PGIS) was measured and repeated after three months Differences were tested by the paired t and the NcNemar test. Reasons for not completing treatment were documented by the nurse practitioner and differences between the group that completed treatment and the drop-out group were tested. RESULTS: We included 103 women, mean age 55 years (SD 12.6). The Sandvik severity categories improved significantly (P < 0.001), as did the impact on daily life (2.54 points, P = 0.012). Among the IIQ score the impact on daily activities increased 0.73 points (P = 0.032), on social functioning 0.60 points (P = 0.030) and on emotional well-being 0.63 points (P = 0.031). The PGIS-score improved in 41.3% of the patients. The most important reasons for not completing the treatment were lack of improvement of the UI and difficulties in performing the exercises. Women who withdraw from guidance by the nurse practitioner perceived more impact on daily life (P = 0.036), in particular on the scores for social functioning (P = 0.015) and emotional well-being (P = 0.015). CONCLUSION: Treatment by a trained nurse practitioner seems positively affects the severity of the UI and the impact on the quality of life. Women who did not complete treatment suffer from more impact on quality of life, experience not enough improvement and mention difficulties in performing exercises.

The Effectiveness of a New Model in Managing Pregnant Women with Iron Deficiency Anemia in Indonesia: A Nonrandomized Controlled Intervention Study.

BACKGROUND: Indonesia has a major problem with iron deficiency anemia among pregnant women. A new model named the Four Pillars Approach was designed to improve antenatal care for these women. This study aimed to measure the effectiveness of the model in managing pregnant women with iron deficiency anemia. METHOD: We used a nonrandomized controlled intervention study. The study, with the Four Pillars Approach as intervention versus usual care as its control, was conducted in two provinces in Java (Indonesia) during the period from March 2012 until May 2013. Main outcome measures were a difference of Hb level ≥ 0.5 g/dL, the number of women who attended five or more antenatal care visits, and birthing with a skilled birth attendant. RESULTS: Three hundred fifty-four participants were enrolled in the study. Participants in the intervention group had an adjusted odds ratio of 25.0 (95% CI 12.03-52.03, p = 0.001) for increased hemoglobin of ≥ 0.5 g/dL at 35-37 weeks of gestation, compared with the control group. In the intervention group, 95.0 percent of women had five or more antenatal care visits, compared with 57.2 percent (p = 0.001) in the control group. All births in both groups were assisted by skilled birth attendants. CONCLUSION: The Four Pillars Approach is effective in increasing the hemoglobin level and the frequency of antenatal care visits of participants when compared with the usual care for pregnant women with anemia.

Prodromal symptoms and early detection of Parkinson's disease in general practice: a nested case-control study.

BACKGROUND: Timely diagnosis of Parkinson's disease (PD), facilitating early intervention, depends largely on the GP's awareness of early symptomatology. For general practice, it is unknown which prodromal symptoms (symptoms preceding the typical motor symptoms of PD) demand the GP's alertness. OBJECTIVE: To assess prodromal symptoms that should alert the GP to the possibility of PD in primary care patients. METHODS: A nested case-control study was carried out in a population of approximately 12000 patients registered in the Continuous Morbidity Registration database affiliated with the University of Nijmegen in the Netherlands. The database pools subject data from four primary care practices. The subjects comprised all 86 patients diagnosed with PD between 1972 and 2007, and 78 controls, matched by sex, age, socioeconomic status and primary care practice. The primary measures of outcome were the prodromal symptoms presenting in the two years prior to the diagnosis of PD. The number (and type) of referrals and diagnostic tests were also assessed. RESULTS: In the two-year period prior to diagnosis, PD patients more often presented with functional somatic symptoms, constipation, hyperhidrosis and sleep disorders than controls. Patients also more frequently experienced more than one prodromal symptom and were more often referred within the primary care team or to a medical specialist. CONCLUSIONS: Prodromal symptoms of PD are encountered in general practice. GPs should be alert when patients present with multiple prodromal symptoms in a two-year period, especially considering the benefits of early intervention, and the future possibilities for disease-modifying therapy.

Multimorbidity in older women: the negative impact of specific combinations of chronic conditions on self-rated health.

BACKGROUND: Chronic diseases are considered major threats to self-rated health (SRH). In many elderly people multimorbidity is present, in elderly women more than in elderly men. This study aims at establishing the impact of multimorbidity and specific disease combinations on SRH in elderly women. OBJECTIVES: To study the relationship between the number of chronic diseases and SRH and explore possible effects of combinations of chronic conditions on SRH in elderly women. METHODS: Health interview data used for this study originated from the second Dutch National Survey of General Practice, a study with a response rate of 64.5%. From the 12 699 respondents, 315 were females between 70 and 74 years old. RESULTS: Of the women, 87% reported one or more chronic condition. Women without any chronic condition rated their health significantly better than those with one or more chronic conditions. Either severe back pain or severe headache was included in return the most prevalent combinations of two chronic conditions with a significantly higher negative impact on SRH than expected. CONCLUSION: All combinations including severe headache and some combinations including severe back pain and another chronic condition had a significantly more negative impact on SRH than expected in women aged 70-74 years. General practitioners should be alert on severe headache and severe back pain in elderly women to improve proactive the quality of care and thus add to the quality of later years of life.

Does prevention of risk behaviour in primary care require a gender-specific approach? A cross-sectional study.

BACKGROUND: In planning a prevention programme, it is important to know to what extent gender, risk behaviour and GP consultation need to be taken into account. OBJECTIVE: To determine whether gender plays a role in the relation between risk behaviour and use of GP services. METHODS: The data used in this study originate from the Second Dutch National Survey of General Practice of 2000-02. We used respondent interviews in three age groups: 555 respondents aged 18-22; 1005 respondents aged 45-49; and 536 respondents aged 70-74. We studied smoking, alcohol abuse, excessive alcohol intake, use of soft drugs, overweight and insufficient physical exercise in relation to use of primary care and gender. RESULTS: Almost all risk behaviours were more prevalent in men. Of all studied risk behaviours, only smoking was related to yearly GP contact and consultation frequency in relation to gender. Smoking men consulted their GP significantly less frequently than non-smoking men, whereas in women, the opposite was the case. CONCLUSIONS: Both rates of consultation and yearly contact were significantly lower in smoking men than in smoking women. Preventive actions by means of case-finding, therefore, are less attainable in men than in women. This outcome may create a double setback for Dutch men, as smoking is a major cause of lower life expectancy in men. Recent data show that under-representation of men among consulters in general practice and excess of smoking men still exist in the Netherlands. This confirms the actual relevance of our findings although these were obtained 10years ago.

Self-reported sick leave and long-term health symptoms of Q-fever patients.

BACKGROUND: In The Netherlands, 1168 Q-fever patients were notified in 2007 and 2008. Patients and general practitioners (GPs) regularly reported persisting symptoms after acute Q-fever, especially fatigue and long periods of sick leave, to the public health authorities. International studies on smaller Q-fever outbreaks demonstrate that symptoms may persist years after acute illness. Data for the Dutch outbreaks were unavailable. The aim of this study is to quantify sick leave after acute Q-fever and long-term symptoms. METHODS: Our study targeted 898 acute Q-fever patients, notified in 2007 and 2008 residing in the Province Noord-Brabant. Patients from the 2008 cohort were mailed a questionnaire at 12 months and those of the 2007 cohort at 12-26 months after onset of illness. Patients reported underlying illness, Q-fever-related symptoms and sick leave. RESULTS: The response rate was 64%. Forty percent of the working patients reported long-term (>1 month) sick leave. Pre-existent heart disease odds ratio (OR) 4.50; confidence interval (CI) 1.27-16.09), hospitalization in the acute phase (OR 3.99; 95% CI 2.15-7.43) and smoking (OR 1.69; 95% CI 1.01-2.84) were significant predictors for long-term absence. Of the patients who resumed work, 9% were-at the time of completing the questionnaire-still unable to function at pre-infection levels due to fatigue or concentration problems. Of the respondents, 40% reported persisting physical symptoms at the time of follow-up. Fatigue (20%) was most frequently reported. Daily activities were affected in 30% of cases. CONCLUSIONS: Q-fever poses a serious persisting long-term burden on patients and society.

Detecting autism spectrum disorders in the general practitioner's practice.

It takes considerable time before Autism Spectrum Disorders are diagnosed. Validated diagnostic instruments are available, but not applicable to primary healthcare. By means of a case-control study we investigated whether there were differences in presented complaints and referral patterns between children with ASD (n = 49) and a control group of children without ASD (n = 81). Children with ASD were often presented as crybabies and often showed feeding problems. They visited the GP's surgery more often with anxiety disorders, enuresis, and sleeping disorders. They were referred more often to physiotherapists and speech-therapists and had tympanostomy tubes and tonsillectomies more often. Depression in the parents of children with ASD was remarkably prevalent.

Effectiveness of problem-solving treatment by general practice registrars for patients with emotional symptoms.

INTRODUCTION: In general practice many patients present with emotional symptoms. Both patients and physicians desire effective non-pharmacological treatments. AIM: To study the effectiveness of problem-solving treatment (PST) delivered by trained general practice registrars (GP registrars) for patients with emotional symptoms. METHODS: In a controlled clinical trial we compared the effectiveness of PST versus usual care for patients with emotional symptoms. Dutch GP registrars provided either PST or usual care, according to their own preference. Patients were included if they (a) had presented for three or more consultations with emotional symptoms in the past six months; and (b) scored four or more on the 12-item General Health Questionnaire. Outcomes at three- and nine-month follow-up were standard measures of depression, anxiety and quality of life. RESULTS: Thirty-eight GP registrars provided PST and included 98 patients; 43 provided usual care and included 104 patients. PST patients improved significantly more than usual care patients: at nine-month follow-up, recovery rates for somatoform disorder and anxiety were higher in the PST group (OR 6.50, p=0.01 respectively OR 11.25, p=0.03). PST patients had improved significantly more on the domains social functioning, role limitation due to emotional problems and general health perception. DISCUSSION: Patients with emotional symptoms improved significantly more after PST delivered by motivated GP registrars than after usual care by GP registrars. Further research, with randomisation of interested registrars or interested GPs, is needed.

The health status of Q-fever patients after long-term follow-up.

BACKGROUND: In the Netherlands, from 2007 to 2009, 3,522 Q-fever cases were notified from three outbreaks. These are the largest documented outbreaks in the world. Previous studies suggest that symptoms can persist for a long period of time, resulting in a reduced quality of life (QoL). The aim of this study was to qualify and quantify the health status of Q-fever patients after long-term follow-up. METHODS: 870 Q-fever patients of the 2007 and 2008 outbreaks were mailed a questionnaire 12 to 26 months after the onset of illness. We assessed demographic data and measured health status with the Nijmegen Clinical Screening Instrument (NCSI). The NCSI consists of three main domains of functional impairment, symptoms and QoL that are divided into eight sub-domains. The NCSI scores of Q-fever patients older than 50 years (N=277) were compared with patients younger than 50 years (N=238) and with norm data from healthy individuals (N=65) and patients with chronic obstructive pulmonary disease (N=128). RESULTS: The response rate was 65.7%. After applying exclusion criteria 515 Q-fever patients were included in this study. The long-term health status of two thirds of Q-fever patients (both younger and older than 50 years) was severely affected for at least one sub-domain. Patients scores were most severely affected on the sub-domains general QoL (44.9%) and fatigue (43.5%). Hospitalisation in the acute phase was significantly related to long-term behavioural impairment (OR 2.8, CI 1.5-5.1), poor health related QoL (OR 2.3,CI 1.5-4.0) and subjective symptoms (OR 1.9, CI 1.1-3.6). Lung or heart disease, depression and arthritis significantly affected the long-term health status of Q-fever patients. CONCLUSIONS: Q-fever patients presented 12 to 26 months after the onset of illness severe -clinically relevant- subjective symptoms, functional impairment and impaired QoL. All measured sub-domains of the health status were impaired. Hospitalisation and co-morbidity were predictors for worse scores. Our data emphasise that more attention is needed not only to prevent exposure to Q-fever but also for the prevention and treatment of the long-term consequences of this zoönosis.

Non-cardiovascular co-morbidity in elderly patients with heart failure outnumbers cardiovascular co-morbidity.

BACKGROUND: Patients with heart failure often suffer from multiple co-morbid conditions. However, until now only cardiovascular co-morbidity has been well described. AIMS: To understand heart failure in the context of multi-morbidity, by describing the age and sex specific patterns of non-cardiovascular co-morbidity in elderly patients with heart failure in general practice. METHODS: All patients aged 65 years and over, diagnosed with heart failure in four practices of the Nijmegen Academic Practice-based Research Network (NPBRN) between January 1999 and December 2003 were selected, and the prevalence of 27 cardio- and non-cardiovascular co-morbidities determined. RESULTS: Of the 269 patients identified (mean age 79 years; 57% women), 80.2% had four or more co-morbidities. With increasing age, a significant increase in the prevalence of non-cardiovascular conditions like visual and hearing impairments, osteoarthritis, dementia and urine incontinence; and a decrease in cardiovascular conditions like myocardial infarction and in women, hypertension, was observed. In patients aged 85 years and over, non-cardiovascular disorders predominated over cardiovascular disorders. CONCLUSIONS: In elderly patients with heart failure, the prevalence of non-cardiovascular co-morbidity is very high and exceeds the prevalence of cardiovascular conditions. Diseases such as dementia and osteoarthritis must be taken into account in the management of elderly patients with heart failure.

Chronic functional somatic symptoms: a single syndrome?

BACKGROUND: Reliable longitudinal data of patients with functional somatic symptoms in general practice are lacking. AIMS: To identify distinctive features in patients with chronic functional somatic symptoms, and to determine whether these symptoms support the hypothesis of the existence of specific somatic syndromes. DESIGN OF STUDY: Observational study, with a comparison control group. SETTING: Four primary care practices affiliated with the University of Nijmegen in the Netherlands. METHOD: One hundred and eighty-two patients diagnosed between 1998 and 2002 as having chronic functional somatic symptoms and 182 controls matched by age, sex, socioeconomic status, and practice were included. Data on comorbidity, referrals, diagnostic tests, and hospital admissions over a period of 10 years prior to the diagnosis were collected. Medication use and number of visits to the general practitioner (GP) were extracted from the moment computerised registration was started. RESULTS: In the 10 years before the diagnosis of chronic functional somatic symptoms, significantly more patients than controls presented functional somatic symptoms in at least two body systems, and used more somatic and psychotropic drugs. They visited the GP twice as much, statistically had significantly more psychiatric morbidity, and were referred more often to mental health workers and somatic specialists. The number of patients undergoing diagnostic tests was higher for patients with chronic functional somatic symptoms than for controls, but hospital admissions rates were equal. CONCLUSION: Patients with chronic functional somatic symptoms have a great diversity of functional somatic symptoms. They use more somatic and psychotropic drugs than controls in the years before diagnosis. Moreover, they show high rates of referrals and psychiatric morbidity. The diversity of symptoms of patients with chronic functional somatic symptoms supports the concept that symptoms do not cluster in well defined distinct syndromes. Therefore, patients with chronic functional somatic symptoms should preferably not be classified into medical subspecialty syndromes.