Fatigue and health-related quality of life in inflammatory bowel disease: results from a population-based study in the Netherlands: the IBD-South Limburg cohort.

BACKGROUND: The importance of fatigue in chronic disease has been increasingly recognized; however, little is known about fatigue in inflammatory bowel disease (IBD). The aim of the present study was to investigate the prevalence and severity of fatigue and the impact on health-related quality of life (HRQoL) in patients included in a population-based IBD cohort in the Netherlands. METHODS: IBD patients, diagnosed between January 1st, 1991, and January 1st, 2003, were followed up for a median of 7.1 years. They completed a questionnaire, which included a disease activity score, the Multidimensional Fatigue Inventory (MFI-20), the Inflammatory Bowel Disease Questionnaire (IBDQ), and the Short Form health survey (SF-36). Hemoglobin levels were recorded. RESULTS: Data were available in 304 Crohn's disease (CD), 368 ulcerative colitis (UC), and 35 indeterminate colitis (IC) patients. During quiescent disease, the prevalence of fatigue was nearly 40%. MFI-20 and HRQoL scores were significantly worse in IBD patients having active disease. In a multivariate analysis, disease activity was positively related with the level of fatigue in both CD and UC. In UC, anemia influenced the general fatigue score independently of disease activity. Disease activity as well as fatigue were independently associated with an impaired IBDQ. CONCLUSIONS: In IBD, even in remission, fatigue is an important feature. Both in CD and in UC, fatigue determined HRQoL independently of disease activity or anemia. This implies that in IBD patients physicians need to be aware of fatigue in order to better understand its impact and to improve the HRQoL.

The contribution of six polymorphisms to cardiovascular risk in a Dutch high-risk primary care population: the HIPPOCRATES project.

This study was designed to examine the contribution of six polymorphisms to the occurrence of cardiovascular disease (CVD) in a Dutch primary care population with a high prevalence of cardiovascular risk factors. In this cross-sectional case-control study, 232 patients with CVD and 571 event-free controls were studied. Patients were genotyped for the AGTR1 (A1166C), AGT (M235T), ACE (4656rpt), NOS3 (E298D), GNB3 (C825T) and ADD1 (G460W) polymorphisms. Univariate and multivariate odds ratios (ORs) were calculated to assess the relationship between genotypes and CVD. Receiver operating characteristic (ROC) analysis was used to quantify the contribution of the polymorphisms to the prediction of CVD. No differences in either genotype or allele frequencies were found between CVD cases and controls. Multivariate analyses, corrected for multiple testing according to Bonferroni, showed significant protective associations for the T-allele of AGT (OR=0.55 (0.34-0.84)) and for the T-allele of ADD1 (OR=0.52 (0.31-0.82)). ROC analysis showed only a very small improvement of CVD risk prediction by adding the six polymorphisms to a model with traditional risk factors. Our data suggest that a major attribution of the six polymorphisms to the cardiovascular risk prediction in a primary care population such as HIPPOCRATES is unlikely.

Influence of phenotype at diagnosis and of other potential prognostic factors on the course of inflammatory bowel disease.

OBJECTIVES: Disease course in inflammatory bowel disease (IBD) is variable and difficult to predict. To optimize prognosis, it is of interest to identify phenotypic characteristics at disease onset and other prognostic factors that predict disease course. The aim of this study was to evaluate such factors in a population-based IBD group. METHODS: IBD patients diagnosed between 1 January 1991 and 1 January 2003 were included. A follow-up questionnaire was developed and medical records were reviewed. Patients were classified according to phenotype at diagnosis and risk factors were registered. Disease severity, cumulative medication use, and "surgical" and "nonsurgical" recurrence rates were calculated as outcome parameters. RESULTS: In total, 476 Crohn's disease (CD), 630 ulcerative colitis (UC), and 81 indeterminate colitis (IC) patients were diagnosed. In CD (mean follow-up 7.6 years), 50% had undergone resective surgery. In UC (mean follow-up 7 years), colectomy rate was 8.3%. First year cumulative recurrence rates per 100 patient-years for CD, UC, and IC were 53, 44, and 42%, respectively. In CD, small bowel localization and stricturing disease were negative prognostic factors for surgery, as was young age. Overall recurrence rate was increased by young age and current smoking. In UC, extensive colitis increased surgical risk. In UC, older age at diagnosis initially increased recurrence risk but was subsequently protective. CONCLUSIONS: This population-based IBD study showed high recurrence rates in the first year. In CD, small bowel localization, stricturing disease, and young age were predictive for disease recurrence. In UC, extensive colitis and older age at diagnosis were negative prognostic predictors.

Feasibility and acceptability of a computerised system with automated reminders for prescribing behaviour in primary care.

OBJECTIVE: To evaluate the feasibility and acceptability of a computer reminder system (CRS) to improve prescribing behaviour in general practice and to explore the strengths and weaknesses of a reminder system. One group of GPs received reminders on cholesterol lowering drugs, the other group on antibiotics, asthma and COPD drugs. METHODS: Process evaluation of the computer reminder system being used by 53 GPs in 20 practices, by means of an analysis of the research database of the CRS. In addition, a questionnaire and semi-structured face-to-face interview were conducted with all GP practices, two project leaders, and one technical consultant. RESULTS: The strategy was largely carried out as planned, although the development period for the CRS had to be extended. Nine percent of the GPs dropped out. We found a significant learning curve without extinguishing effect (p=0.03) for the antibiotics reminders. The questionnaire showed that, in general, GPs were satisfied with the user-friendliness and the content of the different types of reminders, but less satisfied with certain specific technical performance issues of the system. The GPs reported mixed feelings towards the CRS in the interviews. They were generally positive about the guidelines themselves, but negative regarding to the organisational context and the method of implementing the CRS. GPs stated that they sometimes manipulated the system to bypass reminders. Interviews with the project leaders and technical consultant revealed barriers to cooperation and miscommunication between the different parties, and technical problems with multiple updates of the GP information system and the operating system. CONCLUSIONS: This process evaluation demonstrated that the implementation of the CRS was mainly carried out as planned, but the subjective experience of working with the CRS was not only positive. Participating GPs had mixed feelings, and quite a number of barriers need to be addressed to facilitate large-scale implementation of the CRS. Costs cannot be neglected, so it is important to analyse the balance between costs and effects.

The effect of computer reminders on GPs' prescribing behaviour: a cluster-randomised trial.

OBJECTIVE: It is difficult to control drug-prescribing behaviour in general practice, despite the development and distribution of guidelines. The purpose of this study was to assess the effect on drug-prescribing behaviour of implementing prescribing guidelines by means of a reactive computer reminder system (CRS). DESIGN: Cluster-randomised controlled trial with an incomplete block design in the south of the Netherlands: 25 GPs (7 GP practices) received reminders about antibiotics and asthma/COPD prescriptions, 28 GPs (7 GP practices) received reminders about cholesterol prescriptions. Prescription guidelines were integrated into the computerised GP information system. MEASUREMENTS: Both performance indicators and prescription volumes were calculated as the main outcome measures. Next to individual volume measure, sum scores were constructed on the volume measures per drug group (antibiotics, asthma/COPD and cholesterol). RESULTS: Variation between GPs turned out to be larger and more skewed than expected. No differences between groups were found for indicators and volumes related to recommendations advocating certain drugs. Although there was a tendency towards clinically relevant results for prescription volumes that were supposed to drop, the difference in sum score between the groups was not significant. For antibiotic prescriptions that were supposed to drop, the sum score for the intervention group was 28.2 (95% CI: 20.8-44.5) prescriptions per 1000 patients per GP, while this was 39.7 (95% CI: 29.7-64.1) for the control group (p 0.2). For prescriptions asthma/COPD that were supposed to drop, the sum score for the intervention group was 1.1 (95% CI: 0.6-2.6) prescriptions per 1000 patients per GP, while this was 2.2 (95% CI: 1.4-4.3) for the control group (p 0.1). On three specific recommendations (on quinolones for cystitis, corticosteroids for CPOD, and antibiotics for acute sore throat) significant differences were found. CONCLUSIONS: This study turned out to be underpowered due to high inter doctor variation in prescribing behaviour. Nevertheless, computerised reminders sometimes have a favourable effect on restricting certain drugs that are not or no longer indicated in general practice.

Prognostic factors and clinical outcome in acute lower respiratory tract infections: a prospective study in general practice.

BACKGROUND: Unrealistic expectations about illness duration are likely to result in reconsultations and associated unnecessary antibiotic prescriptions. An evidence-based account of clinical outcomes in patients with lower respiratory tract infection (LRTI) may help avoid unnecessary antibiotic prescriptions and reconsultations. OBJECTIVES: We aimed to identify clinical factors that may predict a prolonged clinical course or poor outcome for patients with LRTI and to provide an evidence-based account of duration of an LRTI and the impact of the illness on daily activities in patients consulting in general practice. METHODS: A prospective cohort study of 247 adult patients with a clinical diagnosis of LRTI presenting to 25 GPs in The Netherlands was carried out. Multivariable Cox regression analysis was used to identify baseline clinical and infection parameters that predicted the time taken for symptoms to resolve. A Kaplan-Meier curve was used to analyse time-to-symptom resolution. Clinical cure was recorded by the GPs at 28 days after the initial consultation and by the patients at 27 days. RESULTS: Co-morbidity of asthma was a statistically significant predictor of delayed symptom resolution, whereas the presence of fever, perspiring and the prescription of an antibiotic weakly predicted enhanced symptom resolution. The GPs considered 89% of the patients clinically cured at 28 days, but 43% of these nevertheless reported ongoing symptoms. Patient-reported cure was much lower (51%), and usual daily activities were limited in 73% of the patients at baseline, and 19% at final follow-up. CONCLUSIONS: The course of LRTI was generally uncomplicated, but the morbidity of this illness was considerable with a longer duration than generally reported, especially for patients with co-existent asthma. These results underline once again the importance of providing GPs with an evidence-based account of outcomes to share with patients in order to set realistic expectations and of enhancing their communication skills within the consultation.

Asymptomatic peripheral arterial occlusive disease predicted cardiovascular morbidity and mortality in a 7-year follow-up study.

OBJECTIVE: Asymptomatic peripheral arterial occlusive disease (PAOD) is a common atherosclerotic disorder among the elderly population. Scarce data are available on the risk of nonfatal and fatal cardiovascular diseases in these subjects. We investigated cardiovascular morbidity and mortality of asymptomatic PAOD subjects. STUDY DESIGN AND SETTING: A sample of 3649 subjects (40-78 years of age) was selected in collaboration with 18 general practice centers and followed up after the initial screening (mean follow-up time 7.2 years). Asymptomatic PAOD was determined by means of the ankle-brachial pressure index (ABPI). Main outcome measures were nonfatal cardiovascular events and mortality. RESULTS: Cox proportional hazard models showed that asymptomatic PAOD was significantly associated with cardiovascular morbidity (hazard ratio [HR] 1.6, 95% confidence interval [CI] 1.3-2.1), total mortality (HR 1.4, 95% CI 1.1-1.8), and cardiovascular mortality (HR 1.5, 95% CI 1.1-2.1). CONCLUSION: Asymptomatic PAOD is a significant predictor of cardiovascular morbidity and mortality. In high-risk subjects, measurement of the ABPI provides valuable information on future cardiovascular events.

Long-chain polyunsaturated fatty acids at birth and cognitive function at 7 y of age.

OBJECTIVE: During the central nervous system (CNS) growth spurt, rapid accretion of long chain polyunsaturated fatty acids (LCPUFA) takes place. This particularly concerns docosahexaenoic acid (DHA, 22:6n-3) and arachidonic acid (AA, 20:4n-6), which are thought to play important roles in CNS development and function. The aim of this study was to investigate the relationship between cognitive performance at 7 y of age and LCPUFA levels in umbilical venous plasma phospholipids, representing the prenatal fatty acid availability, and in plasma phospholipids sampled at 7 y. DESIGN: As part of a follow-up study, the cognitive performance of 306 children, born at term, was assessed at 7 y of age with the Kaufman Assessment Battery for Children. Backward stepwise regression analysis was used to study the relationship between the outcomes and LCPUFA status. Social class, maternal intelligence and parenting skills were included as covariables, among others. RESULTS: Results show no significant association with either DHA or AA at birth and the cognitive performance at 7 y of age. The LCPUFA levels at 7 y were not associated with these outcomes either. Consistent with the literature, significant relationships were found between cognitive outcome measures and maternal education, maternal intelligence and the child's birthweight. CONCLUSIONS: In conclusion, our results do not provide evidence for a positive association between cognitive performance at 7 y and LCPUFA status at birth or at 7 y of age.

Diagnostic value of history and physical examination in patients suspected of lumbosacral nerve root compression.

OBJECTIVE: To evaluate patient characteristics, symptoms, and examination findings in the clinical diagnosis of lumbosacral nerve root compression causing sciatica. METHODS: The study involved 274 patients with pain radiating into the leg. All had a standardised clinical assessment and magnetic resonance (MR) imaging. The associations between patient characteristics, clinical findings, and lumbosacral nerve root compression on MR imaging were analysed. RESULTS: Nerve root compression was associated with three patient characteristics, three symptoms, and four physical examination findings (paresis, absence of tendon reflexes, a positive straight leg raising test, and increased finger-floor distance). Multivariate analysis, analysing the independent diagnostic value of the tests, showed that nerve root compression was predicted by two patient characteristics, four symptoms, and two signs (increased finger-floor distance and paresis). The straight leg raise test was not predictive. The area under the curve of the receiver-operating characteristic was 0.80 for the history items. It increased to 0.83 when the physical examination items were added. CONCLUSIONS: Various clinical findings were found to be associated with nerve root compression on MR imaging. While this set of findings agrees well with those commonly used in daily practice, the tests tended to have lower sensitivity and specificity than previously reported. Stepwise multivariate analysis showed that most of the diagnostic information revealed by physical examination findings had already been revealed by the history items.

A risk model for the prediction of recurrent falls in community-dwelling elderly: a prospective cohort study.

The object of this article was to determine the predictive value of risk factors for recurrent falls and the construction of a fall risk model as a contribution to a mobility assessment for the identification of community-dwelling elderly at risk for recurrent falling in general practice. The design was a prospective cohort study (n = 311). There were four primary health care centers. A sample stratified on previous falls, age, and gender of community-dwelling elderly persons aged 70 years or over (n = 311) was taken from the respondents to a mail questionnaire (n = 1660). They were visited at home to assess physical and mental health, balance and gait, mobility and strength. A 36-week follow-up with telephone calls every 6 weeks was conducted. Falls and fall injuries were measured. During follow-up 197 falls were reported by 33% of the participants: one fall by 17% and two or more falls by 16%. Injury due to a fall was reported by 45% of the fallers: 2% hip fractures, 4% other fractures, and 39% minor injuries. A fall risk model for the prediction of recurrent falls with an area under the curve (AUC) of 0.79, based on logistic regression analysis, showed that the main determinants for recurrent falls were: an abnormal postural sway (OR 3.9; 95% Cl 1.3-12.1), two or more falls in the previous year (OR 3.1; 95% Cl 1.5-6.7), low scores for hand grip strength (OR 3.1; 95% Cl 1.5-6.6), and a depressive state of mind (OR 2.2; 95% CI 1.1-4.5). To facilitate the use of the model for clinical practice, the model was converted to a "desk model" with three risk categories: low risk (0-1 predictor), moderate risk (two predictors), and high risk (> or =3 predictors). A fall risk model converted to a "desk model," consisting of the predictors postural sway, fall history, hand dynamometry, and depression, provides added value in the identification of community-dwelling elderly at risk for recurrent falling and facilitates the prediction of recurrent falls.