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.

Clinical items not helpful in differentiating viral from bacterial lower respiratory tract infections in general practice.

OBJECTIVE: Incorrect and unnecessary antibiotic prescribing enhancing bacterial resistance rates might be reduced if viral and bacterial lower respiratory tract infections (LRTI) could be differentiated clinically. Whether this is possible is often doubted but has rarely been studied in general practice. STUDY DESIGN AND SETTING: This was an observational cohort study in 15 general practice surgeries in the Netherlands. RESULTS: Etiologic diagnoses were obtained in 112 of 234 patients with complete data (48%). Viral pathogens were found as often as bacterial pathogens. Haemophilus (para-) influenzae was most frequently found. None of the symptoms and signs correlated statistically significantly with viral or bacterial LRTI. Erythrocyte sedimentation rate >50 (odds ratio [OR] 2.3-3.3) and C-reactive protein (CRP) >20 (OR 2.1-4.6) were independent predictors for viral LRTI and bacterial LRTI when compared with microbiologically unexplained LRTI. CONCLUSION: Extensive history-taking and physical examination did not provide items that predict viral or bacterial LRTI in adult patients in daily general practice. We could not confirm CRP to differentiate between viral and bacterial LRTI.

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.

Contributions of symptoms, signs, erythrocyte sedimentation rate, and C-reactive protein to a diagnosis of pneumonia in acute lower respiratory tract infection.

BACKGROUND: Diagnostic tests enabling general practitioners (GPs) to differentiate rapidly between pneumonia and other lower respiratory tract infections (LRTIs) are needed to prevent increase of bacterial resistance by unjustified antibiotic prescribing. AIMS: To assess the diagnostic value of symptoms, signs, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) for pneumonia; to derive a prediction rule for the presence of pneumonia; and to identify a low-risk group of patients who do not require antibiotic treatment. DESIGN OF STUDY: Cross-sectional. SETTING: Fifteen GP surgeries in the southern part of The Netherlands. METHOD: Twenty-five GPs recorded clinical information and diagnosis in 246 adult patients presenting with LRTI. Venous blood samples for CRP and ESR were taken and chest radiographs (reference standard) were made. Odds ratios, describing the relationships between discrete diagnostic variables and reference standard (pneumonia or no pneumonia) were calculated. Receiver operating characteristic analysis of ESR, CRP, and final models for pneumonia was performed. Prediction rules for pneumonia were derived from multiple logistic regression analysis. RESULTS: Dry cough, diarrhoea, and a recorded temperature of > or = 38 degrees C were independent and statistically significant predictors of pneumonia, whereas abnormal pulmonary auscultation and clinical diagnosis of pneumonia by the GPs were not. ESR and CRP had higher diagnostic odds ratios than any of the symptoms and signs. Adding CRP to the final 'symptoms and signs' model significantly increased the probability of correct diagnosis. Applying a prediction rule for low-risk patients, including a CRP of < 20, 80 of the 193 antibiotic prescriptions could have been prevented with a maximum risk of 2.5% of missing a pneumonia case. CONCLUSION: Most symptoms and signs traditionally associated with pneumonia are not predictive of pneumonia in general practice. The prediction rule for low-risk patients presented here, including a CRP of < 20, can considerably reduce unjustified antibiotic prescribing.

Is roxithromycin better than amoxicillin in the treatment of acute lower respiratory tract infections in primary care? A double-blind randomized controlled trial.

OBJECTIVE: To assess the efficacy of roxithromycin relative to amoxicillin. STUDY DESIGN: We conducted a double-blind randomized controlled trial of oral 500 mg amoxicillin 3 times per day vs oral 300 mg roxithromycin once a day for 10 days. POPULATION: We included 196 adults who had presented to a general practitioner with lower respiratory tract infection (LRTI) and, in the physician's opinion, needed antibiotic treatment. OUTCOMES MEASURED: We measured clinical response after 10 and 28 days, defined in 4 ways: (1) decrease in LRTI symptoms; (2) complete absence of symptoms; (3) decrease in signs; and (4) complete absence of signs. Self-reported response included the decrease in symptoms and the time until resumption of impaired or abandoned daily activities on days 1 through 10, 21, and 27. RESULTS: Clinical cure rates after the completion of antibiotic treatment (10 days) were not significantly different for the 2 groups. After 28 days, the roxithromycin group showed no increase in cure rate as evidenced by the decrease in symptoms, indicating a significantly lower cure rate. However, this difference did not alter physicians' overall conclusion after complete follow-up that 90% of patients, regardless of age, had been effectively treated with either amoxicillin or roxithromycin. CONCLUSIONS: The surplus value of roxithromycin was not confirmed. Amoxicillin remains a reliable first-choice antibiotic in the treatment of LRTI in general practice.

Construction of an algorithm for quick detection of patients with low bone mineral density and its applicability in daily general practice.

OBJECTIVE: To construct a quick algorithm to detect patients with low bone mineral density (BMD) and osteoporosis and determine its applicability in daily general practice. DESIGN: Cross-sectional study in all 9107 postmenopausal women, aged 50-80, registered at 12 general practice centers. SUBJECTS AND MEASUREMENTS: All healthy women (5303) and 25% of the remaining group (943/3804) were invited to participate. Of 6246 invited women, 4725 (76%) participated. The women were questioned (state of health, medical history, family history, and food questionnaire) and examined [weight, height, body mass index (BMI), and BMD of the lumbar spine]. STATISTICS: Multivariable, stepwise backward and forward logistic regression analyses were performed, with BMD of the lumbar spine (L2-L4, cut-off points at 0.800 g/cm(2) for osteoporosis and 0.970 g/cm(2) for low BMD) as the dependent variable. An algorithm was constructed with those variables that correlated statistically significantly and clinically relevant with the presence of both osteoporosis and low BMD. RESULTS: The prevalence of osteoporosis was 23%, that of low BMD was 65%. Only three variables (age, BMI, and fractures) were statistically significant and clinically relevant correlated with the presence of both osteoporosis and low BMD. Age (OR 2.70 for osteoporosis and OR 1.77 for low BMD) and fractures during the past five years (OR 3.60 for osteoporosis and OR 2.85 for low BMD) were found to be the key predictors. From the algorithm the absolute risks varied from 9% to 51% for osteoporosis and from 48% to 84% for low BMD. The corresponding relative risks varied from 1.0 to 5.7 and from 1.0 to 1.8. CONCLUSIONS: Using an algorithm with age, BMI, and fracture history subgroups at high risk could be identified. However, in whatever combination, many women with osteoporosis could not be identified. Despite the differences in methods, we found predictors for osteoporosis which were comparable with the results of other cross-sectional studies, meaning that the first selection of patients at high risk for low BMD can be done adequately by both specialists and general practitioners.

Risk factors and cardiovascular diseases associated with asymptomatic peripheral arterial occlusive disease. The Limburg PAOD Study. Peripheral Arterial Occlusive Disease.

OBJECTIVES: To describe the risk-factor profile and cardiovascular comorbidity of asymptomatic peripheral arterial occlusive disease (PAOD). DESIGN: A cross-sectional survey. Asymptomatic PAOD was defined as an ankle-brachial pressure index < 0.95, measured on two consecutive occasions, without intermittent claudication. Logistic regression analyses were performed to investigate independent associations between age, gender, smoking status, hypertension, obesity, diabetes, hypercholesterolaemia, physical activity, a family history of cardiovascular disease, the occurrence of ischaemic heart disease and cerebrovascular disease (CeVD) and asymptomatic PAOD. SETTING: 18 general practices in the province of Limburg, the Netherlands. SUBJECTS: A total of 3650 subjects, aged 40-78 years. MAIN RESULTS: Asymptomatic PAOD was present in 8.6% (n = 314) and symptomatic disease in 3.8% (n = 138) of the participants. Age, smoking status, hypertension, and diabetes were significantly associated with asymptomatic PAOD. The ratio of asymptomatic to symptomatic PAOD was higher among the younger age groups. Male gender, hypertension and smoking status were stronger associated with symptomatic PAOD compared with asymptomatic PAOD. Asymptomatic subjects had more IHD and CeVD comorbidity compared with the healthy population. CONCLUSION: Our findings suggest that the risk-factor profile and cardiovascular comorbidity of asymptomatic subjects is comparable to claudicants. Preventive efforts could be made to diminish the influence of especially smoking, diabetes and hypertension in asymptomatic subjects.

Arrhythmias in general practice: diagnostic value of patient characteristics, medical history and symptoms.

BACKGROUND: Complaints possibly caused by arrhythmias are frequently seen in general practice. It is unclear to what extent such complaints can differentiate between arrhythmias and other pathology in general practice. OBJECTIVES: We aimed to assess the value of symptoms (a) in diagnosing arrhythmias in general practice and (b) in identifying patients with clinically relevant arrhythmias. METHOD: During a 2-year period, a structured history from 762 patients with new complaints possibly related to an arrhythmia was taken by the GP, and a transtelephonic electrocardiogram (ECG) was made. RESULTS: In 28.3% of the patients, arrhythmias were detected and 8.8% were clinically relevant. Several patient characteristics, symptoms and medical history findings have high predictive values in diagnosing arrhythmias. In the logistic regression analysis, age and, to a lesser extent, male gender, palpitations and dyspnoea during consultation and the use of cardiovascular drugs are associated with the presence of arrhythmias. In detecting clinically relevant arrhythmias the same parameters apart from gender are important, as well as a history of arrhythmias. The use of central nervous system medication and frequent psychosomatic complaints are negatively associated with the presence of clinically relevant arrhythmias. CONCLUSIONS: In general practice, patient characteristics, symptoms and medical history findings can be used in the detection of arrhythmias and the assessment of their severity. They can help in the decision of whether to make an ECG recording.

Diagnostic value of signs and symptoms associated with peripheral arterial occlusive disease seen in general practice: a multivariable approach.

OBJECTIVES: To assess the diagnostic values of single and combined data from the history, physical examination, and medical record with regard to peripheral arterial occlusive disease (PAOD) in patients with leg complaints; to construct a multivariable model for the clinical diagnosis of PAOD by primary care physicians. SETTING: 18 general practice centers in The Netherlands. DESIGN: Cross-sectional comparison of signs, symptoms, and data from the medical record with the independently assessed ankle-brachial systolic pressure index (ABPI; cutoff point < 0.90); analysis: bivariate, multiple logistic regression (MLR). POPULATION: 2,455 individuals with leg complaints, aged 40.7-78.4 years; ABPI < 0.90 present in 9.2% of legs (11.7% of individuals). OUTCOME MEASURES: Clinical variables: sensitivity, specificity, positive and negative predictive values (PV+, PV-), diagnostic odds ratio (OR); models: likelihood ratio test, area under the receiver operating characteristic curve (AUC). RESULTS: Bivariate analysis: highest sensitivity: age more than 60 years (77.3%); highest specificity: wounds or sores on toes and foot (99.7%); highest PV+: typical intermittent claudication (IC) (45.0%) (abnormal foot pulses 41.3%); highest PV-: strong pulses of both foot arteries (97.7%). MRL: the best-performing model (AUC 0.89) consisted of ten clinical variables: gender (OR 1.5), age more than 60 (OR 2.2); IC (OR 3.5); palpation of the skin temperature of the feet (OR 2.5), palpation of both foot pulses [OR 16.4 (abnormal) and 7.0 (doubtful)], auscultation of the femoral artery (OR 3.5); previous diagnosis of IHD (OR 1.7) or diabetes (OR 1.6), history of smoking (OR 2.1), and elevated blood pressure (OR 1.5). The range of predicted probabilities was 0.4-98%. The Hosmer-Lemeshow goodness-of-fit test indicated good overall fit (p = 52). CONCLUSIONS: Palpation of both foot pulses is the key procedure for the clinical diagnosis of PAOD. Traditional clinical evaluation enables the general practitioner to exclude the diagnosis of PAOD in many individuals with a high degree of certainly, to establish the diagnosis in a small group of patients, and to define a limited group of patients where supplementary noninvasive testing is appropriate. The MLR model can be used as a diagnostic checklist and as a reference for the physician's clinical hypothesis.

The diagnostic value of the measurement of the ankle-brachial systolic pressure index in primary health care.

We investigated the value of the ankle-brachial systolic pressure index (ABPI) as a test for the diagnosis of peripheral arterial occlusive disease (PAOD) in general practice. ABPI measurements on 231 legs of 117 subjects performed in three general practice centers (GPC) were compared with the diagnostic conclusions of a Vascular Laboratory. The optimum cutoff value for the ABPI, its accuracy and diagnostic value were estimated. In a subpopulation of 51 subjects for whom repeated measurements were available, we checked whether taking the mean of three consecutive ABPIs for test outcome would enhance diagnostic performance. Receiver Operating Characteristic analysis showed that overall performance of the GPC ABPI was good (area under the curve approximately 0.9). Performing repeated ABPI measurements was superior to performing a single measurement. The optimum cutoff value for the ABPI was 0.97, associated with a diagnostic odds ratio (OR) of 17 and an accuracy of 81%. In a somewhat more selected subpopulation, the optimum cutoff value was 0.92 (OR 70, accuracy 90%). On the basis of our results, we suggest the following rule of thumb: if the ABPI < 0.8 or if the mean of three ABPIs < 0.9, it is highly probable that PAOD is present (PV+ > or = 95%); if the ABPI > 1.1 or if the mean of three ABPIs > 1.0, PAOD can be ruled out (PV- > or = 99%). In conclusion, in primary health care, the ABPI measurement can be a useful supplementary test in ambiguous diagnostic situations with regard to PAOD.

The prevalence of asymptomatic and unrecognized peripheral arterial occlusive disease.

BACKGROUND: The prevalence of peripheral arterial occlusive disease (PAOD), including asymptomatic cases and cases unknown to the general practitioner (GP) was estimated in 18,884 men and women, aged 45-74 years, on the list of 18 general practice centres (GPC). METHODS: The study population (n = 3171) consisted of a stratified sample of the total population. In the GPC data were collected on intermittent claudication (IC), peripheral pulses, vascular risk factors, cardio- and cerebrovascular disease (CCVD) and the ankle brachial systolic pressure ratio (AB ratio) and PAOD was defined as an AB ratio < 0.95 on two consecutive occasions. Results were recalculated for the total population. RESULTS: The prevalence of PAOD was 6.9 percent (95 percent Cl:5.2-7.9 percent), a quarter of which (1.6 percent) met the classic WHO criteria. Peripheral arterial occlusive disease did not occur significantly more often among men than among women but men suffered more often from an advanced stage of PAOD. Of all PAOD cases, 22 percent were symptomatic. The proportion of symptomatic cases correlated positively with higher age, male gender and lower AB ratio. Among asymptomatic PAOD cases the prevelance of concomitant CCVD was three to four times as high as in the group of subjects without PAOD. Of all PAOD cases 68 percent were unknown to the GP and this group mainly represented less advanced cases of atherosclerosis. However, among PAOD cases with an AB ratio <0.75, 42 percent were unknown to the GP. CONCLUSIONS: Our data on asymptomatic and unknown PAOD cases show that GPs can still enhance their efforts towards (secondary) prevention of atherosclerosis.