The SNAQ(RC), an easy traffic light system as a first step in the recognition of undernutrition in residential care.

OBJECTIVE: Development and validation of a quick and easy screening tool for the early detection of undernourished residents in nursing homes and residential homes. DESIGN: Multi-center, cross sectional observational study. SETTING: Nursing homes and residential homes. PARTICIPANTS: The screening tool was developed in a total of 308 residents (development sample; sample A) and cross validated in a new sample of 720 residents (validation sample) consisting of 476 nursing home residents (Sample B1) and 244 residential home residents (sample B2). MEASUREMENTS: Patients were defined severely undernourished when they met at least one of the following criteria: BMI or= 5% unintentional weight loss in the past month and/or >or= 10% unintentional weight loss in the past 6 months. Patients were defined as moderately undernourished if they met the following criteria: BMI 20.1-22 kg/m2 and/or 5-10% unintentional weight loss in the past six months. The most predictive questions (originally derived from previously developed screening instruments) of undernourishment were selected in sample A and cross validated in sample B. In a second stage BMI was added to the SNAQRC in sample B. The diagnostic accuracy of the screening tool in the development and validation samples was expressed in sensitivity, specificity, and the negative and positive predictive value. RESULTS: The four most predictive questions for undernutrition related to: unintentional weight loss more than 6 kg during the past 6 months and more than 3 kg in the past month, capability of eating and drinking with help, and decreased appetite during the past month. The diagnostic accuracy of these questions alone was insufficient (Se=45%, Sp=87%, PPV=50% and NPV=84%). However, combining the questions with measured BMI sufficiently improved the diagnostic accuracy (Se=87%, Sp=82%, PPV=59% and NPV=95%). CONCLUSION: Early detection of undernourished nursing- and residential home residents is possible using four screening questions and measured BMI.

The development of a minimal intervention strategy to address overweight and obesity in adult primary care patients in The Netherlands.

BACKGROUND: Currently, overweight and obesity do not receive the attention they deserve from the Dutch GPs, mostly because of a lack of an effective intervention strategy to tackle this difficult health problem. OBJECTIVE: To develop a minimal intervention strategy (MIS) addressing overweight and obesity among adult primary care patients, resulting in a prototype. METHODS: Following the intervention mapping protocol, the MIS is based on literature study, existing interventions, psychosocial theories, stakeholder interviews and a questionnaire study among stakeholders. This led to the development of a prototype of the MIS materials: a screening flow chart and a treatment flow chart, a manual and patient education materials. A pre-test among 42 general practitioners and practice nurses was conducted to investigate the usefulness of the MIS materials at first sight. RESULTS: The stakeholder interviews and the questionnaire study resulted in insight on what the MIS should look like. For instance, the stakeholders indicated that the treatment needs to focus on helping patients to eat more healthy and exercise more, using techniques like motivational interviewing. The pre-test showed that most participants were enthusiastic about the materials, although they made some suggestions on improvements. CONCLUSION: The MIS materials seem to be useful and promising. A future pilot test is needed to investigate its usefulness in daily practice and to further improve the materials in preparation for a process and effect evaluation.

Nutrition guidance in The Netherlands: the role of the GP in the translation from population strategy to individual approach.

An important pitfall of nutritional guidance in medical practice is how to deal with the prevention paradox: a nutritional advice that is good for the population as a whole is not necessarily proven effective for the individual patient. Evidence-based guidelines are needed to support GPs to translate these advices to the individual patient. We illustrate this with two examples: obesity and undernutrition. The Dutch Ministry of Health started a national partnership on overweight. The role of the Dutch College of GPs (NHG) in this process is to insert the GP's perspective and to 'translate' the multidisciplinary guideline into a practice guideline for GPs. A systematic review on nutritional deficiency in general practice in The Netherlands showed a prevalence ranging from 0% to 13%. The 'National Steering Committee Undernutrition' stimulates GPs to pay more attention to undernutrition, in collaboration with the Dutch College of GPs. The Cochrane Primary Health Care Field (Nijmegen) accommodates the Cochrane Diet and Nutrition Sub Field involving the inclusion of evidence from non-randomized studies, which are generally not included in Cochrane Reviews, but which form an important part of the evidence for the role of nutrition. From this international initiative, a national collaboration in The Netherlands between universities, researchers and the Dutch College was founded, which aims to support the foundation of practice-based nutrition counselling in the consulting room.

Whole grain foods for the prevention of type 2 diabetes mellitus.

BACKGROUND: Diet as one aspect of lifestyle is thought to be one of the modifiable risk factors for the development of type 2 diabetes mellitus (T2DM). Information is needed as to which components of the diet could be protective for this disease. OBJECTIVES: To asses the effects of whole-grain foods for the prevention of T2DM. SEARCH STRATEGY: We searched CENTRAL, MEDLINE, EMBASE, CINAHL and AMED. SELECTION CRITERIA: We selected cohort studies with a minimum duration of five years that assessed the association between intake of whole-grain foods or cereal fibre and incidence of T2DM. Randomised controlled trials lasting at least six weeks were selected that assessed the effect of a diet rich in whole-grain foods compared to a diet rich in refined grain foods on T2DM and its major risk factors. DATA COLLECTION AND ANALYSIS: Two authors independently selected the studies, assessed study quality and extracted data. Data of studies were not pooled because of methodological diversity. MAIN RESULTS: One randomised controlled trial and eleven prospective cohort studies were identified. The randomised controlled trial, which was of low methodological quality, reported the change in insulin sensitivity in 12 obese hyperinsulinemic participants after six-week long interventions. Intake of whole grain foods resulted in a slight improvement of insulin sensitivity and no adverse effects. Patient satisfaction, health related quality of life, total mortality and morbidity was not reported. Four of the eleven cohort studies measured cereal fibre intake, three studies whole grain intake and two studies both. Two studies measured the change in whole grain food intake and one of them also change in cereal fibre intake. The incidence of T2DM was assessed in nine studies and changes in weight gain in two studies. The prospective studies consistently showed a reduced risk for high intake of whole grain foods (27% to 30%) or cereal fibre (28% to 37%) on the development of T2DM. AUTHORS' CONCLUSIONS: The evidence from only prospective cohort trials is considered to be too weak to be able to draw a definite conclusion about the preventive effect of whole grain foods on the development of T2DM. Properly designed long-term randomised controlled trials are needed. To facilitate this, further mechanistic research should focus on finding a set of relevant intermediate endpoints for T2DM and on identifying genetic subgroups of the population at risk that are most susceptible to dietary intervention.

Limited evidence for effects of diet for type 2 diabetes from systematic reviews.

OBJECTIVE: Systematic reviews are an appraised method to summarize research in a concise and transparent way, and may enable to draw conclusions beyond the sum of results of individual studies. We assessed the results, quality and external validity of systematic reviews on diet in patients with type 2 diabetes. DESIGN, SETTING, SUBJECTS: We systematically searched for systematic reviews on nutritional interventions in patients with type 2 diabetes that used a reproducible search strategy in at least one major database that applied some form of quality assessment. We assessed quality and the external validity of the retrieved systematic reviews. Outcomes were defined as statistical meta-analyses or narrative results using a predefined and reproducible method. RESULTS: Six systematic reviews met the inclusion criteria, investigating dietary interventions in general (n=3), chromium supplementation (n=1), fish-oil (n=1) or herbs and nutrition supplements (n=1). Quality assessment showed minimal/minor flaws in four cases and major/extensive flaws in two cases. All reviews had insufficient data needed to judge external validity. In reviews with minimal/minor flaws, we found beneficial effects of very-low-calorie diets and fish-oil supplements. However, the external validity of these results could not be assessed sufficiently. CONCLUSIONS: Systematic reviews largely failed to produce knowledge beyond the sum of the original studies. Furthermore, judgment of external validity was hampered in most cases owing to missing data. To improve the quality and usefulness of systematic reviews of dietary interventions, we recommend the application of more focused research questions, but with broader inclusion criteria, for example, the use of observational studies. SPONSORSHIP: Internal funding Radboud University Nijmegen Medical Centre.

Systematic reviews incorporating evidence from nonrandomized study designs: reasons for caution when estimating health effects.

Systematic reviews that include nonrandomized studies (NRS) face a number of logistical challenges. However, the greatest threat to the validity of such reviews arises from the differing susceptibility of randomized controlled trials (RCTs) and NRS to selection bias. Groups compared in NRS are unlikely to be balanced because of the reasons leading study participants to adopt different health behaviours or to be treated differentially. Researchers can try to minimize the susceptibility of NRS to selection bias both at the design stage, for example, by matching participants on key prognostic factors, and during data analysis, for example, by regression modelling. However, because of logistical difficulties in matching, imperfect knowledge about the relationships between prognostic factors and between prognostic factors and outcome, and measurement limitations, it is inevitable that estimates of effect size derived from NRS will be confounded to some extent. Researchers, reviewers and users of evidence alike need to be aware of the consequences of residual confounding. In poor quality RCTs, selection bias tends to favour the new treatment being evaluated. Selection bias need not necessarily lead to systematic bias in favour of one treatment but, even if it acts in an unpredictable way, it will still give rise to additional, nonstatistical uncertainty bias around the estimate of effect size. Systematic reviews of NRS studies run the risk of compounding these biases. Nutritional choices and uptake of health education about nutrition are very likely to be associated with potential confounding factors. Therefore, pooled estimates of the effects of nutritional exposures and their confidence intervals are likely to be misleading; reviewers need to take into account both systematic and uncertainty bias.

Organisation of a proposed Cochrane Diet and Nutrition Field.

The Cochrane Collaboration helps people make well-informed decisions about health care by preparing, maintaining and promoting the accessibility of systematic reviews of the effects of healthcare interventions. In all, 51 Cochrane Review Groups are responsible for preparing and maintaining the reviews. Most of these Review Groups are problem-based. However, there are a number of areas or dimensions of health care, such as the setting of care (eg primary care) or the type of patient/consumer (eg older persons), that cannot be usefully conceptualised as 'health problems'. In order to reflect the interests of these dimensions, or 'fields', of health care more effectively, the Cochrane Collaboration created another type of entity: Cochrane Fields or Networks. The core functions of these Fields are described. It is proposed that a new Cochrane Subfield for Diet and Nutrition should be set up to attract a cadre of new reviewers in order to ensure the proper representation of diet and nutrition expertise in the relevant Collaborative Review Groups. The methodological pitfalls of the use of nonrandomised studies will be a key issue for the new Subfield, since the focus of the Cochrane Collaboration's programme of searching databases, journals and conference proceedings has been on the identification of reports of randomised controlled trials (RCTs). Some of these sources will be need to be searched again for non-RCT studies. The financial considerations of establishing of a Cochrane Subfield for Diet and Nutrition are discussed.

How can a proposed Cochrane diet and nutrition field work effectively?

The Cochrane Database currently provides relatively little evidence-based guidance about nutrition relevant to general practitioners. This situation could be improved by the establishment of a new Cochrane Field to identify relevant studies, prioritize topics to include nutrition, work with Cochrane methodologists on the inclusion of observational studies, and disseminate results of Cochrane reviews to general practitioners and their patients. A Diet and Nutrition Field could be established as a separate entity or as a Subgroup of the existing Primary Health Care (PHC) Field. The Field would be appropriate if the intent is to immediately cover nutritional interventions of all sorts, in all settings. However, if the focus is nutritional evidence for use by primary care clinicians, organization as a subField would provide a simpler registration process, allow Cochrane activities to begin sooner, and would allow members to focus on primary-care-relevant nutritional issues, conserving their resources and energy. A mechanism exists for conversion to a freestanding Field if the scope later expands. Of the core Field functions, identification and assembly of relevant trials into a specialized register would be among the most important. Special registers are generated by focused literature searches augmented by hand-searching of key journals. Given the importance of studies with observational designs, a nutrition field register will require some additional work on search strategies and inclusion criteria. Other key functions would include ensuring effective communication both with members of other Cochrane entities and with the scientific and clinical community with interests in diet and nutrition.

The Cochrane Library: more systematic reviews on nutrition needed.

The knowledge and relevance of nutrition as well as the demand for well-funded advices increase. The Cochrane Collaboration plays a leading role within the evidence-based medicine and practice. We advocate therefore more specialized nutritional interest within the Cochrane Collaboration. In case 'Nutrition' needs more attention within the Cochrane Library, one of the first priorities is deciding about whether to include non-randomized studies into the Specialized Register and generating lists of journals to handsearch for such a Specialized Register. Preparatory to these activities an inventory of Nutritional content within the Cochrane Library is needed. We estimate that reviews directly related to nutrition and those of borderline interest to nutrition represent less than 4% of all published reviews in The Cochrane Library.

Nutritional deficiency in Dutch primary care: data from general practice research and registration networks.

OBJECTIVE: To explore incidence and prevalence rates of nutritional deficiency in adults in general practice. METHODS: Six Dutch general practice research and registration networks supplied incidence and prevalence rates of nutritional deficiency by the International Classification of Primary Care (ICPC) or 'E-list' labels ('loss of appetite, feeding problem adult, iron, pernicious/folate deficiency anaemia, vitamin deficiencies and other nutritional disorders, weight loss'). In case of disease-related nutritional deficiency, we asked whether this was labelled separately ('co-registered') or included in the registration of the underlying disease. RESULTS: 'Iron deficiency anaemia' had highest incidence (0.3-8.5/1000 person years), and prevalence rates (2.8-8.9/1000 person years). Nutritional deficiency was mostly documented in the elderly. In two networks 'co-registration' was additional, two only documented the underlying disease and two did not specify 'co-registration'. No clear difference was found between networks considering the difference in 'co-registration'. CONCLUSION: Nutritional deficiency is little documented in general practice, and generally is not registered separately from the underlying disease.

Nutritional deficiency in general practice: a systematic review.

OBJECTIVE: Nutritional deficiency is an independent risk factor for mortality. Despite its clinical relevance, the prevalence in a primary care setting is poorly documented. We performed a systematic review of reported prevalence and clinical assessment of nutritional deficiency in general practice. METHODS: From MEDLINE, Current Contents and EMBASE, we derived articles and checked the initially included ones for references on prevalence data. Of the eligible articles, we assessed the quality of research and results. RESULTS: We finally included eight studies. The prevalence ranged from 0 to 13%. However, the study populations were heterogeneous and all studies contained methodological flaws, especially selection bias. In addition, the clinical assessment differed between studies. CONCLUSION: Literature on the prevalence of nutritional deficiency within general practice is rare and provides disputable prevalence assessments.

[Summary of the practice guideline 'TIA' (first revision) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'TIA' (eerste herziening) van het Nederlands Huisartsen Genootschap.

The new practice guideline of the Dutch College of General Practitioners on the management of patients with a TIA resembles the first version, but there are some important changes: The concept TIA has been narrowed to a neurological deficit that has resolved spontaneously by the time the patient consults the doctor. The indications for referral of patients with a TIA in the area supplied by the carotid artery for investigation of a possible carotid stenosis and carotid surgery have been broadened. Auscultation of the internal carotid artery is no longer necessary. The daily amount of acetylsalicylic acid to be taken by a patient with a TIA has been increased from 30 mg to 80 mg. The prescription of dipyridamol following a TIA remains controversial.

[Nutrition science and disease in the medical history of the 20th century]. / Voedingsleer en ziekte in de medische geschiedenis van de afgelopen eeuw.

In the twentieth century Dutch physicians provided major contributions to the development of the science of nutrition. Before the Second World War research was centred around vitamins and infant food, while at the same time the people's nutrition became a topic. Shortage of foodstuffs and nutrients had characterized the Dutch diet in the beginning of the century, but in the fifties the balance shifted towards an abundance of choice, nutrients and energy intake. Improvement of the optimum nutrient concentration pro energy unit became the main scientific challenge in order to prevent chronic degenerative diseases. Today, an unbalanced nutrition pattern is once more an issue as a relative nutrient shortage occurs in case of low energy intake and a limited variation of foodstuffs leading to chronic degenerative diseases. In addition, the difference between food components and medical drugs is decreasing by the advent of 'nutriceuticals'. Considering the variety of nutrition-related diseases the science of nutrition needs a more prominent place in medical academic education.

Improved performance of seroconversion with a 4th generation HIV antigen/antibody assay.

Recently a new fourth generation microELISA for large scale blood screening has been described in which HIV p24 Ag detection was integrated in an anti-HIV-1/-2 and anti-HIV-1 group O assay based on a direct assay format: (Vironostika HIV Uni-Form II Ag/Ab (Van Binsbergen et al., (1998)). When compared to the third generation a-HIV assay (Vironostika HIV Uni-Form II plus O), the seroconversion window was narrowed with more than one week. A more precise window estimation based on seroconversion series with short sampling time intervals of up to 7 days, is described in parallel with that for the single HIV p24 Ag assay. It was found with 10 relevant seroconversion series that the HIV p24 Ag assay closes the seroconversion window with 6.2 days as compared to the 3rd generation a-HIV assay, while a window reduction of 4 days was found with Vironostika HIV Uni-Form II Ag/Ab. These seroconversion data show that with the new assay two-thirds of the current p24 Ag window is closed. There was no statistical difference in seroconversion sensitivity between the HIV p24 Ag and the new assay format. An extended evaluation of the new assay with subtype HIV-1 M and group O p24 Ag strains and with anti-HIV antibodies obtained from individuals infected with different HIV-1 subtypes showed that all subtypes of HIV-1 M and HIV-1 group O p24 antigen were detected as well as of HIV antibody.

ICPC-code approach of nutritional questions in general practice: a look at the future.

The Dutch College of General Practitioners is developing a computerised consult supporting system on nutrition that is integrated in the widely used GP Information System. Connected to every ICPC-code (International Code of Primary Care) for diagnosis relevant nutritional information is available. Short items simple sentences with respect to the content-provide the main nutritional information, needed to inform the patient within the limited consultation time. Background information is the second level and is reachable by clicking on the coloured items in the first part. After all the patients' practical advice is the last part of this so-called: 'P-module of nutrition'.

Strongly enhanced sensitivity of a direct anti-HIV-1/-2 assay in seroconversion by incorporation of HIV p24 ag detection: a new generation vironostika HIV Uni-Form II.

The clinical sensitivity of the current anti-HIV assays is based for an important part on their reactivity with seroconversion panels. The most sensitive assay closes the seroconversion window as much as possible, thereby reducing the risk of transmitting false negative donations obtained from individuals infected recently. Because of the absence of anti-HIV antibodies during the early phase of infection, the seroconversion window can be narrowed partially by detection of HIV p24 Ag. To achieve this, the highest affinity anti-p24 binding antibodies were selected with BlAcore and applied in a direct assay format. To achieve optimal conditions for the anti-HIV part of the assay the HIV specific antigens viral HIV-1 gp160, HIV-2 gp36 and HIV-1 group O gp41 peptides were used. These antigens and antibodies were applied for microELISA coating as well as in the conjugate pearl, which is present in the well of the microELISA plate. The (analytical) anti-HIV-1/-2 and anti-HIV-1 group O sensitivity of this new assay, Vironostika HIV Uni-Form II Ag/Ab, is at least at the level of the current Vironostika HIV Uni-Form II plus O. When compared to the Vironostika HIV Uni-Form II plus O, the seroconversion window is narrowed by 1-2 weeks due to the incorporation of HIV p24 Ag detection. The level of reactivity of the anti-HIV and HIV Ag detection part can be improved by about a factor 2 by applying continuous shaking during sample incubation. Initial studies suggested that the specificity of the assay is identical to that of the Vironostika HIV Uni-Form II plus O, namely > 99.9%. Monitoring of proper execution of the assay handling steps was facilitated by implementing a purple dye in the conjugate pearl. Colourless specimen diluent changes into a green fluid upon dissolving of the conjugate pearl and turns subsequently into blue/purple upon sample addition. These visual changes can also be determined by spectrophotometric measurement at 620 nm.

Nutritional factors in Dutch family medicine: an inventory.

By 1995 the Dutch College of General Practitioners (Nederlands Huisartsen Genootschap, or NHG) had developed 53 standards that spell out the preferred policy of detection, treatment, and control of different clinical conditions in general practice. In 35 of these NHG standards nutrition is of some significance. Each of them is briefly discussed. Eighteen conditions, not yet in the set of standards, have specific pathologies with nutritional factors. Each is briefly explained. Last, 17 groups of diseases or background conditions are discussed in which nutritional advice is especially important. The science of nutrition ought to have an established place in the vocational training of general practitioners. To help general practitioners give adequate nutritional advice, they should have regular consultations with dietitians.

[The role of the consulting physician in situations of active euthanasia]. / De rol van de consulent bij actieve levensbeëindiging in de thuissituatie.

The cases are reported of two patients, a man aged 69 with a metastasized bronchial carcinoma and a woman aged 65 with a frontotemporal glioblastoma no longer responding to irradiation. Both requested active euthanasia. In both cases, euthanasia was performed by injection, after a general practitioner from the same locum group had acted as consultant. The requirements of meticulousness in handling a request for active euthanasia are concerned with the request (which has to be voluntary, thoroughly considered and constant), the suffering (which has to be protracted, unbearable and incurable), consultation and the written report. The consulting or second physician in cases of active euthanasia confirms that the requirements of meticulousness have been met. In addition, the second physician may assist the general practitioner in the detection of factors that may impair correct decision-making by the doctor or the patient. The second physician will be aided in performing these tasks if he is a member of the same locum group as the treating physician. However, if he considers himself too involved, a physician outside the locum group should be available at all times.

Reactivity of a new HIV-1 group O third generation A-HIV-1/-2 assay with an unusual HIV-1 seroconversion panel and HIV-1 group O/group M subtyped samples.

It was shown previously that about 97% of the anti-HIV-1 group O strain-positive samples were detected by crossreaction with native HIV-1 gp160 (Van Binsbergen et al., Evaluation of a new third generation anti-HIV-1/anti-HIV-2 assay with increased sensitivity for HIV-1 group O, J. Virol. Methods 60 (1996) 131-137). Fourteen out of 17 new anti-HIV-1 group O positive samples, selected with the Enzygnost HIV-1/2 plus assay, were already reactive when tested with HIV-1 gp160. When tested by the Vironostika HIV Uni-Form II plus O microELISA all 17 samples were reactive, demonstrating the necessity to implement an HIV-1 group O-specific antigen in the assay. On the other hand, it was surprisingly found that 40 out of 43 (93%) of anti-HIV-1 group M-positive samples, belonging to strain A, B, C, D, E or F, were detected by crossreaction with the HIV-1 group O (strain ANT70) synthetic peptide incorporated in the Vironostika HIV Uni-Form II plus O. Only HIV-1 subtype D-positive samples did not react with this peptide, presumably because of the presence of a histidine residue in the immunodominant region of HIV-1 subtype D gp41. Both crossreactions make the Vironostika HIV Uni-Form II plus O microELISA also sensitive for anti-HIV-1-positive samples originating from different geographical regions and resulting from different HIV-1 subtype infections. With an unusual seroconversion panel in which p24 Ag was present persistently, many anti-HIV-1/-2 assays produce alternating positive/negative results in anti-HIV antibody-positive bleeds. It was shown that the use of viral p24 and gp160 in a direct sandwich, allowing detection of anti-HIV IgG and IgM, explains the identification of all anti-HIV-positive bleeds by the Vironostika HIV Uni-Form II plus O. The high sensitivity of the plus O assay was confirmed with clinical samples of a so-called anti-HIV-1 low titer panel. The specificity of the Vironostika HIV Uni-Form II plus O determined in five blood transfusion centers, based on 135070 tests, was 99.97%.