The medical profile of unidentified problem drinkers in general practice: test of an hypothesis.

In order to facilitate general practitioner (GP) detection of problem drinkers the Dutch College of General Practitioners developed a standard specifying the differences in medical profile between problem drinker and non-problem drinkers. The standard mentions 35 Reasons for Encounter (RFEs) and GP Evaluations (Es) that are thought to be specific for problem drinkers. The studies referred to in the standard base their conclusions about differences in medical profile upon a comparison of problem drinkers already identified by the GP with other patients. This study tests the hypothesis that the medical profile specified by the standard also applies to unidentified problem drinkers. All known problem drinkers in the practices of 16 GPs, as well as a one in 10 random sample of patients considered to be non-drinkers were admitted to the study at their first surgery visit during a 1-year period. Hidden problem drinkers were detected by means of a screening questionnaire, although the results were not conveyed to the GP until the study was completed. Over the 1-year study period the GPs then registered all RFEs and Es of the study population. RFE and E sum scores were then constructed based on the Alcohol Standard. The estimated population prevalence of problem drinking, corrected for the one in 10 sample fraction was 7%. We found 6% problem drinkers (n = 78) in the category regarded by the GPs as non-problem drinkers (n = 1254). Differences in RFEs and Es between hidden problem drinkers and those regarded as non-problem drinkers were significant for irregular heartbeat and psychological problems. Sexual problems were significant at the RFE level, social problems at the E level. When identified problem drinkers are compared with non-problem drinkers more differences in the medical profile are found (four times both RFE and E; twice RFE and once E). We conclude that most of the published differences in the medical profile between problem drinkers and other GP patients are not found for unidentified problem drinkers. The observed differences between unidentified problem drinkers and non-problem drinkers are too small to be helpful to the GP to detect problem drinkers.

Late outcome of mild head injury: results from a controlled postal survey.

There is insufficient information about the long-term sequelae of mild head injury (postconcussional symptoms, PCS). Therefore, a questionnaire-based investigation was carried out in patients 1-5 years after mild head injury (MHI) and in non-concussed subjects in order to study the nature of long-term complaints after MHI. A three-factor model of residual subjective and psychological complaints that contained a dysthymic factor, a vegetative/bodily complaints factor, and a cognitive performance factor were identified in the patient population. Three rating scales were constructed from the relevant items or factors, and were used to compare the MHI patients with non-concussed controls. It was found that the profile of distresses and discomforts mentioned by a population of MHI patients 1-5 years after the trauma was similar to that of a non-concussed control population. These symptoms were indistinguishable from those encountered in ordinary everyday life. These symptoms were significantly more severe in the MHI patients. Stepwise regression analysis in the patient population indicated that a number of parameters were statistically of predictive importance: comorbidity, sex, and neurological complication at the time of the trauma. The results support the hypothesis that MHI may not ever be completely reversible.

Problem drinking in a general practice population: the construction of an interval scale for severity of problem drinking.

The main aim of this article is to describe the construction of an interval scale measuring the severity of problem drinking among patients of general practitioners. A questionnaire, including the existing screening instruments CAGE, SMAST, a shortened version of the SAAST and some additional items on alcohol-related problems, was given to three categories of patients: those who, according to the general practitioner, were not problem drinkers (Group 1), those who perhaps were (Group 2) and those who were known by the general practitioner to be problem drinkers (Group 3). According to the Classical Test Theory, the three existing screening instruments and the combination of all questions form a reliable scale. Advanced scaling techniques were applied to select the best items for the construction of an interval scale. These analyses showed that 18 of the 28 questions in the complete screening list fitted in a unidimensional Rasch scale. These questions can be used to estimate the severity of problem drinking. For research purposes an interval scale is attractive, since no information is lost by dichotomization. Such a scale enables the level of problem drinking to be specified at which correlations with other factors, whether as a cause or as an effect, can be found. The scale could also be a help to general practitioners for referral decisions. In more specialized settings it can be used to assign patients to various treatments.

Short term effect of withdrawal of diuretic drugs prescribed for ankle oedema.

OBJECTIVE: To determine the effect of withdrawing diuretic drugs on oedema in patients prescribed them for only ankle oedema, excluding patients with cardiac, hepatic, or renal failure. DESIGN: Randomised controlled trial. SETTING: 15 general practices in the Netherlands. PATIENTS: 1202 patients aged 65 years or older and taking diuretic drugs, 63 of whom were eligible for the trial. MAIN OUTCOME MEASURE: Change in volumetrically determined ankle oedema (oedema index) over six weeks. RESULTS: 34 patients were randomised to stop diuretics and 29 to the control group. In eight patients diuretics had to be restarted. Among patients who had diuretics withdrawn successfully, rebound oedema caused a temporary increase in mean oedema index. The peak level (3.5% (95% confidence interval 1.5% to 5.2%) was reached in the third week, after which the oedema seemed to be returning to the baseline level. CONCLUSION: Few patients who have been prescribed diuretics for only ankle oedema clearly have no contraindications to withdrawing diuretics. If patients are unlikely to have cardiac insufficiency and careful monitoring is provided, withdrawal of diuretics seems to be feasible, though moderate rebound oedema may occur for a short time.

[The treatment of ankle edema in the elderly in family practice; when and how often are diuretics used?]. / De behandeling van enkeloedeem bij ouderen in de huisartspraktijk; wanneer en hoe vaak worden diuretica gebruikt?

It has long been recommended that one should be careful in prescribing drugs for the elderly. However, it has been shown that more than 20% of those over 65 use diuretics. With advancing age this percentage increases. The sign of ankle oedema appears to be an important factor in the decision to prescribe diuretics. If the oedema is not caused by heart failure, chronic renal failure or hypoproteinaemia, the use of diuretics in ankle oedema is controversial. We used a questionnaire survey to obtain information on the opinions of Dutch general practitioners about the differential diagnosis and treatment of ankle oedema in the elderly. In the questionnaire we presented the case of a 68-year-old woman who complained of ankle oedema without any symptom or sign of heart failure. The questionnaire was sent to 200 Dutch general practitioners (response rate 64%). Chronic venous insufficiency was mentioned by 86% and heart failure by 12% of the responders as the most probable cause of the oedema. The treatment proposed by 59% was advice and (or) compression therapy without drugs, while 40% would have prescribed diuretics.

Recognition of problem drinkers.

General practitioners often see patients with problems related to drinking behaviour, but recognize only a small proportion of these problem drinkers. The authors discuss some mechanisms of this non-recognition phenomenon and suggest ways to enhance early recognition.

Psychological and social complaints reported by Dutch patients to their family doctors.

Ninety-three percent of all problems and complaints reported by patients aged 21 and older to their family physician dealt with somatic disorders, and only 7% with psychosocial problems. Psychological complaints were evenly distributed among major age groups, and between male and female patients. "Social problems" peaked in the middle-age range. The most frequently reported psychological problems were feeling anxious, nervous or tense; feeling irritable, angry, restless or agitated; experiencing feelings of depression; and disturbances of sleep. Marital problems, problems at work, and problems caring for an ill or disabled relative were the most frequently reported "social" reasons for encounter. More women than men reported feelings of depression and marital problems. Men more often felt irritable, angry, restless or agitated, and had more problems at work.

Subjective complaints and blood pressure.

The relationship between blood pressure and subjective complaints concerning physical well-being has been investigated. The complaints have been measured by means of the Inventory of Subjective Health. The total number of complaints are the summation of 39 items. Hypertension is assumed to have no clear-cut symptoms. This statement gives rise to the hypothesis that there is no relationship between blood pressure and subjective complaints. The hypothesis was refuted after several tests. We found a curvilinear relationship between diastolic blood pressure and subjective complaints in representative groups of men of 21-65 and 31-50 years old, valid for the total number of complaints and dizziness. This curvilinear relationship is found again after a matching procedure in order to exclude possible confounding effects of age, cigarette smoking and knowledge about elevated blood pressure status. The total number of complaints of males with a diastolic pressure higher than 95 mmHg are not significantly higher than the total number of complaints of males with a lower diastolic pressure, but the difference is significant for dizziness.