http://repub.eur.nl/res/aut/2589/ List of Publications en http://repub.eur.nl/static-eur/img/logo.png http://repub.eur.nl http://repub.eur.nl/res/pub/39786/ 2013-04-16T00:00:00Z The aim of the current study was to determine the course of back pain in older patients and identify prognostic factors for non-recovery at 3 months' follow-up. We conducted a prospective cohort study (the BACE study) of patients aged >55 years visiting a general practitioner (GP) with a new episode of back pain in the Netherlands. The course of back pain was described in terms of self-perceived recovery, pain severity, disability, pain medication, and GP visits at 6 weeks' and 3 months' follow-up. Prognostic factors for non-recovery at 3 months' follow-up were derived from the baseline questionnaire and physical examination. Variables with a prognostic value were identified with multivariable logistic regression analysis (method backward), and an area under the receiver operating curve (AUC) was calculated for the prognostic model. A total of 675 back pain patients (mean age 66.4 (SD 7.6) years) participated in the BACE cohort study. At 6 weeks' follow-up 64% of the patients reported non-recovery from back pain. At 3 months' follow-up 61% still reported non-recovery, but only 26% of these patients had revisited the GP. Longer duration of the back pain, severity of back pain, history of back pain, absence of radiating pain in the leg below the knee, number of comorbidities, patients' expectation of non-recovery, and a longer duration of the timed 'Up and Go' test were significantly associated with non-recovery in a multiple regression model (AUC 0.79). This information can help GPs identify older back pain patients at risk for non-recovery. http://repub.eur.nl/res/pub/34353/ 2011-10-13T00:00:00Z Background: Osteoarthritis (OA) is the most common joint disease, causing pain and functional impairments. According to international guidelines, exercise therapy has a short-term effect in reducing pain/functional impairments in knee OA and is therefore also generally recommended for hip OA. Because of its high prevalence and clinical implications, OA is associated with considerable (healthcare) costs. However, studies evaluating cost-effectiveness of common exercise therapy in hip OA are lacking. Therefore, this randomised controlled trial is designed to investigate the cost-effectiveness of exercise therapy in conjunction with the general practitioner's (GP) care, compared to GP care alone, for patients with hip OA. Methods/Design. Patients aged 45 years with OA of the hip, who consulted the GP during the past year for hip complaints and who comply with the American College of Rheumatology criteria, are included. Patients are randomly assigned to either exercise therapy in addition to GP care, or to GP care alone. Exercise therapy consists of (maximally) 12 treatment sessions with a physiotherapist, and home exercises. These are followed by three additional treatment sessions in the 5th, 7th and 9th month after the first treatment session. GP care consists of usual care for hip OA, such as general advice or prescribing pain medication. Primary outcomes are hip pain and hip-related activity limitations (measured with the Hip disability Osteoarthritis Outcome Score [HOOS]), direct costs, and productivity costs (measured with the PROductivity and DISease Questionnaire). These parameters are measured at baseline, at 6 weeks, and at 3, 6, 9 and 12 months follow-up. To detect a 25% clinical difference in the HOOS pain score, with a power of 80% and an alpha 5%, 210 patients are required. Data are analysed according to the intention-to-treat principle. Effectiveness is evaluated using linear regression models with repeated measurements. An incremental cost-effectiveness analysis and an incremental cost-utility analysis will also be performed. Discussion. The results of this trial will provide insight into the cost-effectiveness of adding exercise therapy to GPs' care in the treatment of OA of the hip. This trial is registered in the Dutch trial registry http://www.trialregister.nl: trial number NTR1462. http://repub.eur.nl/res/pub/31138/ 2011-08-23T00:00:00Z Background: Although back complaints are common among older people, limited information is available in the literature about the clinical course of back pain in older people and the identification of older persons at risk for the transition from acute back complaints to chronic back pain. The aim of this study is to assess the course of back complaints and identify prognostic factors for the transition from acute back complaints to chronic back complaints in older people who visit a primary health care physician. Methods/design. The design is a prospective cohort study with one-year follow-up. There will be no interference with usual care. Patients older than 55 years who consult a primary health care physician with a new episode of back complaints will be included in this study. Data will be collected using a questionnaire, physical examination and X-ray at baseline, and follow-up questionnaires after 6 weeks and 3, 6, 9 and 12 months. The study 'Back Complaints in the Elders' (BACE) will take place in different countries: starting in the Netherlands, Brazil and Australia. The research groups collaborate in the BACE consortium. The design and basic objectives of the study will be the same across the studies. Discussion. This consortium is a collaboration between different research groups, aiming to provide insight into the course of back complaints in older people and to identify prognostic factors for the transition from acute back complaints to chronic back complaints in older persons. The BACE consortium allows to investigate differences between older people with back complaints and the health care systems in the different countries and to increase the statistical power by enabling meta-analyses using the individual patient data. Additional research groups worldwide are invited to join the BACE consortium. http://repub.eur.nl/res/pub/26632/ 2011-08-01T00:00:00Z Objective: To identify sources of heterogeneity (statistical, methodological, and clinical) in studies evaluating non-steroidal anti-inflammatory drugs (NSAIDs) vs acetaminophen in patients with knee and hip osteoarthritis (OA) to elucidate variations in outcomes. Method: A database search (1966 to January 2010) was made for (randomized) controlled trials ((R)CTs) comparing NSAIDs vs acetaminophen in knee and hip OA. Extracted data included baseline demographic/clinical characteristics, outcomes at follow-up, and characteristics of study design. Heterogeneity was examined with subgroup analyses by exploring changes in effect size and with I2of Higgins. Pain measures were expressed as standardized mean differences. Results: 15 RCTs, including 21 comparisons of NSAIDs and acetaminophen were included. Statistical heterogeneity was absent (Cochran's Q-test=14.11; I2=0; P=0.78). Moderate clinical heterogeneity was found for comparisons which included both hip and knee OA vs knee OA only (I2=51; P=0.09). NSAIDs seemed slightly more effective than acetaminophen if more patients with hip OA were included. However, the pooled effect sizes of comparisons with knee OA vs both knee and hip OA are equal. Low clinical heterogeneity was found for comparisons with low dosage of acetaminophen, normal dosage of NSAIDs, and moderate pain intensity at baseline. Low methodological heterogeneity was found for comparisons with a short duration. Conclusion: Future trials should present the results of hip and knee OA separately, as moderate clinical heterogeneity was found. There might be differences in effectiveness of NSAIDs vs acetaminophen in patients with hip vs knee OA. No significant methodological and statistical heterogeneity was found in studies evaluating NSAIDs vs acetaminophen. http://repub.eur.nl/res/pub/23703/ 2011-05-01T00:00:00Z Abstract. PURPOSE: We undertook a study to evaluate the effectiveness of corticosteroid injections in primary care patients with greater trochanteric pain syndrome (GTPS). METHODS: We evaluated the effect of corticosteroid injections compared with expectant treatment (usual care) in a pragmatic, multicenter, open-label, randomized clinical trial in the Netherlands. Patients (aged 18 to 80 years) with GTPS visiting 81 participating primary care physicians were randomly allocated to receive either local corticosteroid injections (n = 60) or usual care (n = 60). Primary outcomes of pain severity (numerical rating scale 0 to 10) and recovery (yes or no total or major recovery) were evaluated at 3-month and 12-month follow-up visits. Adverse events were collected at 6 weeks. RESULTS: At the 3-month follow-up visit, 34% of the patients in the usual care group had recovered compared with 55% in the injection group (adjusted OR = 2.38; 95% CI, 1.14-5.00, number needed to treat = 5). Pain severity at rest and on activity decreased in both groups, but the decrease was greater in the injection group, for an adjusted difference in pain at rest of 1.18 (95% CI, 0.31-2.05) and in pain with activity of 1.30 (95% CI, 0.32-2.29). At the 12-month follow-up, 60% of the patients in the usual care group had recovered compared with 61% in the injection group (OR = 1.05; 95% CI, 0.50-2.27). Pain severity at rest and on activity decreased in both groups and the 12-month follow-up showed no significant differences, with adjusted differences of 0.14 (95% CI, -0.75 to 1.04) for pain at rest and 0.45 (95% CI, -0.55 to 1.46) for pain with activity. Aside from a short period with superficial pain at the site of the injection, no differences in adverse events were found. CONCLUSION: In this first randomized controlled trial assessing the effectiveness of corticosteroid injections vs usual care in GTPS, a clinically relevant effect was shown at a 3-month follow-up visit for recovery and for pain at rest and with activity. At a 12-month follow-up visit, the differences in outcome were no longer present. http://repub.eur.nl/res/pub/33556/ 2011-01-01T00:00:00Z Purpose Although functional bladder capacity, as expressed by maximum voided volume and other frequency-volume chart parameters, are important determinants of lower urinary tract symptoms, to our knowledge no population based data are available on changes in voided volume. We determined changes in and determinants of voided volume and voiding frequency with advancing age and with time, as measured by frequency-volume charts. Materials and Methods We performed a longitudinal, population based study in 1,688 men 50 to 78 years old with followup at 2.1, 4.2 and 6.5 years. Data were obtained using frequency-volume charts for maximum, 24-hour and average voided volume, and 24-hour voiding frequency as well as physical and urological measurements, and self-administered questionnaires. We used a linear mixed effect model to determine factors predicting volume changes. Results Median maximum and average voided volume decreased with time from 400 to 380 and 245 to 240 ml, respectively, and were smaller in older age groups while 24-hour voided volume showed no change. The 24-hour voiding frequency increased with time and with advancing age. Maximum, 24-hour and average voided volumes were positively related to alcohol intake. Maximum and average voided volumes were negatively related to higher age at baseline and the passage of time. Hypertension, diuretics and post-void residual volume were related to higher 24-hour voided volume. Conclusions In older men maximum and average voided volume show a small but statistically significant decrease with time and with advancing age while 24-hour voided volume does not. Factors predicting the change in maximum or average voided volume are alcohol intake and higher age. http://repub.eur.nl/res/pub/32771/ 2010-07-01T00:00:00Z Introduction: In the general population, erectile dysfunction (ED) is surrounded by a " taboo." Epidemiologists studying this problem have to be aware of the phenomenon of the " tip-of-the-iceberg." Aims: Our aim is to describe the iceberg phenomenon for ED and their help-seeking behavior in the general population during a period when public interest in ED heightened and waned after the introduction of the drug sildenafil. Methods: The data were obtained as part of a large longitudinal community-based study, i.e., the Krimpen study. With four rounds of data collection with an approximate 2.1 years interval, the local pharmacists provided data on medication use, whereas abstracts from the medical record and history were provided by the local general practitioners (GPs). The data from the questionnaires were entered into the Krimpen study database but were not communicated to the GPs. Main Outcome Measures: ED: according to the ICS-questionnaire, GP consultation: search of electronic medical dossier for ED or reports from any specialist, use of ED medication as delivered by the pharmacy. Results: The age-standardized prevalence of ED is stable, i.e., around 40%. During the period 1995 to 2000, the incidence increased from 5% to 6.5%, then it stabilizes around 5% per year. The first-time use of ED medication increases exponentially between 1995 and 2000, then it stabilizes at about 3.5% per year. The number of GP consultations by men with ED increases up to 1999, after which it stabilizes at about 1.8% per year. Conclusion: We suggest that the availability and awareness of a new pharmacological option induced a change of behavior among GPs and their patients. http://repub.eur.nl/res/pub/24000/ 2010-03-11T00:00:00Z Background. Osteoarthritis is the most frequent chronic joint disease which causes pain and disability of especially hip and knee. According to international guidelines and the Dutch general practitioners guidelines for non-traumatic knee symptoms, acetaminophen should be the pain medication of first choice for osteoarthritis. However, of all prescribed pain medication in general practice, 90% consists of non-steroidal anti-inflammatory drugs compared to 10% of acetaminophen. Because general practitioners may lack evidence showing a similar efficacy of acetaminophen and non-steroidal anti-inflammatory drugs, we present the design of a randomized open-label trial to investigate the efficacy of a non-steroidal anti-inflammatory drug (diclofenac) compared with acetaminophen in new consulters with knee osteoarthritis in general practice. Methods/Design. Patients aged 45 years or older consulting their general practitioner with non-traumatic knee pain, meeting the clinical American College of Rheumatology criteria, and with a pain severity score of 2 or higher (on a 0-10 scale), will be randomly allocated to either diclofenac (maximum daily dose of 150 mg) or acetaminophen (maximum daily dose of 3000 mg) for 2 weeks and, if required, an additional 1-2 weeks, with a total follow-up period of 12 weeks. The primary outcomes are knee pain measured with a daily diary, and pain and function measured with the Knee Injury and Osteoarthritis Outcome Score (KOOS) at baseline, and at 3, 6, 9, and 12-weeks follow-up. Secondary outcomes are patients' perceived recovery, quality of life, medical, patient, and productivity costs, compliance to therapy, co-interventions, and adverse reactions. Discussion. The successful completion of this trial would lead to a better understanding of which medication should be used in the treatment of primary care patients with mild knee osteoarthritis. Trial registration. Dutch trial registry NTR1485. http://repub.eur.nl/res/pub/24771/ 2009-04-01T00:00:00Z This report from the Krimpen study explored the relationship between the determinants for worsening of erectile function in the open population. In Krimpen aan den IJssel (a municipality near Rotterdam), all men aged 50-75 years, without cancer of the prostate or the bladder and without a history of radical prostatectomy or neurogenic bladder disease, were invited to participate in June 1995. The response rate was 50%. The follow-up was until June 2004. At baseline a visit to a health centre for the measurement of urinalysis, height, weight and blood pressure was part of the ongoing study. During baseline and at the first follow-up, second follow-up and third follow-up, a self-administered booklet consisting of a compilation of validated questionnaires including the International Continence Society male sex questionnaire was completed. At the urology outpatient clinic, a urological workup was measured. All participants were asked to keep a frequency-volume chart for 3 days. A multivariate Cox-proportional hazard model was constructed to find the determinants of worsening of erectile function, correcting for age. Total follow-up time was 4948 person years consisting of 975 men. During follow-up, 441 events of worsening of erectile function occurred. Multivariate Cox-proportional hazard ratio analyses showed that body mass index (BMI), irritative lower urinary tract symptoms, diabetes mellitus, chronic obstructive pulmonary disease (COPD) and sexual inactivity were determinants with significant hazard ratios. In addition to age, determinants for a deterioration of erectile function based on multivariate longitudinal analyses are BMI, diabetes mellitus, COPD, sexual inactivity and irritative IPSS. The mechanism of various determinants is discussed. http://repub.eur.nl/res/pub/29621/ 2008-04-01T00:00:00Z Objective: We used the database of a longitudinal community-based study to investigate whether real changes in prostate volume (PV) (ie, changes greater than the combination of intra- and interobserver variation of volume measurement) corresponded with significant changes in symptom severity. Methods: In a community-based study of men aged 50-78 yr, the International Prostate Symptom Score (IPSS) and PV were measured at baseline and at 4.2-yr follow-up. Of 1417 men, 864 completed both rounds. A significant change in IPSS was defined as a change of ≥ 4 points. A real change in PV was defined as a percent change of ≥ 26%, or an absolute change of ≥ 10 cc. Results: After 4.2 yr, about 20% of the men had experienced a significant increase in IPSS and 16-23% had a real increase in PV. The age-adjusted odds ratio for a significant increase in symptom severity, which contrasts men who have a real increase in PV and men who do not show such an increase, is 1.38 (95%CI, 1.05-1.85]. The age-adjusted odds ratio for a significant decrease in symptom severity, which contrasts men with a real increase in PV and those without such an increase, is 1.50 (95%CI, 1.11-2.85). Conclusions: Benign prostatic hyperplasia can be characterised as a progressive disease in a certain proportion of men older than 50 yr. Men with growing prostates are at a greater risk of symptomatic deterioration. Men who have prostates that do not grow significantly are more likely to improve symptomatically. http://repub.eur.nl/res/pub/15722/ 2007-12-01T00:00:00Z OBJECTIVE: Hip pain in the elderly is the main feature of osteoarthritis of the hip. In this prospective followup study, we wanted to determine which patients with hip pain show disease progression, and what the incidence of total hip replacement (THR) is in this group of patients after 3 and 6 years of followup. METHODS: Within general practices in the area of Rotterdam (The Netherlands), persons age > or = 50 years with incident hip pain were included. After 3 and 6 years, progression of hip pain was assessed. RESULTS: A total of 224 patients were included. After 3 years disease progressed in 29 (15%) patients and 23 (12%) received a THR. After 6 years disease progressed in 45 (28%) patients and 36 (22%) received a THR. The prognostic variables for a THR after 3 and 6 years related to history taking were age > or = 60 years, morning stiffness, and pain in the groin/medial thigh; variables related to physical examination were decreased extension/adduction, painful internal rotation, and a body mass index < or = 30 kg/m(2); and the variable related to radiologic findings was a Kellgren/Lawrence grade of 2 or higher. CONCLUSION: In this study population, approximately 12% of patients presenting with hip pain to their general practitioner will undergo a THR within 3 years, and approximately 22% after 6 years. Using the variables obtained from history taking, physical examination, and radiologic findings enables better identification of persons at high risk for a THR. http://repub.eur.nl/res/pub/35885/ 2007-12-01T00:00:00Z BACKGROUND. We aim to establish the normal pattern of prostate volume change with age to provide a baseline from which accelerated prostate growth might be identified in patients with lower urinary tract symptoms/benign prostatic hyperplasia (LUTS/BPH). METHODS. In a community-based study, prostate volume was determined at baseline and after 2.1 and 4.2 years in men without prostate cancer. A bivariate multilevel growth curve model was used to estimate the pattern of change of prostate volume with age. RESULTS. The average percentage increase of total prostate volume and transition zone volume per year of follow-up was 2.2% and 3.5%, respectively. The final model showed that prostate volume was related to age only. The future prostate volume of an individual can be predicted based on his age and known history of prostate volume. The model was also used to calculate time needed for the prostate volume to increase with a certain percentage, for men with different baseline prostate volume values at different ages. CONCLUSIONS. This method establishes normal prostate volume values by age using prostate volume history in men without prostate cancer. The model provides baseline data from which disease progression might be detected. http://repub.eur.nl/res/pub/36853/ 2007-11-08T00:00:00Z Background. Regional pain in the hip in adults is a common cause of a general practitioner visit. A considerable part of patients suffer from (greater) trochanteric pain syndrome or trochanteric bursitis. Local corticosteroid injections is one of the treatment options. Although clear evidence is lacking, small observational studies suggest that this treatment is effective in the short-term follow-up. So far, there are no randomised controlled trials available evaluating the efficacy of injection therapy. This study will investigate the efficacy of local corticosteroid injections in the trochanter syndrome in the general practice, using a randomised controlled trial design. The cost effectiveness of the corticosteroid injection therapy will also be assessed. Secondly, the role of co-morbidity in relation to the efficacy of local corticosteroid injections will be investigated. Methods/Design. This study is a pragmatic, open label randomised trial. A total of 150 patients (age 18-80 years) visiting the general practitioner with complaints suggestive of trochanteric pain syndrome will be allocated to receive local corticosteroid injections or to receive usual care. Usual care consists of analgesics as needed. The randomisation is stratified for yes or no co-morbidity of low back pain, osteoarthritis of the hip, or both. The treatment will be evaluated by means of questionnaires at several time points within one year, with the 3 month and 1 year evaluation of pain and recovery as primary outcome. Analyses of primary and secondary outcomes will be made according to the intention-to-treat principle. Direct and indirect costs will be assessed by questionnaires. The cost effectiveness will be estimated using the following ratio: CE ratio = (cost of injection therapy minus cost of usual care)/(effect of injection therapy minus effect of usual care). Discussion. This study design is appropriate to estimate effectiveness and cost-effectiveness of the injection therapy. We choose to use a pragmatic study design and are thus not able to study specific effects of the injection with corticosteroids. A distinction between placebo effect of the injection and specific effects of the corticosteroids is therefore not possible. Trial Registration. The trial is listed in the Dutch Trial Registry with the number ISRCTN16994576. http://repub.eur.nl/res/pub/35153/ 2007-10-01T00:00:00Z Objective: The present study aims to determine the influence of coping on quality of life (QOL) in elderly men developing lower urinary tract symptoms (LUTS). Materials and Methods: Longitudinal population-based study with a follow-up period of 6.5 years on 1,688 men aged 50-78 years. Data were collected through self-administered questionnaires, including the Sickness Impact Profile (SIP, three domains), Inventory of Subjective Health (ISH), International Prostate Symptom Score (IPSS), and the Utrecht Coping List (UCL). Various physical and urological measurements were completed. Multiple linear regressions were used to determine the change in QOL in men with incident LUTS in relation to coping behavior. Results: Overall no significant association is found between changes in LUTS with a change in QOL. However, a positive change in QOL is significantly associated with a change in LUTS when men use the coping style active problem solving and a negative relation exists with coping style reassuring thoughts. Conclusion: Different coping styles have a different impact on the relation between a change in LUTS and a change in generic QOL in community-dwelling elderly men. This makes a future exploration of the clinical treatment possibilities warranted. Copyright http://repub.eur.nl/res/pub/36085/ 2007-06-01T00:00:00Z Objectives: Serum prostate-specific antigen (PSA) is considered a proxy for prostate volume (PV). This study investigates which range of PSA values has the best utility in the determination of PV (<30 cc, at 30, 40, and 50 cc), and whether PSA performs better than digital rectal examination (DRE) when estimating PV. Methods: In a population-based follow-up study of 1688 men in Krimpen aan den IJssel, The Netherlands, at baseline we estimated PV by DRE and by transrectal planimetric ultrasound (TRUS), in addition to measuring PSA. Men who tested positive for prostate cancer (PCa) at baseline and at 2 and 4 yr of follow-up were excluded from the analyses (n = 142). Of the men without PCa, PSA and PV data were available in 1524 participants. Results: Of all 1524 men analysed, 76.7% had a PSA of 0-2.0, 15.0% had a PSA of 2.1-4.0, and 8.3% a PSA > 4. Low PSA ranges (0-2 and 2.1-4.0) discriminate better for a PV of 30 cc (eg, in men with a PSA range of 2.1-2.5 ng/ml there was a 72% chance of having a PV > 30 cc). Higher ranges of PSA (>4.0) discriminate better for a PV > 40 or 50 cc. (eg, in men with a PSA in the range of 4.1-7.0 ng/ml there was a 69% chance of having a PV > 40 cc and in men with a PSA > 10 ng/ml there was a 75% chance of a PV > 50 cc). The receiver operating curve (ROC) for the performance of PSA in estimating a PV > 30 cc shows an area under the curve (AUC) of 0.79, denoting reasonable discrimination, and AUCs of 0.86 and 0.92, denoting good discrimination of PVs > 40 cc and >50 cc, respectively. PSA performed significantly better than DRE at estimating PV. Multiple regression analysis shows that both DRE and an interaction term for age and PSA provided minimal additional information beyond PSA in the prediction of PV; however, their contribution is numerically minimal/not clinically meaningful. Conclusions: In men for whom a diagnosis of PCa has been ruled out, PSA can be used to detect an enlarged prostate (>30 cc and with more accuracy PV > 40 or 50 cc). More precision in estimating PV can be obtained when using a formula that contains PSA, age, DRE, and an interaction term between age and PSA; however, the clinical advantage of the formula over PSA alone is only modest as shown by the ROC curves. Thus, for clinicians looking for an easy and fast way to identify patients with an enlarged prostate, PSA is a good approximation for men without PCa. http://repub.eur.nl/res/pub/9028/ 2006-01-01T00:00:00Z We studied epidemiological aspects of recruitment of volunteers for a non-invasive urodynamic study. MATERIALS AND METHODS: 9,236 volunteers were invited by 20 general practitioners (GPs), using two different recruitment methods, i.e. by mail only, or during a subsequent visit to the GP's office. Factors influencing the response rates were analyzed. We also tested how much the recruited population of volunteers differed from the general population, by comparing it to another, proven representative study carried out earlier in 1,662 subjects. RESULTS: In the recruited population the prostate volumes were not significantly different from the proven representative study, but the symptom score was statistically significantly higher, although the difference was so small it may be called clinically irrelevant. Recruitment of volunteers in two steps, i.e. asking them first to visit the GP's office, and inviting them there to visit the outpatient clinic, rather than directly inviting them (in writing) to the clinic seemed to lead to a higher response, although this effect could not be statistically discriminated from the difference in response rates between GPs. CONCLUSION: The population recruited was not urologically different from the general population. The response depended on age, being highest around the age of 60, and increased with social economic status. It also depended on the GP who recruited the subjects, and/or on the recruitment method. http://repub.eur.nl/res/pub/10380/ 2005-01-01T00:00:00Z BACKGROUND: Trochanteric pain is the second most important diagnosis of hip problems presenting in primary care, but its incidence and prognosis in this context is largely unknown. AIM: To determine the 1- and 5-year prognoses of trochanteric pain and the predictive variables for consistent complaints. DESIGN OF THE STUDY: Retrospective cohort study. SETTING: One hundred and sixty-four patients (mean age = 55 years, 80% female) with incidental trochanteric pain in the years 1996 or 2000 were asked in 2001 for past and present symptoms of trochanteric pain. Therapeutic interventions, demographic factors and comorbidity were also investigated. METHOD: The databases of 39 GPs were screened in order to identify all incident cases with a suspicion of trochanteric pain in the years 1996 or 2000. These cases were sent a questionnaire. RESULTS: The incidence of trochanteric pain in primary care is 1.8 patients per 1000 per year. After 1 year at least 36% still suffered from trochanteric pain, and after 5 years this was 29%. Patients with osteoarthritis (OA) in the lower limbs had a 4.8-fold risk of persistent symptoms after 1 year, as compared to patients without OA. Patients who had received a corticosteroid injection had a 2.7-fold chance of recovery after 5 years, as compared with patients who had not received an injection. CONCLUSION: Trochanteric pain is shown to be a chronic disease in a substantial number of patients. The disorder is associated with much impairment when conducting daily activities. http://repub.eur.nl/res/pub/13633/ 2005-01-01T00:00:00Z Cough may be the consequence of bronchial hyperresponsiveness (BHR) and inflammation. This study was designed to investigate the short-term effects of an inhaled steroid (fluticasone propionate (FP)) on cough, and to determine the effects of smoking, BHR, allergy and forced expiratory volume in one second (FEV1) on the efficacy of FP. In a community-based primary healthcare centre, 135 previously healthy adults suffering from cough for > or =2 weeks were enrolled in a randomised, double-blind, placebo-controlled trial of inhaled FP 500 microg b.i.d. for 2 weeks. Participants completed daily diary cards of lower respiratory tract symptoms. The primary outcome measure was the decrease in mean total daily cough score (0-6) during the second week of treatment. In the FP group, the cough score decreased from 3.8 at baseline to mean+/-SEM 1.4+/-0.2 during the second week. In the placebo group, this decrease was from 3.8 to 1.9+/-0.1 and was statistically significantly less. A favourable effect of FP was only detectable in nonsmokers, in whom the score was 0.9 points lower compared with placebo. The clinical relevance of this finding has to be established further. Allergy, FEV1 and BHR at baseline did not affect the efficacy of FP. In conclusion, anti-inflammatory treatment with the inhaled steroid fluticasone propionate reduces cough in otherwise healthy adults who do not smoke. http://repub.eur.nl/res/pub/14392/ 2004-01-31T00:00:00Z OBJECTIVES: To report on the applicability, reproducibility, and adverse events of the noninvasive condom catheter method in the first 730 subjects of a longitudinal survey of changes in urinary bladder contractility secondary to benign prostatic hyperplasia, in which 1300 men will be evaluated three times in 5 years using this method. METHODS: Subjects were recruited by general practitioners, general publicity, and e-mail. Only those meeting the study criteria were entered in the study. If the free flow rate exceeded 5.4 mL/s, at least two consecutive condom pressure measurements were attempted using the condom catheter method. The condom pressure measured reflected the isovolumetric bladder pressure, a measure of urinary bladder contractility. The reproducibility of the method was quantified by a difference plot of the two maximal condom pressures measured in each subject. RESULTS: In 618 (94%) of 659 eligible participants, one condom pressure measurement was completed; two measurements were done in 555 (84%). The maximal condom pressure ranged from 28 to 228 cm H2O (overall mean 101, SD 34). A difference between the two pressures of less than +/-21 cm H2O was found in 80%. The mean difference was -1 cm H2O (SD 18), significantly different from 0. Some adverse events such as terminal self-limiting hematuria were encountered. CONCLUSIONS: The condom catheter method is very suitable for large-scale use. It has a success rate of 94% and a reproducibility comparable to that of invasive pressure flow studies http://repub.eur.nl/res/pub/10357/ 2004-01-01T00:00:00Z BACKGROUND: The uncertainty around true clinical manifestations of gallbladder stone disease is in contrast with the unanimous recommendation that only symptomatic gallstones should be treated. AIM: To evaluate the relationship between biliary pain, other gastrointestinal symptoms and gallstones. DESIGN OF STUDY: A pragmatic, prospective cohort questionnaire study. SETTING: Seventy-five general practices in Rotterdam, The Netherlands. METHOD: All patients suspected by their general practitioner (GP) to have gallstone disease underwent ultrasound examination of the upper abdomen. Using a self-administered questionnaire, the presence of 11 gastrointestinal symptoms was assessed at inclusion and after 1 year. Likelihood ratios (LRs) for the presence of gallstones and symptom relief rates after 1 year were calculated. The mean difference in health status at inclusion and after follow-up was calculated for patients without gallstones, for patients with gallstones who were operated on and for patients with gallstones who were not operated on. RESULTS: In total, 61% of the patients with gallstones diagnosed by ultrasound scan reported biliary pain, as did 45% of the patients without gallstones (LR = 1.34, 95% confidence interval [CI] = 1.05 to 1.71). Patients operated on for gallstone disease did not show significant relief of biliary pain compared to patients not operated on for gallstones or patients without gallstones (87%, 63% and 83%, respectively). Health status improved in all patients. The mean improvement in health status did not differ between the three patient groups. GPs were able to discriminate between patients with high and low probability of gallbladder stones by ultrasound examination (53% versus 23%). This selection, however, did not predict the outcome of cholecystectomy. CONCLUSION: Neither biliary pain nor any other gastrointestinal symptom was consistently related to gallstone disease. Therefore, the indication for elective cholecystectomy cannot be based on the presence of biliary pain alone. Relief of biliary pain in patients operated on for gallstones should not simply be attributed to a successful cholecystectomy. http://repub.eur.nl/res/pub/15551/ 2002-08-01T00:00:00Z OBJECTIVE: To study whether clinical symptoms and signs can predict radiological osteoarthritis (OA) of the hip in primary care patients with hip pain. METHODS: Consecutive patients (n = 220) aged 50 years or older consulting the general practitioner for hip pain and referred for radiological investigation underwent a standardized history, radiological, laboratory, and physical examination. Radiological OA was confirmed with joint space < or = 2.5 mm. Additionally, a more stringent definition was used (< or = 1.5 mm). The relationship between radiological OA and possible clinical symptoms/signs of OA was tested. Combinations of clinical symptoms/signs that had shown an independent relationship with radiological OA in multivariate analyses were tested for their predictive value. RESULTS: Radiological OA (joint space < or = 2.5 mm) of the (more) symptomatic hip was present in 35.5% of the study population and more severe OA (joint space < or = 1.5 mm) in 11.4%. Presence of 4 specific symptoms/signs from history and examination showed a positive predictive value (PPV) of 73% (specificity 91%, sensitivity 45%) for radiological OA. When 5 specific symptoms/signs were present, the PPV for the more severe radiological OA was 82% (specificity 98%, sensitivity 72%), and when 6 or 7 specific symptoms/signs were present the PPV was 100% (specificity 100%, sensitivity 40% and 8%, respectively). Negative predictive values were high for almost all combinations. CONCLUSION: In primary care patients with hip pain, clinical symptoms and signs can to a moderate extent predict radiological OA and to a large extent more severe radiological OA. http://repub.eur.nl/res/pub/31837/ 2002-06-01T00:00:00Z Objective: To study health status and its correlates in older men with and without lower urogenital tract dysfunction. Methods: Cross-sectional population-based study on 1688 men aged 50-78 years without bladder or prostate cancer, radical prostatectomy, neurogenic bladder dysfunction or a negative advice from their general practitioner. Data were collected through self-administered questionnaires, including Sickness Impact Profile (SIP, three domains), Inventory of Subjective Health (ISH), International Prostate Symptom Score (IPSS) and International Continence Society (ICS) Male Sex questionnaire, medication use, socio-economic and lifestyle factors. Additional information was collected by measurement of blood pressure, transrectal ultrasonography of the prostate and uroflowmetry. Four health status domains were analyzed using the ISH and three domains of the SIP. Lower urinary tract symptoms (LUTS) were categorised using IPSS, erectile and ejaculatory dysfunction were defined using the ICS questionnaire. Results: All urogenital characteristics and parameters were related to at least two of the health status domains. Multivariate regression analyses yielded that LUTS and cardiac symptoms were associated with suboptimal scores of all four domains. Chronic obstructive pulmonary disease and drugs for abdominal symptoms were related to three domains; erectile and ejaculatory dysfunction, muskuloskeletal or psycho(ana)leptic drugs and marital status to two domains. Conclusions: The impact of LUTS on health status was equally important as the impact of cardiac symptoms. The impact of sexual dysfunction was smaller than expected. Longitudinal studies are needed to determine how health status and illnesses interact. http://repub.eur.nl/res/pub/9809/ 2002-01-01T00:00:00Z BACKGROUND: Guidelines are viewed as a mechanism for disseminating a rapidly increasing body of knowledge. We determined the compliance of Dutch general practitioners with the recommendations for blood test ordering as defined in the guidelines of the Dutch College of General Practitioners. METHODS: We performed an audit of guideline compliance over a 12-month period (March 1996 through February 1997). In an observational study, a guideline-based decision support system for blood test ordering, BloodLink, was integrated with the electronic patient records of 31 general practitioners practicing in 23 practices (16 solo). BloodLink followed the guidelines of the Dutch College of General Practitioners. We determined compliance by comparing the recommendations for test ordering with the test(s) actually ordered. Compliance was expressed as the percentage of order forms that followed the recommendations for test ordering. RESULTS: Of 12 668 orders generated, 9091 (71%) used the decision-support software rather than the paper order forms. Twelve indications accounted for >80% of the 7346 order forms that selected a testing indication in BloodLink. The most frequently used indication for test ordering was "vague complaints" (2209 order forms; 30.1%). Of the 7346 order forms, 39% were compliant. The most frequent type of noncompliance was the addition of tests. Six of the 12 tests most frequently added to the order forms were supported by revisions of guidelines that occurred within 3 years after the intervention period. CONCLUSIONS: In general practice, noncompliance with guidelines is predominantly caused by adding tests. We conclude that noncompliance with a guideline seems to be partly caused by practitioners applying new medical insight before it is incorporated in a revision of that guideline. http://repub.eur.nl/res/pub/15539/ 2001-11-01T00:00:00Z No validated classification system of hip disorders in primary care is available. This study explores whether it is possible to obtain such a classification with the method of cluster analyses. A total of 224 consecutive patients aged 50 years or older, consulting the general practitioner for pain in the hip region, and referred for X-ray investigation of the hip, underwent a standardized examination. Ward's cluster analysis with variables from history and physical examination of the hip region resulted in a classification with nine different clusters. These clusters were reproduced in 10 random subsamples and with an alternative cluster analysis. Significant relationships of various external variables (radiological and sonographic signs and variables of low-back and knee examination) with the distinctive clusters were found. Twenty of the approached experts recognized the symptoms in seven clusters as identifiable syndromes. However, further validation of the achieved classification system, especially with respect to the clinical importance, is needed before introducing it into clinical practice. http://repub.eur.nl/res/pub/9282/ 2000-01-01T00:00:00Z OBJECTIVE: To study the prevalence of ultrasonic hip joint effusion and its relation with clinical, radiological and laboratory (ESR) findings in adults with hip pain. METHODS: Patients (n = 224) aged 50 years or older with hip pain, referred by the general practitioner for radiological investigation, underwent a standardised examination. The distance between the ventral capsule and the femoral neck, an increase in which represents joint effusion, was measured sonographically. Joint effusion was defined in three different ways: "effusion" according to Koski's definition, "major effusion", and "asymmetrical effusion" based on only individual side differences. RESULTS: "Effusion" was present in 80 (38%), "major effusion" in 20 (9%), and "asymmetrical effusion" in 47 (22%) patients. Pain in the groin or medial thigh, pain aggravated by lying on the side, decreased extension/internal rotation/abduction/flexion, painful external rotation, and pain on palpation in the groin showed a significant relation (adjusted for age and radiological osteoarthritis of the hip) with ultrasonic hip joint effusion. "Major effusion" showed a significant relation with an increased ESR. When patients with bilateral pain and increased ESR were excluded, a side difference in the range of motion of extension of the hip was shown to be a good predictor for "asymmetrical effusion" (positive predictive value: 71%, negative predictive value: 80%). CONCLUSION: This study showed a relatively high prevalence of ultrasonic joint effusion in adults with hip pain in general practice. Furthermore the results indicate a relation between joint effusion and clinical signs. http://repub.eur.nl/res/pub/9140/ 1999-01-01T00:00:00Z OBJECTIVE: To determine the consistency among the practice guidelines of the Dutch College of General Practitioners with respect to the use of blood tests. METHODS: The authors evaluated 64 practice guidelines of the Dutch College of General Practitioners. For each guideline, they analyzed each sentence that contained a reference to a blood test to determine the clinical situation in which the test should be performed (the indication) and to determine the tests that should be performed in that situation (the recommended test). An incomplete recommendation refers to a guideline that mentioned a blood test but did not identify the indication for that test. An inconsistency refers to the situation in which one guideline recommended a certain test for a given indication whereas another guideline mentioned the same indication but did not recommend the same test. RESULTS: Twenty-seven practice guidelines mentioned blood tests. Of these, three explicitly recommended not to request blood tests. Five guidelines contained incomplete recommendations, and the authors encountered two inconsistencies among the guidelines. Twenty-three guidelines mentioned blood tests and allowed the authors to identify indications and recommended tests. CONCLUSION: The identification of indications and recommended tests allows evaluation of consistency among practice guidelines. Although some incomplete recommendations and inconsistencies were discovered, the majority of the guidelines provide clear and unambiguous recommendations for blood-test ordering in primary care.