1901-2001: 100 years of physicians of infant and toddler welfare centers in the Netherlands]

This year marks the centenary of infant welfare centres in the Netherlands. In 1901, Plantenga opened the first infant welfare centre in The Hague, the Netherlands. Initially, only advice about feeding was given and the growth of the infant was monitored. To support mothers, extra milk was supplied in so-called 'milk kitchens'. Over the years the tasks have been extended to include a wide range of preventive measures. At first the doctors in infant welfare clinics were predominantly paediatricians but later general practitioners and doctors specialised in infant primary health care followed. In their 100-years existence, infant welfare clinics have grown into an intricate network which sees 98% of Dutch infants.     

The treatment of ankle edema in the elderly in family practice; when and how often are diuretics used?

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.     

Dietary advice, nutritional knowledge and attitudes towards nutrition in primary health care

The high priority of health promotion within primary health care in the UK is evidenced through the acceptance, by the primary health care team (PHCT), of a contractual responsibility for health promotion, including the provision of dietary advice. This study sought to investigate the level of advice given on dietary matters, the methods used to give this advice and the nutritional knowledge and attitudes towards nutrition of Sheffield PHCTs; general practitioners (GPs) and practice nurses (PNs) were compared. All active practices ( n = 100) on Sheffield Health Authority's GP practice lists were invited to participate. A total of 58 interviews in 46 practices were completed, representing a response rate of 46%. Information was collected using an interviewer-administered questionnaire. Data analysis was carried out using MINITAB (Minitab Inc., Pennsylvania, USA); differences between groups were tested using the x² test.
It was found that PNs gave dietary advice more frequently than GPs ( P <0.05). GPs were more likely ( P <0.05) to give verbal advice only, whereas PNs tended to take a dietary history and to give both written and verbal advice. GPs were less likely than PNs to give comprehensive advice for type II (maturity onset) diabetes, hypercholesterolaemia and obesity. There were appreciable gaps in the nutritional knowledge of both groups. The majority of GPs and PNs believed nutrition to be important in disease prevention and expressed a desire for nutritional teaching as part of their medical training. The primary health care team is in a prime position to give dietary advice, however, it is evident that there is a need for improved nutrition education and training in dietary counselling.     

The practice guideline 'The red eye' (first revision) of the Dutch College of General Practitioners; a response from the perspective of the general practitioner

The revised version of the practice guideline 'The red eye' of the Dutch College ofGeneral Practitioners gives the general practitioner useful information on new insights into diagnosis and therapy for a red eye. An important therapeutic advice is prescribing chloramphenicol ointment instead of fusidic acid ointment in the case of bacterial conjunctivitis after one-week treatment without positive results, since 80% of the conjunctivitis causing bacteria does not react to fusidic acid. A slit lamp is helpful in the diagnosis of a case of red eye, but is not present in every general practitioner's office. Joint efforts of a group of general practitioners in obtaining such a slit lamp may reinforce the diagnosis in general practice.     

Current management of acute bronchiolitis in Tunisia

AIM: The purpose of this study was to assess the current management practices of acute bronchiolitis by tunisian paediatricians. METHODS: A questionnaire was sent by mail to all tunisian paediatricians, about the most widely used drugs during the first stage of acute bronchiolitis. The answers were sent to us by mail in pre-stamped envelopes. RESULTS: Out of total of 420 questionnaires sent, 180 (42.8%) were returned, out of which 177 (42%) were analysed. Of the respondents, 117 (66%) were working in hospitals and, 60 (34%) were working in the private sector. Bronchodilatators were used by 93.3% of peadiatricians either routinely (35.6%) or occasionally (44.1%). Steroids were used by 88.7% of pediatricians either routinely (28.8%) or occasionally (43.5%) Nasal drops, were prescribed routinely by 80.2% of the pediatricians. Physiotherapy was performed routinely or occasionally in 91.5% of the cases. Oygen and antibiotics were respectively used by 92% and 70% of the paediatricians. A comparaison between the practices of the hospital paediatricians and their private sector conterparts showed that private practitioners, statistically, prescribe more bronchodilatators (42.7% vs 21.7%) (p < 0.05) and corticosteroids (36.8% vs. 13.3%) (p < 0.05) than their hospital colleagues. Hospital physicians, more than the private sector ones, tend to never prescribe bronchodilatators ,2 (15% vs. 2.6%) (p < 0.05) and steroids (25% vs. 4.3) (p < 0.05). CONCLUSIONS: Despite the absence of the scientific evidence showing a beneficial effect of the pharmaceutical agents, most paediatricians, during the initial phase of acute bronchiolitis, resort to prescribing bronchodilators (93.3%) and corticosteroids (88.7%). There is a great variety of therapeutic practices among hospital paediatricians and private practitioners. National guidelines could be helpful in reducing this disparity.     

Guideline on the use of corticosteroids in Duchenne muscular dystrophy from paediatric neurologists, neurologists and rehabilitation physicians

A guideline on the treatment of boys with muscular dystrophy with corticosteroids has been written and is available from the Dutch patients' organization. The guideline has been approved by the Dutch Societies of Neurology, Rehabilitation and Paediatrics. Based on the available literature the advice is to treat the boys with corticosteroids as soon as they become symptomatic. Prednisone is the drug ofchoice. The recommended dosage is 0.75 mg/kg body weight/day, every day or in a schedule of 10 days with treatment and 10 days without. From the initiation of the prednisone treatment dietary advice is given to control body weight. Monitoring for adverse effects takes place regularly.     

Case mix presenting to paediatricians in a UK district (1998)

This observational study analysed paediatric outpatient referrals to a district service in the UK in 1998 and compared results with studies conducted 10 y previously.Data was collected prospectively from the written correspondence on all new outpatient referrals offered appointments by paediatricians at Northampton General Hospital over a 3-month period.Two hundred and ninety-seven (66%) referrals were to general paediatricians, 108 (24%) to 'patch' community paediatricians and 47 (10%) to community paediatrician consultant clinics. The referral rate to general outpatients was 20/1000 per annum, similar to referral rates in 1988. Urogenital and cardiac problems have overtaken asthma as the most commonly referred conditions. Referrals to consultant community paediatricians were predominantly development and behaviour difficulties and were more complex than those referred to other groups. 'Patch' community paediatricians received 87% of their referrals from practitioners other than doctors and played a significant role in co-ordinating care in the community. They referred less than 3% for consultant assessment.The referral rate to general paediatric outpatients has remained stable over the last decade although the case mix has changed. For the first time, we provide population-based case mix and referral rates to community paediatricians. We highlight the important role of non-consultant career grade paediatricians in supporting clinical services in the community. Open access to some investigations for general practitioners (GPs) could be explored as a way of managing demand for general paediatric outpatient appointments.     

Practitioner and lay perspectives of the service provision of nutrition information leaflets in primary care

Background: In primary care, leaflets are often used to communicate health information. Increasingly, primary healthcare practitioners need to provide dietary advice. There is limited research exploring how nutrition information leaflets are used in primary care. The present study explored practitioner and lay experiences with respect to providing and receiving nutrition information in primary care, focusing in particular on the use of leaflets for nutrition information. Methods: A qualitative design was used incorporating focus groups with 57 practitioners based at seven general practitioner practices and a purposive sample of 30 lay participants attending six Consumer Health Organisations within one primary care trust. Focus groups were taped and transcribed verbatim and data were analysed thematically, assisted by computer software n6 ® (QSR International Pty Ltd, Melbourne, Australia). Results: Practitioners discussed barriers to giving nutritional advice, access to leaflets, lay receptiveness to advice and their perceptions about the value of leaflets to lay people. Food was not considered in terms of its nutritional components by lay participants and the need for nutritional information was not perceived to be relevant until they had received a medical diagnosis. Lay participants discussed the importance of receiving nutritional advice relating to their medical diagnosis and the altered status of written information that was delivered personally. Practitioner and lay groups suggested improvements to ensure that nutritional advice be supported by relevant and appropriate written information. Conclusions: This research has underlined the continuing importance of nutrition information leaflets and concludes that there is particular value in involving lay participants in the development of nutrition information leaflets.     

The 'Diabetes mellitus type 2' guideline (first revision) of the Dutch College of General Practitioners: response from family practice]

The first revision of the guidelines of the Dutch College of General Practitioners on diabetes mellitus type 2 has been prepared by experts from primary and secondary care. This might be a big improvement, since the guidelines will be welcomed by general practitioners as well as by specialists. One item that will cause debate is that the threshold to make the diagnosis of diabetes is decreased to 6.1 mmol/l. This will increase the number of diabetes patients and the GP's workload. Another controversy is made by the advice to screen for unknown diabetics in risk groups using case-finding. There are many questions about the feasibility of this advice while conclusive evidence that it will lead to better prognosis is not yet established.     

The knowledge of healthcare professionals with regard to the treatment and prevention of head lice

This study examined the knowledge and practice of healthcare professionals regarding the prevention and treatment of head lice 18 months after dissemination of local guidelines. A self-administered postal questionnaire was sent to all primary healthcare professionals (general practitioners and practice nurses), community healthcare professionals (community paediatricians, health visitors and school nurses) and pharmacists in South Staffordshire health district, UK. The overall response rate was 48% (range 24-63%). Compared to other groups: community healthcare professionals were more likely to refer to the guidelines and have adequate knowledge of treatment and prevention; pharmacists were least likely to refer to the guidelines; and primary healthcare professionals were most likely to have poor knowledge about prevention and treatment. Overall, healthcare professionals' knowledge regarding prevention methods was significantly better than their knowledge of treatment methods (63% vs. 5%, P <0.00001). In conclusion, the results of this study suggest that healthcare professionals' knowledge of control methods for head lice varies widely and is sub-optimal and may contribute to ineffective head lice control.     

The Dutch College of General Practitioners' practice guideline, "Vaginal bleeding"; reaction from a gynaecological perspective

The Dutch College of General Practitioners' practice guideline 'Vaginal bleeding' is a useful instrument for general practitioners. The changes in the present version are based on recent developments in diagnostic and therapeutic possibilities, such as (hydro-)ultrasonography to diagnose intracavitary abnormalities, progesterone-containing 'intra-uterine devices' (IUDs) and endoscopic techniques for destroying the endometrium. The recommendation to prescribe cyclical progestogens in the case of hypermenorrhoea is not supported by randomised studies. On balance, this guideline provides clear and useful advice for the treatment of abnormal vaginal blood loss.     

The practice guideline 'Dementia' (second revision) from the Dutch College of General Practitioners; a response from the perspective of neurology

The revised version of the practice guideline 'Dementia' from the Dutch College of General Practitioners provides a sound and comprehensive overview, and a practical guideline especially for the period following the diagnostic evaluation. The advice on the issues of whether to refer patients and whether to start symptomatic drug treatment is stated in rather general terms. Therefore, for most general practitioners it will still be difficult to decide how best to act on these issues. The fact that the cognitive examination is treated as part of the history taking will, most probably, negatively affect the quality of the diagnostic evaluation.     

European Academy of Paediatrics Research in Ambulatory Setting network (EAPRASnet): a multi‐national general paediatric research network for better child health

Background In 2008, the European Academy of Paediatrics launched a paediatric‐based research network – EAPRASnet (European Academy of Paediatrics Research in Ambulatory Setting network). The network has recruited primary care and general paediatricians from European and Mediterranean countries. Methods Every paediatrician joining the network has been asked to complete a recruitment survey. The aims of the survey were to characterize paediatrician's demographics, practice arrangements and patient's demographics, to define main incentives for research, and to learn what paediatricians view as unsolved issues that need to be studied. Results A total of 156 paediatricians from 19 countries were recruited with 144 completing the questionnaire (92%). Majority of respondents (89%) were general paediatricians for more than half of their time. Practice arrangement of 47% of paediatricians was solo practice, with 40% in group practice. Electronic medical records were being used by 72% of respondents. Over 70% of the paediatricians had more than 1000 patients under their clinical care, and patients younger than 6 years old contributed nearly half of the patient population. Areas of most interest for research were: quality of care indicators, communication with parents, obesity, attention deficit hyperactivity disorder and effective well child care. Main incentives for participation in a research project were interest in the topic (81%) and effort to improve quality of care (71%). Lack of time was the leading reported obstacle for research activity (72%). EAPRASnet is growing, and the network's structure, operation and funding are described. Methods for joining the network and the process of study development are presented. Conclusion A core group of EAP general paediatricians are committed to research in their practices. The information gathered will serve for future planning of research projects in the EAPRASnet to harmonize and optimize the care given to children in the primary care setting in Europe.     

The actual role of general practice in the Dutch health-care system

A second Dutch national Survey of General Practice was carried out in 2001 with the aim of providing actual information about the role of general practice in the Dutch health-care system for researchers and policy makers. Data were collected on different levels (patients, general practitioners, practices) and included morbidity (self-report and presented to general practitioners), diagnostic and therapeutic interventions, doctor–patient communication, and background characteristics. Compared to 1987 (the first National Survey), Dutch general practitioners had organized their work more efficiently. Patients were less satisfied (78% satisfied) about the organizational aspects of general practice care than about the care actually provided (90% satisfied). Dutch general practitioners provide high-quality care: on average their performance was in 74% of cases in accordance with national guidelines. Communication in general practice had become less social and more medically oriented compared to 1987. General practice still acts in a gatekeeper role; this is illustrated by 96% of contacts handled solely by the general practitioner.This article is based partly on a previously published report: Schellevis FG, Westert GP, Bakker DH de, Grol RPTM, Groenewegen PP, Zee J van der, Bensing JM. Nog altijd poortwachter. Rol en positie huisarts opnieuw in kaart gebracht (in Dutch). Med Contact 2004;59:622–625.     

Preventive care for patients following myocardial infarction. The Wessex Research Network (WReN)

OBJECTIVE: We aimed to assess general practice care for patients following a myocardial infarction (MI). METHOD: A structured review was carried out of general practice records of patients identified from hospital administration data. A total of 266 survivors following MI were identified from the discharge data of 13 hospitals in Southern England and registered with 71 GPs belonging to the Wessex Research Network. Median time since hospital discharge was 2.1 years. The main outcome measures were the provision of appropriate preventive care, including cardiac rehabilitation, drug therapy, and lifestyle advice for modifiable risk factors. RESULTS: Basic care was provided to nearly all patients; 253 (95.1%, 95% Cl 91.8-97.4) had blood pressure documented after their MI, 216 of 234 patients eligible for aspirin (92.3%; 88.1-95.4) had been recommended treatment, and the provision of advice on smoking cessation was documented for 27 of 33 continuing smokers (81.8%; 64.5-93.0). However, only 73 of 236 patients eligible to attend a structured rehabilitation programme (30.9%; 25.0-36.8) were documented as having received rehabilitation. Of 89 patients with heart failure following MI, 33 (37.1%; 27.1-48.0) had no record of having been offered treatment with an ACE inhibitor. Total cholesterol measurement was documented for only 144 patients (54.1%; 48.1-60.1). We estimate that there is still the potential to prevent between 4 and 9 deaths in this group of 266 surviving patients in the next 2 years by further improving the quality of follow-up care. CONCLUSIONS: Preventive care in patients with proven ischaemic heart disease in general practice remains haphazard, even among doctors enthusiastic to participate in research and to audit their quality of care. As general practitioners we should ensure that we are providing high quality preventive care to patients with clinical disease before we focus on the even more demanding task of primary prevention.      

The results of dietary advice on lipoprotein levels among patients attending for lipid-lowering drugs

The aim of this study was to evaluate the changes in fasting lipoproteins levels before and after a dietary advice among the patients attending for a lipid-lowering treatment. In total 286 patients attending for reimbursement of a lipid-lowering drug were recorded at two regional health insurance offices. Lipid levels measured at least three months after the dietary advice were compared with those before the dietary advice. The mean age of the included patients was 61 years. The average fasting total cholesterol (TC) was 7.4 mmol/l before the dietary advice as well as after the dietary advice. Fasting TC did not decrease with the dietary advice in 51% of the included patients. In the logistic regression not one of the studied factors was correlated with a successful dietary advice. Half of the patients receiving lipid-lowering drugs in Belgium were not able to decrease their TC with dietary advice before the initiation of the treatment.     

Epistaxis in general practice

Objective: To explore the way in which general practitioners deal with cases of epistaxis.

Methods: Seventy-three Dutch general practitioners attending a postgraduate continuing education course were presented with a questionnaire regarding their management of epistaxis in general practice.

Results: Eighty-five per cent would initially deal with the question over the telephone. Almost half recommended ‘blowing the nose well, putting pressure on the nose for 10 minutes, tilting the head forwards’. Nearly a quarter gave the inadequate advice to ‘tilt the head backwards’. After failure of the initial advice, over 50% would switch to packing, predominantly using a gauze-cotton tampon. If this proved to be unsuccessful, three-quarters would refer the patient and 15% would resort to coagulation, mostly with trichloroacetic acid, seventy-five per cent a nasal speculum.

Conclusion: Given the non-representative population and the method chosen — reported behaviour — further research will be necessary to determine possible gaps in knowledge.     

The practice guideline 'Pregnancy and puerperium' (first revision) from the Dutch College of General Practitioners; a response from the perspective of general practice medicine

The first revision of the Dutch College of General Practitioners' practice guideline about pregnancy and puerperium does not significantly differ from the first edition. The guideline is extensive, is well-worth reading and supports daily practice. There is a greater emphasis on the importance of cooperation and differentiation in primary care (midwifes and general practitioners). During the last decade many general practitioners stopped doing home deliveries and have therefore lost their experience in obstetric care and pathology. The guideline describes the general practitioner's tasks as a preconception counsellor, a professional expert on illnesses during pregnancy and after the delivery, and as the doctor of the newborn baby. It will hopefully stimulate a revived interest of and involvement in pregnancy and post-partum care among general practitioners.     

The practice guideline 'Diabetes mellitus type 2' (second revision) from the Dutch College of General Practitioners; a response from the perspective of general practice

The publication of the practice guideline 'Diabetes mellitus' by the Dutch College of General Practitioners in 1989 marked the start of an era of publication of several guidelines that helped general practitioners using evidence-based medicine in clinical practice; the guidelines also helped to teach students. The second revision of this guideline presents many improvements, especially simplifications in the medication-schedules. However, the new recommendation to use thiazolidines is based on only one large study and has some unpractical aspects. The new guidelines do not mention preventive action, nor advice regarding early detection. Clinical practice has changed in recent years with the introduction of nurses specialising in diabetes and, despite published research on this subject, the guidelines do not give any recommendations for this. What is also missing are national clinical guidelines for doctors specialising in internal medicine. When patients do not respond to treatment according to the general practitioners' guidelines and are referred to a specialist in internal medicine, the treatment is diverse and seems to be doctor-dependent. It is important that treatment there be standardised as well so that general practitioners can refer more effectively.     

The epidemiology of community paediatric outpatient referrals 2006

Background Wirral University Teaching Hospital is a large district general hospital situated on the Wirral Peninsula, UK. Because of the district's geographical and demographic characteristics, Wirral is an ideal location for population‐based studies. Information on community paediatric referrals, case mix and outcomes is scarce. We took advantage of our situation to conduct an epidemiological study of referrals to community paediatrics in Wirral. A companion paper examines referrals to general paediatricians during the same period. Methods A prospective observational study of community paediatric outpatient referrals between 1 February and 31 May 2006 for all children under the age of 15 offered a new patient appointment during the study period. The study was conducted using the same methodology as a previous population‐based study of community paediatric outpatients in Northampton, UK in 1998. We compared our results with this previous study. Results The referral rate was 10.1 per 1000 children under 15 per annum. School nurses and health visitors made nearly half the referrals, with general practitioners referring most of the remainder. Compared with the Northampton study, more children were seen by consultants. Case mix showed a shift towards behavioural and neurodevelopmental disorders, with less general paediatrics. Attention deficit hyperactivity disorder was the commonest disorder seen (28.2%), a significant increase from the previous study (3.4%) (P < 0.01). Autism spectrum disorder showed little change (8.1% vs. 9.6%; NS). The Wirral study showed significantly more follow‐up compared with the Northampton. Conclusions This population‐based study gives a unique insight into the epidemiology of referrals to community paediatricians in the UK in 2006 and how these differ from those recorded in a different UK district in 1998.