Service profiles of general practitioners in Europe. European GP Task Profile Study.

BACKGROUND: General practice is the focal point of primary care. There are national differences in the structure and organization of practice, the relationship with secondary care is being redefined, and in some countries major changes are taking place. AIM: To describe and examine differences in the service profiles of general practitioners (GPs) in European countries. METHOD: Standardized questionnaires in the national languages were sent to samples of GPs in 1993. Four areas of service provision were measured: the GP's position in the first contact with selected health problems, the involvement in minor surgery and the application of medical procedures, disease management and preventive care. The importance of the gatekeeping role, remuneration system, and geographical region in Europe was examined by comparing scores in appropriate national groupings. RESULTS: Data were received from 7233 GPs in 30 countries. Most national samples were random and the average response rate was 47%. In countries where GPs have a gatekeeping role, they had a relatively stronger position as doctors of first contact. In those countries where GPs were usually self-employed, they had a stronger role in disease management and screening for blood cholesterol. In the examination of the three structural elements of health care, the most striking differences were evident in the comparison between eastern and western Europe. GPs throughout Europe had a comparatively small role in organized health education. CONCLUSION: The position of GPs is weak in eastern Europe and some Mediterranean countries, where service profiles have a limited range. General practice was more comprehensive where the doctors had a gatekeeping role.     

Research into the results of resection of hilar bile duct cancer

We found mentions of 581 resections of hilar bile duct cancer in the literature to January 1989. Resection in 499 patients, reported or updated since 1980, resulted in an operative mortality of 12% and a 5-year survival rate of 13%. Resections confined to the hepatic duct confluence or extended to the quadrate lobe led to an 8% operative mortality and a 7% 5-year survival rate, although resections combined with major liver resection gave a 15% operative mortality and a 17% 5-year survival rate. Despite the best treatments available, present-day resection modalities are usually still not radical. Extension of resection in the retrohilar and hepatoduodenal direction might further improve the long-term surgical results.     

Comparative expression profiling in primary and immortalized endothelial cells: changes in gene expression in response to hydroxy methylglutaryl-coenzyme A reductase inhibition.

Immortalized cell lines offer significant logistical advantages over primary cells when used for in-vitro studies. Immortalized cells may, however, exhibit important differences relative to their primary cell counterparts. In this study, microarrays were used to make a genome-wide comparison between primary human umbilical vein endothelial cells (HUVECs) and EA.hy926, an immortalized HUVEC cell line, in their baseline properties and in their response to inhibition of the mevalonate pathway with an inhibitor of hydroxy methylglutaryl-coenzyme A reductase (statin). HUVECs and EA.hy926 were incubated with control medium, atorvastatin, mevalonate, or a combination of atorvastatin and mevalonate for 24 h. Gene expression profiles were obtained in duplicates using Affymetrix Human Genome U133A 2.0 arrays (Santa Clara, California, USA). Probe-sets were selected according to the following criteria: a twofold or greater increase/decrease in atorvastatin-treated cells compared with untreated cells; a twofold or greater reversal of the effect of atorvastatin by combined treatment with atorvastatin and mevalonate; no significant change in gene expression in cells treated with mevalonate alone compared with untreated cells. Most genes that were expressed by untreated HUVECs, were also expressed by untreated EA.hy926 cells. EA.hy926 cells, however, constitutively expressed a large number of additional genes, many of which were related to cell cycle control and apoptosis. Atorvastatin induced differential expression (> or = twofold) of 103 genes in HUVECs (10 up, 93 down) and 466 genes in EA.hy926 cells (198 up, 268 down). Applying the above selection criteria, thrombomodulin and tissue plasminogen activator were up-regulated in both cell types, whereas, connective tissue growth factor, thrombospondin-1, and cysteine-rich angiogenic inducer 61 were down-regulated. In conclusion, EA.hy926 cells retain most of the characteristics of endothelial cells under baseline conditions as well as after treatment with atorvastatin. It is necessary, however, to carefully select and validate changes in genes that are the focus of studies when using EA.hy926 cells. While this cell line is highly useful in studies on some genes, including genes encoding molecules involved in regulating thrombohemorrhagic homeostasis, they appear to be less suited for studies focused on other genes, particularly those involved in the regulation of cell proliferation and apoptosis.     

Local housing scheme and political preference as conditions for the results of a health centre-stimulating policy in The Netherlands.

About two decades ago, changes in the demand for primary care in the Netherlands resulted in a need for more interprofessional collaboration. Health centres developed as a new supply of integrated care. The government was aware of the importance of this phenomenon in its policy to strengthen primary care. The encouragement of health centres was a crucial part of it. The development of this policy and the resulting growth in the number of health centres will be reviewed here. In general, this growth is lagging behind initial policy expectations, partly because of a lack of instruments to implement PHC policy. Examination of geographical distribution of health centres, however, shows a variation suggesting that local factors also affect the development of health centres. Empirical findings show that the number of newly built houses in an area and the political 'colour' of the alderman for public health play a role in the development of health centres and thus co-determine the results of a central promotion policy to a certain extent.     

Thermo-oxidative degradation of polyamide 6 and polyamide 6,6. Structure of UV/VIS-active chromophores

In heat-treated polyamide 6 and polyamide 6,6 fibres UV/VIS-active chromophores are found, which originate from two different sources: one type of chromophore (structured UV spectrum) arises during polycondensation and the spinning of the fibres (molten phase), the other (nonstructured UV spectrum) occurs as a result of a thermo-oxidation is based on conjugated oligoenimies , as is shown by a combination of UV/VIS spectroscopy and fluorescence excitation and emission spectroscopy with chemical analysis. The concentration of the various oligoenimine species depends upon the temperature and duration of the thermooxidation. For a temperature of 160°C and a duration of 2 hours, for example, the following oligoenimine concentrations were found (UV spectroscopy with computer-aided evaluation): for i = 0: 44; i = 1: 13; i = 2: 4; i = 3: 1; i = 4: 0,3 (values expressed in mmol/kg).     

A model for the evaluation of search queries in medical bibliographic sources

The aim of this study was to develop a model to evaluate the retrieval quality of search queries performed by Dutch general practitioners using the printed Index Medicus, MEDLINE on CD-ROM, and MEDLINE through GRATEFUL MED. Four search queries related to general practice were formulated for a continuing medical education course in literature searching. The selected potential relevant citations from the course instructor and the 103 course participants together served as the basic set for the three judges to evaluate for (a) relevance and (b) quality, with the latter based on journal ranking, research design and publication type. Relevant individual citations received a citation quality score from 1 (low) to 4 (high). The overall search quality was expressed in a formula, which included the individual citation quality score of the selected and missed relevant citations, and the number of selected non-relevant citations. The outcome measures were the number and quality of relevant citations and agreement between the judges. Out of 864 citations, 139 were assessed as relevant, of which 44 citations received an individual citation quality score of 1, 76 of 2, 19 of 3 and none of 4. The level of agreement between the judges was 68% for the relevant citations, and 88% for the non-relevant citations. We describe a model for the evaluation of search queries based not only on the relevance, but also on the quality of the citations retrieved. With adaptation, this model could be generalized to other professional users, and to other bibliographic sources.     

Long-term results of suture rectopexy in patients with fecal incontinence associated with incomplete rectal prolapse

Suture rectopexy is the recommended therapy for complete rectal prolapse that is associated with fecal incontinence. It has been suggested that correction of an incomplete rectal prolapse is also worthwhile for patients with fecal incontinence. PURPOSE: Aims of this study were 1) to evaluate the clinical outcome of suture rectopexy in a consecutive series of patients with incomplete rectal prolapse associated with fecal incontinence, and 2) to compare these results with those obtained from patients with complete rectal prolapse. METHODS: Between 1979 and 1994, suture rectopexy was performed in 13 incontinent patients (3 males; median age, 65 (range, 45–77) years) with incomplete rectal prolapse (Group I) and in 24 incontinent patients (21 females; median age, 71 (range, 24–86) years) with complete rectal prolapse (Group II). RESULTS: After a median follow-up of 67 months, continence was restored in 5 of 13 (38 percent) patients with incomplete rectal prolapse and in 16 of 24 (67 percent) patients with complete rectal prolapse. In both groups, all male patients became continent. CONCLUSIONS: For the majority of incontinent patients with incomplete rectal prolapse, a suture rectopexy is not beneficial. The clinical outcome of this procedure is only good in incontinent patients with complete rectal prolapse. Based on these data, it is questionable whether incomplete rectal prolapse plays a causative role in fecal incontinence.Read at the meeting of the International Society of University Colon and Rectal Surgeons, Lisboa, Portugal, April 14 to 18, 1996.No reprints are available.     

Filter run time in CVVH: pre- versus post-dilution and nadroparin versus regional heparin-protamine anticoagulation

BACKGROUND/AIMS: To study the effect of different modes of continuous veno-venous haemofiltration (CVVH) on filter run time (FRT). METHODS: We studied, in two consecutive prospective, randomised and crossover studies, 16 and 15 patients with acute renal failure during critical illness. Study A compared pre- versus post-dilution, and study B compared regional anticoagulation with heparin (pre-filter) and protamine (post-filter) (HP) versus nadroparin (NP) pre-filter. All CVVH sessions were standardised. Analyses were by Wilcoxon rank sum tests. RESULTS: Study A: During pre-dilution the median FRT was 45.7 vs. 16.1 h in post-dilution CVVH (p = 0.005). The median creatinine clearance during pre-dilution was 33 vs. 45 ml/min in post-dilution (p = 0.001). Study B: During NP, median FRT was 39.5 vs. 12.3 h during HP CVVH (p = 0.045). CONCLUSIONS: Pre-dilution CVVH results in the greatest FRT but a lower plasma creatinine clearance compared to post-dilution. Regional anticoagulation with heparin-protamine resulted in a significantly shorter FRT compared to systemic NP anticoagulation.     

The strength of primary care in Europe: an international comparative study

Background

A suitable definition of primary care to capture the variety of prevailing international organisation and service-delivery models is lacking.

Aim

Evaluation of strength of primary care in Europe.

Design and setting

International comparative cross-sectional study performed in 2009–2010, involving 27 EU member states, plus Iceland, Norway, Switzerland, and Turkey.

Method

Outcome measures covered three dimensions of primary care structure: primary care governance, economic conditions of primary care, and primary care workforce development; and four dimensions of primary care service-delivery process: accessibility, comprehensiveness, continuity, and coordination of primary care. The primary care dimensions were operationalised by a total of 77 indicators for which data were collected in 31 countries. Data sources included national and international literature, governmental publications, statistical databases, and experts’ consultations.

Results

Countries with relatively strong primary care are Belgium, Denmark, Estonia, Finland, Lithuania, the Netherlands, Portugal, Slovenia, Spain, and the UK. Countries either have many primary care policies and regulations in place, combined with good financial coverage and resources, and adequate primary care workforce conditions, or have consistently only few of these primary care structures in place. There is no correlation between the access, continuity, coordination, and comprehensiveness of primary care of countries.

Conclusion

Variation is shown in the strength of primary care across Europe, indicating a discrepancy in the responsibility given to primary care in national and international policy initiatives and the needed investments in primary care to solve, for example, future shortages of workforce. Countries are consistent in their primary care focus on all important structure dimensions. Countries need to improve their primary care information infrastructure to facilitate primary care performance management.