Patient characteristics and factors contributing to recurrence of bacterial vaginosis presented in primary care

BACKGROUND

Bacterial vaginosis (BV) is a common problem in primary care. BV symptoms often have a negative impact on patients' quality of life and may predispose to gynaecological problems. Some patients experience recurring episodes of BV. This study's objective is to identify possible factors that may be associated with BV recurrence and describe the characteristics of these patients and interventions performed by general practitioners.

METHODS

In this retrospective cohort study, we used data from a primary care registration network in the Netherlands in the period 2015-2020. We analysed differences between patients with recurrent BV and patients with a single episode of BV in terms of characteristics and interventions performed by general practitioners.

RESULTS

We found that patients with recently prescribed antibiotics, and a medical history of sexually transmitted infections and/or Candidiasis significantly more often presented with recurrent BV. Patients with recurrent BV had more remote consultations and less in-person consultations than single-episode patients. The reason for encounter was more often a request for medication. Regarding GPs' diagnostic and therapeutic interventions, microbiological tests were more frequently performed in recurrent BV patients. Moreover, most patients in both groups were prescribed oral metronidazole most frequently.

CONCLUSIONS

Our findings might help GPs to better recognise patients at risk of recurrence. GPs could re-evaluate their approach to the diagnosis and treatment of recurrent BV, opting for in-person consultation and using standardised diagnostic criteria and microbiological testing in patients with recurrent complaints. Antibiotic use for other conditions in these patients may lead to new BV episodes.

Effect of Pessary vs Surgery on Patient-Reported Improvement in Patients With Symptomatic Pelvic Organ Prolapse: A Randomized Clinical Trial

IMPORTANCE

Pelvic organ prolapse is a prevalent condition among women that negatively affects their quality of life. With increasing life expectancy, the global need for cost-effective care for women with pelvic organ prolapse will continue to increase.

OBJECTIVE

To investigate whether treatment with a pessary is noninferior to surgery among patients with symptomatic pelvic organ prolapse.

DESIGN, SETTING, AND PARTICIPANTS

The PEOPLE project was a noninferiority randomized clinical trial conducted in 21 participating hospitals in the Netherlands. A total of 1605 women with symptomatic stage 2 or greater pelvic organ prolapse were requested to participate between March 2015 through November 2019; 440 gave informed consent. Final 24-month follow-up ended at June 30, 2022.

INTERVENTIONS

Two hundred eighteen participants were randomized to receive pessary treatment and 222 to surgery.

MAIN OUTCOMES AND MEASURES

The primary outcome was subjective patient-reported improvement at 24 months, measured with the Patient Global Impression of Improvement scale, a 7-point Likert scale ranging from very much better to very much worse. This scale was dichotomized as successful, defined as much better or very much better, vs nonsuccessful treatment. The noninferiority margin was set at 10 percentage points risk difference. Data of crossover between therapies and adverse events were captured.

RESULTS

Among 440 patients who were randomized (mean [SD] age, 64.7 [9.29] years), 173 (79.3%) in the pessary group and 162 (73.3%) in the surgery group completed the trial at 24 months. In the population, analyzed as randomized, subjective improvement was reported by 132 of 173 (76.3%) in the pessary group vs 132 of 162 (81.5%) in the surgery group (risk difference, -6.1% [1-sided 95% CI, -12.7 to ∞]; P value for noninferiority, .16). The per-protocol analysis showed a similar result for subjective improvement with 52 of 74 (70.3%) in the pessary group vs 125 of 150 (83.3%) in the surgery group (risk difference, -13.1% [1-sided 95% CI, -23.0 to ∞]; P value for noninferiority, .69). Crossover from pessary to surgery occurred among 118 of 218 (54.1%) participants. The most common adverse event among pessary users was discomfort (42.7%) vs urinary tract infection (9%) following surgery.

CONCLUSIONS AND RELEVANCE

Among patients with symptomatic pelvic organ prolapse, an initial strategy of pessary therapy, compared with surgery, did not meet criteria for noninferiority with regard to patient-reported improvement at 24 months. Interpretation is limited by loss to follow-up and the large amount of participant crossover from pessary therapy to surgery.

TRIAL REGISTRATION

Netherlands Trial Register Identifier: NTR4883.

Female Sexual Functioning in Women With a Symptomatic Pelvic Organ Prolapse; A Multicenter Prospective Comparative Study Between Pessary and Surgery

BACKGROUND

Female pelvic organ prolapse (POP) has a negative effect on female sexual functioning and with an increasing life expectancy female sexual dysfunction caused by POP will be an arising global issue.

AIM

Improvement in female sexual functioning, measured with the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire IUGA-Revised (PISQ-IR), 24-months after pessary or surgery, for both sexually active (SA) and sexually inactive women (NSA) presenting with POP.

METHODS

A multicenter prospective comparative cohort study was conducted in 22 Dutch hospitals. Women referred with moderate to severe POP symptoms and POP stage ≥ 2 were included and chose either pessary therapy or surgical intervention. The PISQ-IR was filled in at baseline and 24-months, the delta of change was calculated and compared between both groups. Multivariate linear regression was performed to adjust for potential confounding factors in the association between the summary score of the PISQ-IR and therapy.

OUTCOMES

Change in PISQ-IR between pessary and surgical intervention.

RESULTS

The delta of change at 24-months was calculated for 198 women in the pessary group and 129 women in the surgery group. SA women in the surgery group reported statistically significant more improvement on the condition-specific (-0.19 95%CI -0.35; -0.03, P = .02), and condition-impact (-0.48 95%CI -0.69; -0.28, P < .001) domains as well as on the summary score (-0.15 95%CI -0.23; -0.08, P < .001) as compared to the pessary group. No significant differences between pessary and surgery were found on the domains for NSA women. After controlling for potential baseline confounders, surgery still had a statistically significant effect on the summary score (B = 0.08; 95%CI interval 0.007-0.15, P = .03). Women having surgery had 2.62 times higher odds of changing from NSA to SA than pessary therapy.

CLINICAL IMPLICATIONS

SA women who clearly express that POP-related symptoms limit their sexual functioning should be counseled that surgery results in a more remarkable improvement.

STRENGTHS & LIMITATIONS

Our strengths include the large sample size, long-term follow-up, the use of the PISQ-IR as a validated outcome tool evaluating both SA and NSA women, and this study reflects real-life clinical practice that enhances the external validity of the findings. A limitation of our study is the considerable proportion of non-responders at 24-months follow-up.

CONCLUSION

Sexual function in SA women with POP is superior in case surgery is performed as compared to pessary therapy. van der Vaart LR, Vollebregt A, Pruijssers B, et al. Female Sexual Functioning in Women With a Symptomatic Pelvic Organ Prolapse; A Multicenter Prospective Comparative Study Between Pessary and Surgery. J Sex Med 2022;19:270-279.

Pessary or surgery for a symptomatic pelvic organ prolapse: the PEOPLE study, a multicentre prospective cohort study

OBJECTIVE

To compare the 24-month efficacy of pessary or surgery as the primary treatment for symptomatic pelvic organ prolapse (POP).

DESIGN

Multicentre prospective comparative cohort study.

SETTING

Twenty-two Dutch hospitals.

POPULATION

Women referred with symptomatic POP of stage ≥2 and moderate-to-severe POP symptoms.

METHODS

The primary outcome was subjective improvement at the 24-month follow-up according to the Patient Global Impression of Improvement (PGI-I) scale. Secondary outcomes included improvement in prolapse-related symptoms measured with the Pelvic Floor Distress Inventory (PFDI-20), improvement in subjective severeness of symptoms according to the Patient Global Impression of Severity (PGI-S) scale and crossover between therapies. The primary safety outcome was the occurrence of adverse events.

MAIN OUTCOME MEASURE

PGI-I at 24 months.

RESULTS

We included 539 women, with 335 women (62.2%) in the pessary arm and 204 women (37.8%) in the surgery arm. After 24 months, subjective improvement was reported by 134 women (83.8%) in the surgery group compared with 180 women (74.4%) in the pessary group (risk difference 9.4%, 95% CI 1.4-17.3%, P < 0.01). Seventy-nine women (23.6%) switched from pessary to surgery and 22 women (10.8%) in the surgery group underwent additional treatment. Both groups showed a significant reduction in bothersome POP symptoms (P ≤ 0.01) and a reduction in the perceived severity of symptoms (P ≤ 0.001) compared with the baseline.

CONCLUSIONS

Significantly more women in the surgery group reported a subjective improvement after 24 months. Both therapies, however, showed a clinically significant improvement of prolapse symptoms.

TWEETABLE ABSTRACT

Pessary treatment and vaginal surgery are both efficacious in reducing the presence and severity of prolapse symptoms, although the chance of significant improvement is higher following surgery.

Work-relatedness of the presented health problem and sickness absence

BACKGROUND

Perception by workers of their health problems as work-related is possibly associated with sickness absence (SA). The aim of this study was to to study the relationship between perceived work-relatedness of health problems and SA among workers who visit their GP, taking the influence of other potential determinants into account and to study the influence of these determinants on SA. Design and setting prospective cohort study in 32 Dutch GP practices.

METHODS

A secondary analysis of RCT data among workers, aged 18-63 years, who visited their GP. We measured self-reported SA days in 12 months and high SA (>20 days in 12 months) and compared workers who perceived work-relatedness (WR+) with workers who did not (WR-). With multivariable linear and logistic regression models, we analyzed the influence of age, gender, experienced health, chronic illness, prior SA, number of GP consultations and perceived work ability.

RESULTS

We analyzed data of 209 workers, 31% perceived work-relatedness. Geometric mean of SA days was 1.6 (95% CI: 0.9-3.0) for WR+- workers and 1.2 (95% CI: 0.8-1.8) for WR- workers (P = 0.42). Incidence of high SA was 21.5 and 13.3%, respectively (odds ratio 1.79; 95% CI: 0.84-3.84). SA was positively associated with chronic illness, prior SA, low perceived work ability and age over 50.

CONCLUSIONS

Perceived work-relatedness was not associated with SA. SA was associated with chronic illness, prior SA, low perceived work ability and age over 50.

Women's appraisal of the management of vulvodynia by their general practitioner: a qualitative study

BACKGROUND

Provoked Vulvodynia (PVD) is the most common cause of vulvar pain. General practitioners (GPs) are insufficiently familiar with it, causing a delay in many women receiving correct diagnosis and treatment. Besides patients factors, this delay can partly be explained by the reluctance of GPs to explore the sexual context of PVD and by their negative emotional reactions such as helplessness and frustration when consulted by patients with medically unexplained symptoms like PVD.

OBJECTIVE

To gain insight into how women with PVD perceive and evaluate condition management by their GP, in order to support GPs in the consultation of women with PVD.

METHODS

We performed face-to-face in-depth interviews with women diagnosed with PVD. The interviews were recorded, transcribed verbatim and thematically analysed. The Consolidated Criteria for reporting Qualitative Research (COREQ-criteria) were applied.

RESULTS

Analysis of the interviews generated four interrelated themes: Doctor-patient relationship, Lack of knowledge, Referral process and Addressing sexual issues. Empathy of the GP, involvement in decision-making and referral were important factors in the appreciation of the consultation for women with PVD who were referred to a specialist. Because women were reluctant to start a discussion about sexuality, they expected a proactive attitude from their GP. The communication with and the competence of the GP ultimately proved more important in the contact than the gender of the GP.

CONCLUSION

Women with PVD prefer a patient-centred approach and want GPs to acknowledge their autonomy and to address sexuality proactively.

Facilitators and barriers in the diagnostic process of vulvovaginal complaints (vulvodynia) in general practice: a qualitative study

BACKGROUND

The gap between the relatively high prevalence of provoked vulvodynia (PVD) in the general population and the low incidence in primary care can partly be explained by physicians' lack of knowledge about the assessment and management of PVD.

OBJECTIVES

To recognize barriers and facilitators of GPs in the diagnostic process of women presenting with recurrent vulvovaginal complaints.

METHODS

A qualitative focus group study in 17 Dutch GPs, five men and 12 women. An interview guide, based on the scientific literature and the expertise of the researchers, including a vignette of a patient, was used to direct the discussion between the GPs. The interviews were audiotaped and transcribed verbatim. A systematic text analysis of the transcripts was performed after data saturation was reached.

RESULTS

Analysis of the interviews generated three major themes: Identifying and discussing sexual complaints, importance of gender in professional experience, and coping with professional uncertainty. Within these themes, the reluctance regarding sexual complaints, male gender, negative emotional responses when faced with professional uncertainty, as well as lack of education were barriers to the diagnostic process and management of PVD. Female gender and understanding that patients can profit from enquiring about sexual health issues were found to be facilitating factors.

CONCLUSIONS

To improve the care for women with PVD, attitude and skills of GPs regarding taking a sexual history and performing a vulvovaginal examination should be addressed, as well as GPs' coping strategies regarding their professional uncertainty.

Health information exchange in general practice care for people with intellectual disabilities--a qualitative review of the literature

Many barriers to the provision of general practice (GP) care for people with intellectual disabilities (ID) relate to problems in exchanging health information. Deficits in the exchange of health information may have an adverse impact on healthcare access and health outcomes in individuals with ID. The aim of this paper is to report how health information exchange (HIE) in GP care for people with ID is being described in the ID healthcare literature. Thematic analysis of 19 included articles resulted in six major themes: (1) communication skills; (2) organisational factors; (3) record keeping and sharing; (4) health literacy and self-advocacy; (5) carers and health professionals' knowledge; and (6) third parties. The results indicate that HIE takes place in a chain of events happening before, during, and after a medical consultation, depending on specific contextual care factors. The included papers lack a broad focus on the entire HIE process, and causes and effects of gaps in health information are described only marginally or on a very general level. However, a study of the HIE process in its entirety is imperative in order to identify weak links and gaps in information pathways. The themes presented here provide a starting point for an in-depth study on the HIE process in GP care for individuals with ID that may facilitate future research on health interventions in this setting.

[A fresh look at psychiatric disorders]

BACKGROUND

The a-theoretical approach to psychiatric disorders, introduced via dsm iii, has had a tremendous impact. It has stimulated a large body of research, facilitated by the concurrent development of new techniques in genetics, neuro-imaging and neuropsychology. However, the research results of the last twenty years or so have cast doubt on the validity of the clinical categories set out in dsm iii.

AIM

To develop a new view on developmental pathways in psychopathology, clinical assessment and scientifically acceptable classification.

METHOD

In this article we review the state of the art with regard to underlying endophenotypes at the level of brain and neurotransmitter functioning and neuropsychology and we consider the effect of social determinants on the developments of psychopathology.

RESULTS

Our results show that neither genotypes and endophenotypes, nor brain mechanism, nor neuropsychological deviances have a one-to-one correlation with clinical categories as defined in even the dsm 5.

CONCLUSION

dsm-5 provides a range of possibilities for classifying psychiatric disorders at symptom level. But these categories seem to be less distinct than was at first assumed. Recent research has shown that there is a great deal of overlap at the genetic, epigenetic and endophenotype level. This calls for more emphasis on individual assessment and diagnostics in both clinical practice and scientific research. More attention needs to be given to the dimensions of emotion and behavior, vulnerability and resilience. This type of approach, involving genotypes, endophenotypes, epigenetics and brain functioning, could help to elucidate the interaction between these various levels and/or explain the underlying mechanisms of psychiatric disorders.

[Fecal incontinence in community-dwelling elderly: findings from a study of prevalence, consultation of physicians, psychosocial aspects and treatment]

OBJECTIVE

To gain insight into the prevalence of faecal incontinence, looking for medical attention, treatment and the impact of faecal incontinence on the quality of life in community-residing men and women of 60 years and over.

DESIGN

Enquiry and interview.

METHOD

A questionnaire about the incidence of faecal incontinence and the request for help from the family doctor was mailed in 2000 to persons aged 60 and older listed in seven general practices in and round Nijmegen. In an interview with persons with faecal incontinence questions were asked about the need for assistance and the psychosocial consequences of the incontinence.

RESULTS

Of the 3887 questionnaires mailed, 3345 were available for analysis, from 1536 males and 1809 females. The prevalence of faecal incontinence was 6%. The male-female distribution was equal and a rise in prevalence was seen with advancing age. One-third of the population discussed the incontinence with their physician, more women (58%) than men (42%). The faecal incontinence had hardly any impact on daily or social activities but the subjects did feel anxiety, shame or frustration. Treatment, if given (14/17), consisted of a prescription for diapers (n = 2) or of referral to an internist for examination of the intestines (n = 4).

CONCLUSION

Faecal incontinence occurred in 6% of persons aged 60 or older living independently. Explicit looking for medical attention was not common. There were hardly any male-female differences. The most impact on the quality of life concerned the emotional wellbeing. Treatment had a little effect.

The effects of physiotherapy for female urinary incontinence: individual compared with group treatment

OBJECTIVES

To compare, in a randomized trial, the effects of individual and group physiotherapy for urinary incontinence in women referred by their general practitioner (GP).

PATIENTS AND METHODS

The study included women of all ages (mean 47.8 years) with stress, urge or mixed incontinence; 126 received individual and 404 group treatment. Both groups undertook the same pelvic floor exercises and bladder training, and received the same information. The effects were measured soon after treatment and again 9 months later. The main outcome measures were objective changes in the severity of incontinence, frequency of urine loss and frequency of nocturnal urine loss. The trial was nationwide; 25 physiotherapists and 337 GPs participated.

RESULTS

There were no significant differences in effect between the groups; after individual treatment the severity of incontinence improved in 60% of the patients and the mean (95% confidence interval, CI) frequency of urine loss decreased, by -8.7 (-6.4 to -11.1) times/week. After group therapy continence improved in 57% and the frequency of urine loss decreased, by -8.4 (-6.8 to -10.0) times/week. For women who had nocturnal urine loss (at baseline), the frequency decreased after individual treatment by -11.2 (4 to -26.4) and after group therapy by -14 (-9.1 to -18.9) times/month. All improvements persisted in full for up to 9 months.

CONCLUSION

Individual and group physiotherapy are equally effective for at least 9 months in improving incontinence in women. Factors should be sought that can predict the effectiveness of therapy, and thus better select those patients most likely to benefit from therapy.

[Fecal incontinence: prevalence and role of rupture of the anal sphincter during delivery; literature analysis]

OBJECTIVE

To obtain insight regarding the prevalence of faecal incontinence according to age and sex and the influence of an anal sphincter rupture during vaginal delivery on its development.

METHOD

Literature search in Medline (1966-May 1998), Huisarts en Wetenschap (1972-1997) and Nederlands Tijdschrift voor Geneeskunde (1986-1997).

RESULTS

The prevalence of faecal incontinence was 0.75-2.2% of the adult population, increasing to 2.8-9% at the age of 65 years and older. Among people aged 85 years and older and those living in homes for the aged, the prevalence was much higher (up to 16.7%). There was no clear difference between the sexes, but dependable research on sex differences at a younger age did not exist. There was a significantly higher risk of developing faecal incontinence after an intrapartum anal sphincter rupture, compared to women without an anal sphincter rupture. This difference persisted until 30 years postpartum, but disappeared afterwards. A possible explanation is a persistent anal sphincter defect, despite surgical repair immediately postpartum. Decreased innervation of the sphincter may also play a role.

CONCLUSION

Faecal incontinence is a frequent problem, especially in the elderly. There is no clear sex difference in prevalence. In younger women, there is a higher risk of developing faecal incontinence after an anal sphincter rupture during a vaginal delivery. This is probably due to a persistent sphincter defect in combination with decreased innervation of the sphincter.

[Angina pectoris and myocardial infarction: sex differences in risk profile, prognosis and referral by family physician]

OBJECTIVE

To detect possible sex differences in risk factors, referrals and prognosis after angina pectoris (AP) and myocardial infarction (MI).

DESIGN

Retrospective.

METHOD

From 4 general practices in/around Nijmegen, the Netherlands, patients were selected who in 1985-1989 had a first episode of AP or a first MI. Sex differences regarding risk factors, referrals and prognosis were studied by means of patients' files.

RESULTS

There were 71 men and 55 women with AP and 97 men and 58 women with MI. Mean age in AP was 69.6 year in women and 63.6 year in men, mean ages in MI were 74.9 and 64.4 year, respectively. Women with MI more frequently suffered from hypertension, AP or CVA/transient ischaemic attack (TIA). Men with MI were referred more often to a specialist than women, but not sooner. Development of cardiovascular co-morbidity after AP and after recovery from a MI were the same for both sexes. Of all patients with a MI 36% suffered a sudden unexpected death, mostly women.

CONCLUSION

Women with a first episode of AP and a MI were 6-10 years older than men. Women with a MI suffered more frequently from hypertension, AP and CVA/TIA. The prognosis after angina pectoris showed no sex differences. The prognosis after MI was worse in women than in men.

[Angina pectoris and normal coronary arteries: prevalence and prognosis in men and women]

OBJECTIVE

To determine whether women with anamnestic suspicion of angina pectoris more often than men with suspicion of angina pectoris have normal coronary arteries on coronary arteriograms. Second, to compare the prognosis of these patients with that of the mean population.

DESIGN

Literature study.

METHOD

Articles were selected from Medline over the period 1966 to May 1998 with the use of search terms, and in De geïnformeerde huisarts (The informed GP) over 1992 to November 1998 following which the relevance of the articles was assessed on the basis of title and abstract. Data on the prognosis of the general population were obtained from a WHO project.

RESULTS

Three articles were selected about sex differences in the presence of angiographically normal coronary arteries in patients with suspected angina pectoris. In 2 articles normal coronary arteries were found more often in women (40-41%) than in men (8-12%). In 1 article women were found to have less severe and extensive coronary artery disease then men. Eight articles were selected about the prognosis of patients with suspected angina pectoris and angiographically normal coronary arteries. Per 1000 patient years the total number of deaths ranged from 0 to 6.59 (weighted mean: 4.05), the number of deaths due to coronary disease from 0 to 0.92 (0.47) and the number of patients with non fatal myocardial infarctions from 0 to 1.83 (0.94). These figures were similar to those in an average population.

CONCLUSION

Women with anamnestic suspicion of angina pectoris have normal coronary angiograms more often than mean with anamnestic suspicion of angina pectoris. The prognosis of patients with suspected angina pectoris and normal coronary arteries in terms of mortality and number of non fatal myocardial infarctions is the same as in the general population.

Sex differences in cardiovascular disease: are women with low socioeconomic status at high risk?

BACKGROUND

Cardiovascular disease is still portrayed as a typical male disease, and men are more often submitted to invasive procedures or referred earlier.

AIM

To explore sex differences in morbidity and referral patterns in cardiovascular disease in general practice, and the role of age and socioeconomic status.

METHOD

Data were obtained from a continuous morbidity registration project in the Netherlands from 1986 to 1995 in which 12,000 patients were followed over 10 years. The effects of sex, age, and socioeconomic status on morbidity of cardiovascular disease and the referral patterns were established.

RESULTS

The sex difference in morbidity becomes smaller with increasing age. Morbidity was highest in the lower socioeconomic status in general and for angina pectoris in particular. Women with angina pectoris with low socioeconomic status have a relative risk of 2.24 (CI = 1.17-3.26) compared with women with high socioeconomic status. In men, no significant difference was found between the socioeconomic status groups. For angina pectoris the sex difference in referral to the specialist was most significant: 50.6% and 26.6% (P = 0.002) for men and women respectively.

CONCLUSION

For women, low socioeconomic status was associated with relatively higher morbidity of angina pectoris and myocardial infarction than for men. Women are less likely to be referred than men are, in particular for angina pectoris.

[The 'Osteoporosis' guideline of the Dutch College of General Practitioners; response from family practice]

The guideline gives a well considered view of the management of osteoporosis. According to the characteristics of general practice the guideline emphasises good information to patients about lifestyle and nutrition. There is a strong advice against screening for osteoporosis. Case-finding of high risk patients in general practice meets a reticent attitude. The guideline indicates precisely the conditions to consider interventions by drugs. The decision to start drug therapy can only be made after adequate information in consultation with the patient. The management of osteoporosis needs much more reserve than most physicians and patients (want to) know.

[Clinical diagnosis and decision in practice. A young woman with back pain]

A woman aged 23 visited the GP because of nagging back pain at the level of L.2-L.3. In spite of the atypical symptom, the GP made the diagnosis of 'back pain of myogenic origin', possibly the result of camping in inclement weather. When the pain was still present after one week, the patient coughed, produced greyish-green mucus, was dyspnoeic, had 38.5 degrees C fever, while crepitations and reduced breathing sounds were heard in the right lower lung fields, the working diagnosis of 'pneumonia' was made. No laboratory studies were done; X-ray diagnostics and a good response to antibiotic treatment confirmed the diagnosis. After the symptoms recurred and patient's use of an oral contraceptive was established, she was examined for 'pulmonary embolism'. After this condition was shown to be likely, anticoagulant treatment was instituted, which led to rapid recovery.

[The ambiguity of the difference]

The article concentrates on the process of diagnosing disease, especially of common health problems. The biomedical concept dominates medicine in our days. However, the majority of the complaints presented to the general practician cannot be classified as distinct disease entities. An integral concept is far more suitable to integrate biomedical and psychosocial factors. In this way biomedical aspects acquire significance within an individual life story and social context in which gender plays a role. That is why the integral concept is more adequate to focus on sex differences in the diagnostic process. The article describes the impediments in this process, mainly due to the fact the prevailing concepts of disease ignore sex differences.

[Sex differences in angina pectoris; a literature study]

OBJECTIVE

To gain insight into differences in frequency, presentation and course of angina pectoris between males and females.

DESIGN

Literature study.

SETTING

Department of General Practice, Social Medicine and Nursing Home Medicine, University of Nijmegen, the Netherlands.

METHODS

Articles were selected by automatized search systems (Nederlands Tijdschrift voor Geneeskunde, Huisarts en Wetenschap, Medline, FAMLI), with use of search terms, following which the relevance of the articles was assessed on the basis of title and abstract. Use was also made of publications on four major Dutch registration systems of general practices.

RESULTS

The four articles on incidence and prevalence showed that angina pectoris occurs as often in males as in females. However, females on average were 10 years older at onset. In females, angina pectoris was more frequently the first manifestation of cardiovascular disease, as against myocardial infarction in males. No articles on research into the sex differences in presentation of angina pectoris were found. The course of angina pectoris (five articles) were more favourable in females: they less often developed myocardial infarction and the mortality rates after 5 and after 9 years were lower.

CONCLUSION

There were no differences between males and females in the frequency of angina pectoris, but in females the prognosis is better.

Sex differences in health problems, diagnostic testing, and referral in primary care

BACKGROUND

The aim of the study was to investigate sex differences in health problems and in the use of referrals for additional diagnostic procedures, specialists, and paramedical care in the primary care setting.

METHODS

Data stored from 1988 to 1992 by the continuous morbidity registration project of the department of general practice at Nijmegen University were used. The study population consisted of about 60,000 general practice male and female patients of all ages. Recorded health problems, diagnostic investigations, and referrals to specialists were assessed and analyzed. Health problems were categorized into diagnostic rubrics according to the International Classification of Health Problems in Primary Care (ICHPCC-2).

RESULTS

Women presented with more health problems (2286 vs 1598 per 1000 patients per year) and made greater use of secondary medical care (603 vs 376 referred diagnoses per 1000 patients per year) than men, especially in the age group of 25 to 44 years. The category of screening and health education accounted for more than 30% of the sex difference with reference to the diagnostic rubrics overall. When this category was combined with obstetrical diagnoses (9.4%) and diseases of the genitourinary system (18.1%), 60% of the sex difference between men and women was accounted for. Over 60% of the higher overall use of secondary medical care by women was in the prevention and health education category. Mental disorders did not play a major role in the greater overall use of medical care by women.

CONCLUSIONS

Screening tests and health education play a major role in the greater number of health problems presented by women in primary care and in the greater use of additional diagnostic procedures.

[No sex differences observed in thrombolysis treatment in acute myocardial infarct but they are found in contraindications and complications]

OBJECTIVE

To detect possible differences between men and women in thrombolytic treatment after acute myocardial infarction.

DESIGN

Retrospective chart study.

SETTING

University Hospital Nijmegen, the Netherlands.

METHOD

The data were studied of all patients diagnosed at discharge as 'myocardial infarction' during the period July 1992 to December 1993, with comparison of men and women.

RESULTS

There were 181 patients with myocardial infarction: 53 women (29%) and 128 men (71%). At the time of diagnosis, the women on average were 9 years older than the men. Of these patients, 24 women (45%) and 66 men (52%) were treated with a thrombolytic agent. In 30% of the cases in both men and women, the main reason not to give a thrombolytic agent was exceeding the time limit of 6 hours after the first symptoms. In addition, thrombolysis was refrained from because of contraindications in 23% of the women and in 17% of the men. In women, an 'inconclusive' ECG was an important reason for not giving thrombolysis. There was a difference between the numbers of women and men who developed complications after thrombolysis (25% as against 8%); in women these complications were mostly haemorrhages. 25% of the women and 15% of the men died in hospital.

CONCLUSION

Women with a myocardial infarction were given thrombolytic treatment about as often as men. There were sex differences regarding the contraindications to thrombolysis and the complications after thrombolysis.

[Beneficial effect of exercise therapy in urinary incontinence in family practice depends largely on therapy compliance and motivation]

OBJECTIVE

Determining the factors which influence the success of training therapy in women suffering from urinary incontinence.

DESIGN

Descriptive.

SETTING

Thirteen general practices in Nijmegen and environs, the Netherlands.

METHOD

A total of 110 women between 20 and 65 years old, suffering from urinary incontinence were examined by their general practitioners. Age, personality, parity, psychological features and type, duration, severity, beginning of the disease, as well as the presence of cystocele or prolapse were recorded. Women were asked about their own experiences regarding factors that influenced success. The treatment consisted of training of pelvic muscles in stress incontinence and bladder training in urge incontinence. Outcomes and compliance were measured 3 and 12 months after start of treatment by means of a so-called incontinence diary.

RESULTS

After 3 months the mean frequency of urine loss per week diminished from 21 to 8, and after 12 months to 6 times. Compliance was the most important contribution to success. Patients were more motivated to practise when the subjective burden of the urine loss was more severe. Other features did not influence success.

[Profiles of regular consumers of benzodiazepines in a family practice]

OBJECTIVE

To describe the profile of regular users of benzodiazepines in a general practice.

DESIGN

Case-control study.

SETTING

A duo general practice in Nijmegen.

METHOD

Of all regular users of benzodiazepines in a general practice, socio-demographic and morbidity data were collected and the use of benzodiazepines (duration, frequency, type of agent) was determined. By means of a semi-structured interview, the users' experiences and opinions were inventoried. Psychological and physical functioning were determined using the symptom checklist (SCL-90).

RESULTS

In the group of 99 users (3.1% of the practice population), 53 (1.6% of the practice population) used benzodiazepines every day and had done so for over one year. Most were women over 65 years of age, living alone and with a low educational level. Over 25% were patients with psychiatric/psychogeriatric disorders. Users had frequent chronic diseases, particularly articular disorders and chronic skin diseases. The SCL-90 results indicated a high degree of psychoneuroticism. Most patients felt the medication enabled them to cope better with difficult situations, and the side effects reported were limited in number and severity.

CONCLUSION

Users of benzodiazepines were in a high-risk position, both socio-economically and as regards health and mental well-being. Given a strict prescribing policy, the group of chronic users of benzodiazepines was small and easy to control in this practice.

Psychological aspects of female urinary incontinence in general practice

The aim of this study was to determine whether urge incontinence was associated with a higher prevalence of psychological symptoms than other types of incontinence. The psychological aspects of 110 women presenting with urinary incontinence in general practice were assessed by means of standardised questionnaires and medical history-taking. The results showed no difference in psychological characteristics between patients with urge incontinence and those with other types of incontinence. These findings were contrary to the conclusions of almost all other studies based on populations selected for specialist care. It was concluded that in general practice the psychological approach to urinary incontinence depends more on the individual needs of the patient than specifically on the type of incontinence.

The effects of treatment of urinary incontinence in general practice

A total of 110 women who had reported urinary incontinence to their general practitioners were randomly assigned to a treatment or control group. Treatment consisted of pelvic floor exercises in the case of stress incontinence and bladder training in the case of urge incontinence. The results were measured after 3 and 12 months by a research assistant on the basis of a constructed severity scale, an incontinence diary, and a comparison by the patients themselves of their previous and current conditions. After 3 months the control group were given the same treatment. After a further 3 and 12 months, they were assessed in exactly the same way as the treatment group. After 3 months about 60% of the patients were either dry or only mildly incontinent; the mean number of wet episodes had gone down from 20 to 7, and 74% of the women felt improved or cured. These results were later corroborated by the control group. After 12 months this successful outcome was improved slightly further. It may be concluded that the majority of women with incontinence can be successfully treated by the general practitioner. The effect of this treatment continues after one year.

Value of the patient's case history in diagnosing urinary incontinence in general practice

What is the value of the case history in diagnosing urinary incontinence in general practice? A total of 103 women with urinary incontinence presented to their general practitioner (GP) and underwent a standard history-taking, physical examination and urodynamic testing. The urodynamic diagnoses were analysed against symptoms and symptom complexes. Symptoms of stress incontinence in the absence of symptoms of urge incontinence had a sensitivity of 78%, specificity of 84% and predictive value of 87%. Symptoms of urge incontinence in the absence of symptoms of stress incontinence excluded genuine stress incontinence. Information on age, parity, enuresis, nocturia, frequency, urgency, cystocele, prolapse and hysterectomy did not contribute to a correct diagnosis. It was concluded that urodynamics are unnecessary in most women presenting with urinary incontinence in general practice.