Biomedical subjects
Publications and source records attributed to F Buntinx.
A literature review compared the results of different kidney function tests using the inulin clearance or similar methods as a gold standard. The methodological strength of the available studies was weak. For the time being, the calculated creatinine clearance using formula, is a first choice, especially in general practice.
Standardized patients (SPs) are simulated patients or actual patients who have been carefully coached to present their illness in a standardized way. Much is known about the use of standardized patients in medical education. This article reviews advantages and disadvantages, reliability and validity of the use of standardized patients in general practice and primary care research. Performance in general practice can be measured with direct or indirect methods. With direct methods the physician-patient contact is directly observed or heard. Indirect methods are seldom complete and seldom accurate and therefore often invalid. Direct methods (observation, video, audiotapes, etc.) have face validity, but nevertheless have shortcomings. The SP method can mainly avoid the disadvantages of the other methods. The presentation of the case by the SP is accurate. The judgement of physician's behaviour during the consultation by the SP is accurate and reliable. SPs are generally believable. Less than one in five SPs is detected by the physicians, so the method has face validity. To obtain sufficient reliability and validity, a thorough selection and training of SPs is required, as is careful organization with an eye for detail. The SP method also has some important shortcomings. The method is time and work demanding, limiting the number of physicians that can be measured. In addition, measurement is usually limited to one consultation. In reality, however, diagnostic and therapeutic interventions are often spread over several consultations. This 'first-visit-bias' hampers conclusive answering of some research questions.
OBJECTIVE: To evaluate the diagnostic value of macroscopic haematuria for the diagnosis of urological cancers in primary care as well as referred patients. METHOD: Systematic review of published reports, identified by a search on Medline and FAMLI and by screening of reference lists of selected papers. The evaluation of the sensitivity was based on patients with proven cancer of the kidney, ureter, bladder, urethra or prostate. The evaluation of the positive predictive value (PPV) was based on patients complaining to their physicians of macroscopic haematuria. RESULTS: No study executed in a primary care setting was included. In referred patients the pooled sensitivity of macroscopic haematuria for bladder cancer, based on seven remarkably homogeneous studies, was 0.83 (95% CI = 0.80-0.85). For ureteral cancer, this was 0.66 (95% CI = 0.53-0.77) based on four reports and for renal cancer 0.48 (95%) CI = 0.36-0.60) based on three studies. The pooled PPV of haematuria for urological cancer was 0.22 (0.17-0.27) in referred patients. Most malignancies detected were bladder cancers (255/317). PPV was highest in patients aged 40 or more at 0.41 (95% CI = 0.10-0.78). CONCLUSIONS: The advice that all patients with macroscopic haematuria should receive a thorough diagnostic programme seems justified in a specialized setting, dealing with referred patients. At this moment no data are available to support or discourage a similar policy for GPs. Prospective studies on the diagnostic value of macroscopic haematuria for urological cancer in a primary care setting are urgently needed.
OBJECTIVE: We aimed to examine sensitivity and positive predictive value of MEDLINE searching for diagnostic studies, relevant for the primary health care setting. METHOD: Results of MEDLINE searches were compared with a reference standard collection of studies on two subjects, the diagnostic value of ESR in discriminating between 'pathology' and 'no pathology', and the dipstick method in diagnosing urinary tract infections. The main outcome measures were sensitivity (proportion of the total number of reference standard diagnostic studies that could be identified by the search) and positive predictive value (proportion of the total number of publications retrieved by MEDLINE that were incorporated in the reference standard). RESULTS: The combined MeSH and freetext search was more sensitive than MeSH term searching only, for both the ESR and the dipstick search. With this combined search sensitivities of 0.91 and 0.98 and predictive values of 0.10 and 0.68 were found for ESR and dipstick respectively. By restricting the search with keywords describing the primary health care setting the predictive values increased to 0.72 and 1.00 but sensitivity dropped to 0.10 and 0.07 (ESR and dipstick respectively). CONCLUSION: Combining freetext and MeSH term searching, without restriction to the primary health care setting, is a valuable strategy in systematically searching for available evidence on the value of a diagnostic test in the scope of a specific disease. The predictive value seems to depend on the breadth of the disease area. MEDLINE should provide a term such as 'diagnostic evaluation study' to be used in the limit field Publication Type to specify diagnostic studies.
OBJECTIVES: To study the relation between the blood pressure and the neurocognitive function within the full adult age range in a large population sample. DESIGN: A cross-sectional study of 936 healthy adults who were recruited from a register of family practices, stratified for age (24-81 years), sex, and occupational level, who took part in a medical and neurocognitive test program. METHODS: The blood pressure status was studied in relation to five measures of cognitive ability, including verbal memory and speed of information processing. Other vascular risk factors were treated as control variables and included smoking, alcohol intake, body mass index, and body fat distribution. The blood pressure was measured five times using an automatic recording technique (with a Dinamap 8100 device). RESULTS: After adjustment for age, sex, and educational level in a hierarchical regression analysis, we found no unequivocal association between the mean systolic and diastolic blood pressures (or any other studied vascular risk factor) and cognitive test performance both for the whole group and for the subgroup of subjects who were not being administered antihypertensive medication and whose medical history did not include cardiovascular events. Stratified analysis within four age levels revealed no age-specific associations between the blood pressure and the cognitive function. Subjects whose blood pressure was within the hypertensive range performed worse than did matched controls at letter digit copying, but not according to other cognitive measures. CONCLUSIONS: With a population-based sample unselected for blood pressure status we found no linear relationship between the actual blood pressure level and various aspects of cognitive performance. Prospective studies are needed to investigate the possibility that the systemic blood pressure load over time is associated with a decline in specific cognitive abilities.
Despite its clinical relevance, an extensive literature search for papers reporting on the relationship between prolonged cough and lung cancer revealed only one paper from a specialized setting. No study originating from primary care could be identified.
OBJECTIVE: To assess the diagnostic yield of different sampling devices used in cervical screening. DESIGN: Meta-analysis of randomised and quasi-randomised studies. SETTING: All randomised and quasi-randomised studies comparing the yield of cytological or histological abnormalities when two or more different sampling devices were used. SUBJECTS: 85,000 patients included in 29 studies reported in 28 papers. MAIN OUTCOME MEASURES: Pooled relative risk and 95% confidence interval of the yield of mild dysplasia or worse in smears recovered by each sampling method versus each other method with which it was compared; sensitivity or positive predictive value, or both, of cytological versus histological results in six studies from which sufficient data were available. RESULTS: There were no substantial differences in the yield of cytological abnormalities between the Ayre spatula, the Cytobrush, and the cotton swab used alone. There were also no substantial differences in the yield of cytological abnormalities between the extended tip spatula, the Ayre spatula combined with the Cytobrush or cotton swab, or the Cervex brush. The Ayre spatula, Cytobruah, or cotton swab used alone generally performed significantly worse than the combinations, the extended tip spatula, or the Cervex brush. There were no substantial differences in sensitivity or positive predictive value between the sampling methods. CONCLUSIONS: These results support the use of either the extended tip spatula, a combination of any spatula plus the Cytobrush or cotton swab, or the Cervex brush for cervical screening.
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We used a retrospective cohort study design to test the hypothesis of a relation between old-age depression and subsequent dementia. The study sample comprised 19103 patients aged 50 or more and born after 1910, included in a family-practice-based registration network. We estimated odds ratio (OR) and 95% confidence interval (95% CI) for a diagnosis of dementia in patients with or without previous late-onset depression and survival analysis, including hazard ratios resulting from Cox regression analysis. The OR for a diagnosis of dementia subsequent or not to late-onset depression was found at survival analysis: p = 0.26 (log rank test). Hazard ratio for patients with and without previous old age depression and subsequent dementia in patients aged 50 or more and born after 1910. This supports the hypothesis of old-age depression being a predictor, and possibly a causal factor, of subsequent dementia.
Six observers (three physicians and three nurses) assessed 27 wounds of different types in 20 elderly patients, using five different classification systems. Using classification by colours, inter-observer agreement was moderate when six colours were used (70% agreement, group kappa 53%), and good if this was reduced to three (80% agreement, group kappa 64%). Results were only moderate using the Shea scoring system (68% agreement, group kappa 42%). Assessment for signs of infection was fair to moderate (75-85% agreement, group kappa 29-55%), but there was high inter-observer agreement for size and area (analysis of variance, p > or = 0.88).
In a randomized controlled trial the effect of feedback and peer review directed at the sample-taking doctor (n = 179) on the sampling quality of cervical smears (n = 21,240) was studied. This paper reports the impact 6 and 12 months after the end of the intervention. Monthly feedback with peer comparison was related to a net improvement in the proportion of cervical smears without endocervical cells during the intervention period, as well as during a follow-up period lasting until 15 months after the end of the intervention. This improvement seemed to be related to a minimum of 50 or even 100 smears performed each year and was therefore not confirmed on clustered data analysis. There is a strong suggestion that the intervention also related to an increase of the number of smears showing cytological pathology, although this study lacked sufficient power to test this hypothesis.
AIMS: To test the hypothesis that absence of squamous cells in cervical smears obtained by an endocervical sampling technique is more prominent in patients with a cervical ectropion. METHODS: Prospective study exploring the relation between the composition of cervical smears obtained using an endocervical cotton swab in patients with (n = 188) and without (n = 341) a cervical ectropion. Subjects were 529 consecutive patients from whom a cervical smear was prepared at a university gynaecological clinic. RESULTS: In 7% of the endocervical samples no squamous cells were found. There was no correlation, however, between the presence or the size of an ectropion and the absence of squamous cells in those samples. CONCLUSIONS: It was confirmed that endocervical sampling alone is insufficient to obtain good quality cervical smears. The presence of an ectropion proved to be an unreliable predictor of the absence of squamous cells.
The U.S. Food and Drug Administration designed the trough-to-peak ratio as an instrument for the evaluation of long-acting antihypertensive drugs, but the ratios are usually reported without accounting for interindividual variability. This study investigated how the trough-to-peak ratio would be affected by interindividual and intraindividual variability and by smoothing of the diurnal blood pressure profiles. The ambulatory blood pressure was recorded on placebo in 143 hypertensive patients (diastolic pressure on conventional measurement > 95 mm Hg). After 2 months, the recordings were repeated on 10 mg (n = 66) or 20 mg (n = 77) lisinopril given once daily between 7 and 11 PM. The baseline-adjusted trough-to-peak ratios were determined from diurnal blood pressure profiles with 1-hour precision. Lisinopril reduced (+/- SD) the 24-hour pressure by 16 +/- 17 mm Hg for systolic and 10 +/- 10 mm Hg for diastolic (P < .001). According to the usual approach, disregarding interindividual variability, the trough-to-peak ratio was 0.72 for systolic pressure and 0.67 for diastolic pressure. In the 143 patients the ratios were not normally distributed. They were the same on both lisinopril doses. When interindividual variability was accounted for, the median trough-to-peak ratio was 0.34 (P5 to P95 interval, -0.46 to 0.87) for systolic pressure and 0.26 (-0.44 to 0.84) for diastolic pressure. In 66 patients examined twice on 10 mg lisinopril at a median interval of 32 days, the trough-to-peak ratios were characterized by large intraindividual variability.(ABSTRACT TRUNCATED AT 250 WORDS)
OBJECTIVE: Determining the role of the general practitioner (GP) in the management of the postinfarction patient, the factors that influence this role, and the relation between GP and cardiologist. DESIGN: Descriptive. SETTING: Registration Network of Family Practice (RNF) of the University of Limburg, the Netherlands. METHOD: Data were obtained from a sample of 284 patients from 30 GPs, all participating in the RNF. The GPs completed a questionnaire about their own patients while the data concerning the cardiac state of the patients were obtained from their problem lists. RESULTS: Postinfarction care was given in only 50% of the patients. Relatively more patients with a more severe cardiac condition were under regular medical follow-up than those with a less severe cardiac condition. However, the severity of the disease had no effect on the specialty of the doctor performing the follow-up (GP or cardiologist), nor had the time expired after the myocardial infarction. In almost 50% of the cases the GPs found continuation of the follow-up by the cardiologist not necessary, in 25% of the cases they were not satisfied with the complementary roles of both disciplines. CONCLUSION: Postinfarction care by the GPs was not uniform. They need guidelines for the management of such patients, based on the patient's risk profile. There is a need for better coordination between GP and cardiologist.
By means of a qualitative study, we set out to generate hypotheses about the way general practitioners (GPs) diagnosed dementia. We looked for triggers for the diagnosis of dementia. Ten GPs were interviewed about four dementia cases taken from their own practices. GPs are more concerned with treatment than with the diagnosis of dementia as such, as diagnosis is performed in relation to treatment. The most important aid was the evolution of the clinical tables based on the information of caregivers. Important triggers were changes of activities of daily life function, behaviour and cognition. Acute illness and loss of the key caregiver were relevatory moments. Recommendations are made for the improvement of the diagnostic abilities of GPs.
A literature search examined 39 reports on the relationship between the absence of endocervical cells in a cervical smear and the sampling technique used. Using (pooled) ratios we compared the results for different pairs of sampling devices, thereby controlling for the design of each study when appropriate. The Cytobrush appears the most efficient sampling method with regard to the presence of endocervical cells. Combining the results of this review with the results of a previous meta-analysis on the effect of the sampling technique on the detection of pathology, the combined spatula and Cytobrush technique seems to be the best sampling method.
In order to assess the interobserver variation among cytological assistants in evaluating the sampling quality of cervical smears, all four laboratory assistants from one cytological department examined the same set of 71 smears. They assessed the presence of endocervical cells, the quality of fixation, the number of cells and the undesirable presence of clumps of cells. The interobserver agreement, uncorrected for chance, varied from 73 to 93% for the presence of endocervical cells and from 86 to 100% for the three other criteria. For the presence of endocervical cells, the kappa values, a measure for the interobserver agreement corrected for chance, varied from 42 to 84%. This is a reasonable outcome. For the three other criteria many kappa values were zero or uncalculable. The interobserver agreement in evaluating the sampling quality of cervical smears is reasonable to good, but not perfect. Prudence in the interpretation of quality data is warranted.