Treatment of heart failure in Dutch general practice

BACKGROUND: To study the relation between the prescription rates of selected cardiovascular drugs (ACE-inhibitors and Angiotensin receptor blockers, beta-blockers, diuretics, and combinations), sociodemographic factors (age, gender and socioeconomic class) and concomitant diseases (hypertension, coronary heart disease, cerebrovascular accident, heart valve disease, atrial fibrillation, diabetes mellitus and asthma/COPD) among patients with heart failure cared for in general practice. METHODS: Data from the second Dutch National Survey in General Practice, conducted mainly in 2001. In this study the data of 96 practices with a registered patient population of 374.000 were used. Data included diagnosis made during one year by general practitioners, derived from the electronic medical records, prescriptions for medication and sociodemographic characteristics collected via a postal questionnary (response 76%) RESULTS: A diagnosis of HF was found with 2771 patients (7.1 in 1000). Their mean age was 77.7 years, 68% was 75 years or older, 55% of the patients were women. Overall prescription rates for RAAS-I, beta-blockers and diuretics were 50%, 32%, 86%, respectively, whereas a combination of these three drugs was prescribed in 18%. Variations in prescription rates were mainly related to age and concomitant diseases. CONCLUSION: Prescription is not influenced by gender, to a small degree influenced by socioeconomic status and to a large degree by age and concomitant diseases

Relevance of neuroimaging for neurocognitive and behavioral outcome after pediatric traumatic brain injury

This study aims to (1) investigate the neuropathology of mild to severe pediatric TBI and (2) elucidate the predictive value of conventional and innovative neuroimaging for functional outcome. Children aged 8–14 years with trauma control (TC) injury (n = 27) were compared to children with mild TBI and risk factors for complicated TBI (mildRF+, n = 20) or moderate/severe TBI (n = 17) at 2.8 years post-injury. Neuroimaging measures included: acute computed tomography (CT), volumetric analysis on post-acute conventional T1-weighted magnetic resonance imaging (MRI) and post-acute diffusion tensor imaging (DTI, analyzed using tract-based spatial statistics and voxel-wise regression). Functional outcome was measured using Common Data Elements for neurocognitive and behavioral functioning. The results show that intracranial pathology on acute CT-scans was more prevalent after moderate/severe TBI (65%) than after mildRF+ TBI (35%; p = .035), while both groups had decreased white matter volume on conventional MRI (ps ≤ .029, ds ≥ −0.74). The moderate/severe TBI group further showed decreased fractional anisotropy (FA) in a widespread cluster affecting all white matter tracts, in which regional associations with neurocognitive functioning were observed (FSIQ, Digit Span and RAVLT Encoding) that consistently involved the corpus callosum. FA had superior predictive value for functional outcome (i.e. intelligence, attention and working memory, encoding in verbal memory and internalizing problems) relative to acute CT-scanning (i.e. internalizing problems) and conventional MRI (no predictive value). We conclude that children with mildRF+ TBI and moderate/severe TBI are at risk of persistent white matter abnormality. Furthermore, DTI has superior predictive value for neurocognitive out-come relative to conventional neuroimaging

Therapy resistant hypertension

Abstract Background Hypertension is a common problem in Dutch general practice. Although many hypertensive patients are adequately treated, a substantial number of patients do not reach treatment goals. The most important reasons for treatment failure are white-coat hypertension, nonadherence to treatment or therapy resistant hypertension (TRH).TRH is defined as having an office BP measurement with systolic blood pressure ≥ 140 mmHg while using three different classes of antihypertensive agents, ideally including a diuretic, in an adequate dose. Patients with TRH bear an increased risk for target organ damage, cardiovascular morbidity and mortality compared to patients with adequately controlled hypertension. At the moment, reliable information about TRH is scarce, and better understanding of the prevalence and characteristics of TRH can make an earlier diagnosis of TRH possible. In this way, patients can benefit from the diagnostic and therapeutic considerations available

A Novel Approach to Office Blood Pressure Measurement: 30-Minute Office Blood Pressure vs Daytime Ambulatory Blood Pressure

PURPOSE Current office blood pressure measurement (OBPM) is often not executed according to guidelines and cannot prevent the white-coat effect. Serial, automated, oscillometric OBPM has the potential to overcome both these problems. We therefore developed a 30-minute OBPM method that we compared with daytime ambulatory blood pressure

GPs' assessment of patients' readiness to change diet, activity and smoking

BACKGROUND: The Stages of Change Model is increasingly used for lifestyle counselling. In general practice, the use of algorithms to measure stage of change is limited, but for successful counselling it is important to know patients' readiness to change. AIM: To assess the accuracy of the assessment of patients' readiness to change fat consumption, physical activity, and smoking by GPs and general practice registrars. DESIGN OF STUDY: Cross-sectional questionnaire-based survey. SETTING: One hundred and ninety-nine patients at elevated cardiovascular risk aged 40–70 years, 24 GPs, and 21 registrars in Dutch general practices. METHOD: Patients were asked to complete an algorithm to measure their motivation to change fat consumption, physical activity, and smoking. GPs and registrars were given descriptions of the stages of change for the three lifestyles, and were asked to indicate the description that matched their patient. Cohen's κ was calculated as measure of agreement between patients and GPs/registrars. RESULTS: Registrars' patients were younger, and less often overweight and hypertensive than GPs' patients. Cohen's κ for smoking was moderate (0.50, 95% confidence interval [CI] = 0.34 to 0.67 for GPs and 0.47, CI = 0.27 to 0.68 for registrars). Agreement for fat and activity was poor to fair. No differences in accuracy were observed between GPs and registrars (P = 0.07–0.83). CONCLUSIONS: Low accuracy indicates that counselling in general practice is often targeted at the wrong people at the wrong time. Improvements can possibly be achieved by making registration of lifestyle parameters in patient records common practice, and by simply asking patients where they stand in respect to lifestyle change

Adherence to the guidelines of paediatric cervical spine clearance in a level I trauma centre: A single centre experience

International guidelines define if and what type of radiography is advised in children to clear the cervical spine (C-spine). However, adherence to these guidelines has never been evaluated in a paediatric population. Therefore, we wanted to assess the adherence to the guidelines for C-spine clearance in a level-one trauma centre. We retrospectively included all children, presented at the ED between January 2006 and December 2013, in whom radiographic imaging of the C-spine was obtained following blunt trauma. Primary outcome was the adherence to the international guidelines with regard to (1) if the indication for radiographic imaging was correct and (2) if the type of radiographic imaging was correct. Included were 573 patients; 336 boys (58.7%). Median age was 11 years (IQR 5.25-15). The indication for radiographic imaging was correct in all cases. The type of primary imaging modality was concordant with the guidelines in 99,7%. In 41% of the cases supplementary radiographs were made. The most common supplementary view was the odontoid. In 15% an incomplete set of radiographs was obtained. The adherence to the international guidelines when to obtain radiographic imaging was 100%. However, in a large proportion of patients (56%), not the recommended number of radiographs was obtaine

The structural connectome of children with traumatic brain injury

This study aimed to investigate the impact of mild to severe pediatric TBI on the structural connectome. Children aged 8-14 years with trauma control (TC) injury (n = 27) were compared to children with mild TBI and risk factors for complicated TBI (mildRF+, n = 20) or moderate/severe TBI (n=16) at 2.8 years post-injury. Probabilistic tractography on diffusion tensor imaging data was used in combination with graph theory to study structural connectivity. Functional outcome was measured using neurocognitive tests and parent and teacher questionnaires for behavioral functioning. The results revealed no evidence for an impact of mildRF+ TBI on the structural connectome. In contrast, the moderate/severe TBI group showed longer characteristic path length (P=0.022, d=0.82) than the TC group. Furthermore, longer characteristic path length was related to poorer intelligence and poorer working memory in children with TBI. In conclusion, children have abnormal organization of the structural connectome after moderate/severe TBI, which may be implicated in neurocognitive dysfunction associated with pediatric TBI. These findings should be interpreted in the context of our exploratory analyses, which indicate that the definition and weighting of connectivity (e.g., streamline density, fractional anisotropy) influence the properties of the reconstructed connectome and its sensitivity to the impact and outcome of pediatric TBI

Relevance of neuroimaging for neurocognitive and behavioral outcome after pediatric traumatic brain injury

RF+TBI and moderate/severe TBI are at risk of persistent white matter abnormality. Furthermore, DTI has superior predictive value for neurocognitive out-come relative to conventional neuroimagin