The prevalence of malnutrition and its predictive value for the incidence of complications were determined in 155 patients hospitalized for internal or gastrointestinal diseases. At admission, 45% of the patients were malnourished according to the Subjective Global Assessment (physical examination plus questionnaire), 57% according to the Nutritional Risk Index [(1.5 X albumin) + (41.7 X present/usual weight)], and 62% according to the Maastricht Index [(20.68 -(0.24 X albumin) -(19.21 X transthyretin (prealbumin) -(1.86 X lymphocytes) -(0.04 X ideal weight)]. Crude odds ratios for the incidence of any complication in malnourished compared with well-nourished pa tients during hospitalization were 2.7 (95% Cl: 1

Objective To assess the long term effects of two different modes of disease management (comprehensive self management and routine monitoring) on quality of life (primary objective), frequency and patients' management of exacerbations, and self efficacy (secondary objectives) in patients with chronic obstructive pulmonary disease (COPD) in general practice.Design 24 month, multicentre, investigator blinded, three arm, pragmatic, randomised controlled trial.Setting 15 general practices in the eastern part of the Netherlands.Participants Patients with COPD confirmed by spirometry and treated in general practice. Patients with very severe COPD or treated by a respiratory physician were excluded.Interventions A comprehensive self management programme as an adjunct to usual care, consisting of four tailored sessions with ongoing telephone support by a practice nurse; routine monitoring as an adjunct to usual care, consisting of 2-4 structured consultations a year with a practice nurse; or usual care alone (contacts with the general practitioner at the patients' own initiative). Outcome measuresThe primary outcome was the change in COPD specific quality of life at 24 months as measured with the chronic respiratory questionnaire total score. Secondary outcomes were chronic respiratory questionnaire domain scores, frequency and patients' management of exacerbations measured with the Nijmegen telephonic exacerbation assessment system, and self efficacy measured with the COPD self-efficacy scale.Results 165 patients were allocated to self management (n=55), routine monitoring (n=55), or usual care alone (n=55). At 24 months, adjusted treatment differences between the three groups in mean chronic respiratory questionnaire total score were not significant. Secondary outcomes did not differ, except for exacerbation management. Compared with usual care, more exacerbations in the self management group were managed with bronchodilators (odds ratio 2.81, 95% confidence interval 1.16 to 6.82) and with prednisolone, antibiotics, or both (3.98, 1.10 to 15.58). ConclusionsComprehensive self management or routine monitoring did not show long term benefits in terms of quality of life or self efficacy over usual care alone in COPD patients in general practice. Patients in the self management group seemed to be more capable of appropriately managing exacerbations than did those in the usual care group.Trial registration Clinical trials NCT00128765.

METHOD Study design and participantsFocus group interviews with Dutch GPs were carried out. In the Netherlands, all patients are enlisted with a GP, who on average deals with more than 95% of presented medical problems 26 and HD Luijks, MD, GP in training, junior researcher; MJW Loeffen, MD, GP in training, psychologist, junior researcher; AL Lagro-Janssen, MD, PhD, GP, professor of primary care, senior researcher; C van Weel, MD, PhD, GP, professor of primary care, senior researcher; PL Lucassen, MD, PhD, GP, senior researcher; TR Schermer, PhD, senior researcher, Department of Primary Care and Community Care, Radboud University Nijmegen Medical Centre, The Netherlands. AimTo explore GPs' considerations and main objectives in the management of multimorbidity and to explore factors influencing their management of multimorbidity. Design and settingFocus group study of Dutch GPs; with heterogeneity in characteristics such as sex, age and urbanisation. MethodThe moderator used an interview guide in conducting the interviews. Two researchers performed the analysis as an iterative process, based on verbatim transcripts and by applying the technique of constant comparative analysis. Data collection proceeded until saturation was reached. ResultsFive focus groups were conducted with 25 participating GPs. The main themes concerning multimorbidity management were individualisation, applying an integrated approach, medical considerations placed in perspective, and sharing decision making and responsibility. A personal patient-doctor relationship was considered a major factor positively influencing the management of multimorbidity. Mentalhealth problems and interacting conditions were regarded as major barriers in this respect and participants experienced several practical problems. The concept of patient-centredness overarches the participants' main objectives. ConclusionGPs' main objective in multimorbidity management is applying a patient-centred approach. This approach is welcomed since it counteracts some potential pitfalls of multimorbidity. Further research should include a similar design in a different setting and should aim at developing best practice in multimorbidity management.

Objective: To investigate the validity of spirometric tests performed in general practice. Method: A repeated within subject comparison of spirometric tests with a ''gold standard'' (spirometric tests performed in a pulmonary function laboratory) was performed in 388 subjects with chronic obstructive pulmonary disease (COPD) from 61 general practices and four laboratories. General practitioners and practice assistants undertook a spirometry training programme. Within subject differences in forced expiratory volume in 1 second and forced vital capacity (DFEV 1 and DFVC) between laboratory and general practice tests were measured (practice minus laboratory value). The proportion of tests with FEV 1 reproducibility ,5% or ,200 ml served as a quality marker. Results: Mean DFEV 1 was 0.069 l (95% CI 0.054 to 0.084) and DFVC 0.081 l (95% CI 0.053 to 0.109) in the first year evaluation, indicating consistently higher values for general practice measurements. Second year results were similar. Laboratory and general practice FEV 1 values differed by up to 0.5 l, FVC values by up to 1.0 l. The proportion of non-reproducible tests was 16% for laboratory tests and 18% for general practice tests (p = 0.302) in the first year, and 18% for both in the second year evaluation (p = 1.000). Conclusions: Relevant spirometric indices measured by trained general practice staff were marginally but statistically significantly higher than those measured in pulmonary function laboratories. Because of the limited agreement between laboratory and general practice values, use of these measurements interchangeably should probably be avoided. With sufficient training of practice staff the current practice of performing spirometric tests in the primary care setting seems justifiable.

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