Medically unexplained symptoms: the person, the symptoms and the dialogue.

Background: Many general practitioners (GPs) find the care for patients with medically unexplained symptoms (MUS) challenging. The patients themselves are often not satisfied with the care they receive. Objectives: The aim of this study is to explore what patients with MUS expect from their GP by looking at relevant communication elements in consultations as identified by patients. Methods: We video-recorded everyday consultations with GPs and asked the GPs immediately after the consultation whether MUS were presented. The patients in these MUS consultations were asked to reflect on the consultation during a semi-structured interview while watching a recording of their own MUS consultation. The interviews were analysed qualitatively according to the principles of constant comparative analysis. Results: Of the 393 video-recorded consultations, 43 concerned MUS. All MUS patients said that they wanted to be taken seriously. According to the patients, their feeling of being taken seriously is enhanced when the GP: (i) pays empathic attention to them as individuals, meaning that the GP knows their personal circumstances and has an open and empathic approach, (ii) ensures a good conversation by treating the patient as an equal partner and (iii) is attentive to their symptoms by exploring these symptoms in depth and by acting on them. Conclusion: Like chronic patients, patients with MUS value a personalised approach in which GPs pay attention to patients' personal circumstances, to proper somatic management of their symptoms and to a proper conversation in which they are treated as equal partners. Use of these basic consultation skills may greatly improve care of MUS patients.

Brief multimodal psychosomatic therapy in patients with medically unexplained symptoms: feasibility and treatment effects.

BACKGROUND: Patients repeatedly presenting with medically unexplained symptoms (MUS) to their GPs, suffer from their symptoms. Experts in the field suggest a multicomponent approach for these patients. Brief multimodal psychosomatic therapy (BMPT) is such an intervention. OBJECTIVES: To test the systematic identification of eligible patients, acceptability of BMPT and potential treatment effects of BMPT. METHODS: The participants in this randomized pilot trial, patients consulting their GPs more than once with MUS, were randomized to intervention [usual care (UC) and additional BMPT] or control condition (UC alone).We monitored the number of patients identified and recruited, trial recruitment and retention. Potential treatment effects were measured with perceived symptom severity [Visual Analogue Scale (VAS)]; patients' self-rated symptoms of distress, depression, anxiety and somatization [Four-Dimensional Symptom Questionnaire (4DSQ)]; symptoms of hyperventilation [Nijmegen Hyperventilation List (NHL)]; physical and mental health status and quality of life [Short-Form Health Survey-36 items (SF-36)]; and level of functioning (measure of general functioning). Follow-up was 1 year. RESULTS: A total of 42 patients could be included in the trial. Four patients withdrew after randomization and two patients were lost to follow-up, resulting in 36 patients (86%). During the 12-month follow-up after BMPT, there was an improvement in perceived symptom severity [adjusted mean difference -2.0, 95% confidence interval (CI) -3.6 to -0.3], in somatization (adjusted mean difference -4.4, 95% CI -7.5 to -1.4) and in symptoms of hyperventilation (adjusted mean difference -5.7, 95% CI -10.5 to -0.8). CONCLUSIONS: This randomized pilot study shows that a larger trial studying the effectiveness of BMPT in patients with MUS in primary care is feasible and useful.

Longitudinal outcomes of different asthma phenotypes in primary care, an observational study.

While asthma presentation is heterogeneous, current asthma management guidelines in primary care are quite homogeneous. In this study we aim to cluster patients together into different phenotypes, that may aid the general practitioner in individualised asthma management. We analysed data from the ACCURATE trial, containing 611 adult asthmatics, 18-50 year-old, treated in primary care, with one year follow-up. Variables obtained at baseline (n = 14), were assessed by cluster analysis. Subsequently, established phenotypes were assessed separately on important asthma outcomes after one year follow-up: asthma control (Asthma Control Questionnaire (ACQ)), quality of life (Asthma Quality of Life Questionnaire (AQLQ)), exacerbation-rate and medication-usage. Five distinct phenotypes were identified. The first phenotype was predominantly defined by their early onset atopic form of asthma. The second phenotype mainly consisted of female patients with a late onset asthma. The third phenotype were patients with high reversibility rates after bronchodilator usage. The fourth phenotype were smokers and the final phenotype were frequent exacerbators. The exacerbators phenotype had the worst outcomes for asthma control and quality of life and experienced the highest exacerbation-rate, despite using the most medication. The early onset phenotype patients were relatively well controlled and their medication dosage was low. ASTHMA: INDIVIDUALIZING TREATMENT BY PHENOTYPE: Asthma patients should be characterised according to their individual asthma type to ensure more targeted treatment. Even though asthma manifests itself in a wide variety of forms with differing degrees of severity, treatment of the disease often takes a broad, one-size-fits-all approach. To determine if asthma can indeed be split into distinct phenotypes, Rishi Khusial at the Leiden University Medical Center and co-workers across the Netherlands analysed data from 611 adult asthmatics treated in primary care, and followed them up after one year. The team identified five phenotypes in the primary care cohort, including one group with early onset asthma, another whose asthma responded well to bronchodilators, and a group classed as frequent exacerbators. Further analysis of long-term asthma outcomes showed clear differences between phenotypes, particularly in terms of asthma control and quality of life.