[Is it a sexually transmitted disease?] / Is dit een soa?

STD-associated questions and symptoms are submitted frequently to general practitioners and STD outpatient-clinics. In this teaching article we address 10 important clinical questions regarding epidemiology, risk assessment, testing policy, diagnostics and prevention. STD's form a separate category of infectious diseases because of the role of sexuality. Good communication about sexual behavior is indispensable for an adequate diagnosis. We discuss the recognition of extragenital manifestations of STD, which requires alertness. Estimating the STD-risk based on sexual behavior is essential for testing policy. Persons at high risk are tested for the big five. In other cases testing is based on symptoms and complaints. HIV and syphilis are serious std's. Early detection followed by treatment is important in preventing health damage and preventing further spread. Hiv-indicator-conditions are useful alarm-signs for this purpose. PrEP can help not to acquire hiv and increases sexual health. It can be prescribed by gp's and public health clinicians. But condom-use remains crucial in prevention.

Prevalence of vitamin D deficiency among Turkish, Moroccan, Indian and sub-Sahara African populations in Europe and their countries of origin: an overview.

UNLABELLED: Vitamin D status of nonwestern immigrants in Europe was poor. Vitamin D status of nonwestern populations in their countries of origin varied, being either similar to the immigrant populations in Europe or higher than in European indigenous populations. Vitamin D concentrations in nonwestern immigrant populations should be improved. PURPOSE: The higher the latitude, the less vitamin D is produced in the skin. Most European countries are located at higher latitudes than the countries of origin of their nonwestern immigrants. Our aim was to compare the serum 25-hydroxyvitamin D (25(OH)D) concentration of nonwestern immigrant populations with those of the population in their country of origin, and the indigenous population of the country they migrated to. METHODS: We performed literature searches in the "PubMed" and "Embase" databases, restricted to 1990 and later. The search profile consisted of terms referring to vitamin D or vitamin D deficiency, prevalence or cross-sectional studies, and countries or ethnicity. Titles and abstracts were reviewed to identify studies on population-based mean serum 25(OH)D concentrations among Turkish, Moroccan, Indian, and sub-Sahara African populations in Europe, Turkey, Morocco, India, and sub-Sahara Africa. RESULTS: The vitamin D status of immigrant populations in Europe was poor compared to the indigenous European populations. The vitamin D status of studied populations in Turkey and India varied and was either similar to the immigrant populations in Europe (low) or similar to or even higher than the indigenous European populations (high). CONCLUSIONS: In addition to observed negative consequences of low serum 25(OH)D concentrations among nonwestern populations, this overview indicates that vitamin D status in nonwestern immigrant populations should be improved. The most efficacious strategy should be the subject of further study.

Sunlight exposure or vitamin D supplementation for vitamin D-deficient non-western immigrants: a randomized clinical trial.

UNLABELLED: Vitamin D deficiency is very common in non-western immigrants. In this randomized clinical trial, vitamin D 800 IU/day or 100,000 IU/3 months were compared with advised sunlight exposure. Vitamin D supplementation was more effective than advised sunlight exposure in improving vitamin D status and lowering parathyroid hormone levels. INTRODUCTION: Vitamin D deficiency (25-hydroxyvitamin D [25(OH)D] < 25 nmol/l) is common among non-western immigrants. It can be treated with vitamin D supplementation or sunlight exposure. METHODS: To determine whether the effect of vitamin D(3) supplementation (daily 800 IU or 100,000 IU/3 months) or sunlight exposure advice is similar with regard to serum 25(OH)D and parathyroid hormone (PTH) concentrations. Randomized clinical trial in 11 general practices in The Netherlands. Non-western immigrants, aged 18-65 years (n = 232) and serum 25(OH)D < 25 nmol/l were randomly assigned to supplementation (daily 800 IU or 100,000 IU/3 months) or advice for sunlight exposure for 6 months (March-September). Blood samples were collected at baseline, during treatment (3 months, 6 months), and at follow-up (12 months). Statistical analysis was performed with multilevel regression modelling. RESULTS: The intention-to-treat analysis included 211 persons. Baseline serum 25(OH)D was 22.5 ± 11.1 nmol/l. After 6 months, mean serum 25(OH)D increased to 53 nmol/l with 800 IU/day, to 50.5 nmol/l with 100,000 IU/3 months, and to 29.1 nmol/l with advised sunlight exposure (supplementation vs sunshine p < 0.001). Serum PTH decreased significantly in all groups after 3 months, more in the supplementation groups than in the advised sunlight group (p < 0.05). There was no significant effect on physical performance and functional limitations. CONCLUSION: Vitamin D supplementation is more effective than advised sunlight exposure for treating vitamin D deficiency in non-western immigrants.

Human papillomavirus DNA testing for the detection of cervical intraepithelial neoplasia grade 3 and cancer: 5-year follow-up of a randomised controlled implementation trial.

BACKGROUND: Tests for the DNA of high-risk types of human papillomavirus (HPV) have a higher sensitivity for cervical intraepithelial neoplasia grade 3 or worse (CIN3+) than does cytological testing, but the necessity of such testing in cervical screening has been debated. Our aim was to determine whether the effectiveness of cervical screening improves when HPV DNA testing is implemented. METHODS: Women aged 29-56 years who were participating in the regular cervical screening programme in the Netherlands were randomly assigned to combined cytological and HPV DNA testing or to conventional cytological testing only. After 5 years, combined cytological and HPV DNA testing were done in both groups. The primary outcome measure was the number of CIN3+ lesions detected. Analyses were done by intention to treat. This trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN20781131. FINDINGS: 8575 women in the intervention group and 8580 in the control group were recruited, followed up for sufficient time (> or =6.5 years), and met eligibility criteria for our analyses. More CIN3+ lesions were detected at baseline in the intervention group than in the control group (68/8575 vs 40/8580, 70% increase, 95% CI 15-151; p=0.007). The number of CIN3+ lesions detected in the subsequent round was lower in the intervention group than in the control group (24/8413 vs 54/8456, 55% decrease, 95% CI 28-72; p=0.001). The number of CIN3+ lesions over the two rounds did not differ between groups. INTERPRETATION: The implementation of HPV DNA testing in cervical screening leads to earlier detection of CIN3+ lesions. Earlier detection of such lesions could permit an extension of the screening interval.

[Advisory report from the Health Council of the Netherlands to include human papillomavirus vaccination in the national immunisation programme for the prevention of cervical cancer]. / Advies van de Gezondheidsraad om vaccinatie tegen Humaan papillomavirus op te nemen in het Rijksvaccinatieprogramma om baarmoederhalskanker te voorkomen.

The Health Council of the Netherlands has advised the Minister of Health, Welfare and Sport to include vaccination against Human papillomavirus (HPV) for girls aged 12 years as part of the National Immunisation Programme. A catch-up vaccination is proposed for girls aged 13-16 years. High-risk HPV infections cause cervical cancer. Approximately 70% of these infections are attributed to HPV-16 and HPV-18. Vaccination was shown to prevent these infections and subsequent precursor lesions. Its efficacy in preventing cervical cancer has not yet been proven but is highly plausible. Protection lasts for more than so years. A booster may be needed after so years. The efficacy and safety of the two available vaccines are comparable. State-mandated vaccination is effective and ensures equal treatment regardless of economic status. Maintenance of the population screening programme for cervical cancer is important, and this must be communicated to the public properly. Careful monitoring is necessary for surveillance of effects, side effects, response rates and participation rates in cervical cancer screening. Guidelines are needed to aid physicians in determining whether to provide individual vaccination.

[Carotid calcification on a panoramic radiograph: what to do?]. / Een opaciteit in de hals op het orthopantomogram: wat te doen?

A 71-year-old man is discussed in whom the oral and maxillofacial surgeon observed, by chance, a radiopacity on the panoramic radiograph that was highly suggestive of a calcification at the bifurcation of the internal and external carotid artery. While, on the basis of international literature, various treatments are advanced with respect to the importance of vascular investigation and possible surgical removal of significant calcification, at present the view in The Netherlands is that the family doctor has the responsibility to assess whether such patient should be referred for further evaluation by the neurologist or vascular surgeon. The same applies to the possible indication for prescription of antitrombotics.

[Summary of the practice guideline 'Vaginal discharge' (first revision) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Fluor vaginalis' (eerste herziening) van het Nederlands Huisartsen Genootschap.

The 1996 practice guideline of the Dutch College of General Practitioners (NHG) on vaginal discharge has been updated. Most women who visit their doctor with complaints about vaginal discharge do not have an increased risk of a sexually-transmitted disease. Investigations into vaginal discharge comprise history taking, physical examination and microscopic analysis in the laboratory of the general practitioner. Additional investigation into Chlamydia, gonorrhoea and Trichomonas infection is only necessary if the patient history reveals an increased risk of a sexually-transmitted disease. A Candida infection or bacterial vaginosis should only be treated if the patient experiences bothersome complaints. Treatment of a Candida infection consists of a vaginally applied imidazole compound. Bacterial vaginosis can be treated with oral administration of metronidazole. Patients with vaginal fluor can be examined and, if necessary, treated by their general practitioner. Referral to a gynaecologist is rarely necessary.

Implementation of human papillomavirus testing in cervical screening without a concomitant decrease in participation rate.

Adding high-risk human papillomavirus (hrHPV) testing to screening increases the efficacy of cervical screening programmes. However, hrHPV testing may result in a lower participation rate because of the perceived association with sexually transmitted infections. We describe how testing for hrHPV was added to cervical screening in the POpulation-BAsed SCreening study AMsterdam (POBASCAM) trial. Participation rates of the screening programme before and after hrHPV implementation were evaluated in the region where the POBASCAM trial was carried out. The participation rate was 58.7% before and 61.4% after the addition of hrHPV testing to screening (p<0.001). An inventory of frequently asked questions is presented. Thus, hrHPV testing can be added to cervical screening by cytology without a decrease in participation rate.

[The practice guideline 'Urinary-tract infections' (second revision) from the Dutch College of General Practitioners; a response from the perspective of general practice]. / De standaard 'Urineweginfecties' (tweede herziening) van het Nederlands Huisartsen Genootschap; reactie vanuit de huisartsgeneeskunde.

The Dutch College of General Practitioners recently published an update of the practice guideline on urinary-tract infections. This guideline provides a clear overview of the medical history, the diagnostic methods and the treatment options. Sixteen management modalities are presented in relation to specific patient characteristics. However, this revised guideline warrants some minor comments. According to the guideline, the dipstick (nitrite) test and dipslide form the two cornerstones of the diagnosis of urinary-tract infections. The value of the dipslide, however, seems to have been overestimated and that of microscopic examination of the urine by skilled physicians to have been underestimated. New in this guideline compared to that of 1999 is that nitrofurantoin (the treatment of first choice in uncomplicated infections) should be given for five instead of three days. The guideline motivates this change in policy on the basis of the numerous treatment failures seen in practice. The most convincing type of evidence, however, is not available due to the lack of relevant randomised clinical trials. The introduction of the prescription of phosphomycin, which is unusual in the Netherlands, as an alternative treatment for uncomplicated infections requires supportive evidence before it will be accepted by general practitioners. This well-documented guideline provides clear guidance for the general practitioner faced with patients with urinary-tract symptoms that could be caused by infection.

[Psychiatric manifestations due to abnormal glucocorticoid levels]. / Psychiatrische beelden bij afwijkende cortisolproductie.

This clinical case presentation describes the disease trajectory in two patients who presented with psychiatric symptoms as a result of abnormal serum glucocorticoid levels. One case involves a 58-year-old man with hypercortisolism, the other case concerns a 55-year-old woman with hypocortisolism. In both cases there was a considerable diagnostic delay in recognizing the underlying adrenal gland pathology. Abnormal glucocorticoid levels, caused by endocrine disorders, often results in psychiatric symptoms. Delay in diagnosis may have adverse consequences. Hyper- or hypocortisolism should be considered in patients who present with an atypical presentation of psychiatric symptoms. Moreover, the absence of specific physical signs or symptoms at first presentation in such patients does not exclude an underlying endocrinological cause. Therefore, physical and psychiatric reassessment of such patients should be considered at regular intervals.

[The risk of pelvic inflammatory disease associated with urogenital infection with Chlamydia trachomatis; literature review]. / De kans op 'pelvic inflammatory disease' bij urogenitale infectie met Chlamydia trachomatis; literatuuronderzoek.

OBJECTIVE: To determine the rate of PID in women with genital Chlamydia trachomatis infection. DESIGN: Systematic literature review. METHOD: MEDLINE and EMBASE were searched over the years 1975-2003 using the keywords 'Chlamydia trachomatis', 'complication', 'pelvic (inflammatory disease)', 'PID', 'endometritis', 'adnexitis', and 'salpingitis'. The reference lists ofthe articles retrieved were checked for other relevant publications. The PID complication rate was determined, as were the characteristics of the study populations and the validity of the diagnostic methods and outcome measures used. RESULTS: 9 prospective studies were identified. The rate of PID in women with a genital C. trachomatis infection varied between o and 72%. Asymptomatic women who were diagnosed with C. trachomatis infection in general screening had the lowest rate of PID: 0-4%. PID occurred in 12-30% of symptomatic women or women with a higher risk of having an STD (e.g. visitor of an STD clinic, double-infection with gonorrhoea, high risk assessed by questionnaire, having a partner with symptomatic C. trachomatis infection). Women who underwent legal abortion had the highest rate of PID (27-72%). CONCLUSION: The PID rate in women with C. trachomatis varied considerably. Risk depended on whether the infection was symptomatic and the prior probability of having an STD.

Self-reports and general practitioner information on the presence of chronic diseases in community dwelling elderly. A study on the accuracy of patients' self-reports and on determinants of inaccuracy.

OBJECT: The object of the study is to investigate the (in)accuracy of patients' self-reports, as compared with general practitioners' information, regarding the presence of specific chronic diseases, and the influence of patient characteristics. METHODS: Questionnaire data of 2380 community-dwelling elderly patients, aged 55-85 years, on the presence of chronic non-specific lung disease, cardiac disease, peripheral atherosclerosis, stroke, diabetes, malignancies, and osteoarthritis/rheumatoid arthritis were compared with data from the general practitioners, using the kappa-statistic. Associations between the accuracy of self-reports and patient characteristics were studied by multiple logistic regression analyses. RESULTS: Kappa's ranged from 0.30 to 0.40 for osteoarthritis/rheumatoid arthritis and atherosclerosis, to 0.85 for diabetes mellitus. In the multivariate analyses, educational level, level of urbanization, deviations in cognitive function, and depressive symptomatology had no influence on the level of accuracy. An influence of gender, age, mobility limitations, and recent contact with the general practitioner was shown for specific diseases. For chronic non-specific lung disease, both "underreporting" and "overreporting" are more prevalent in males, compared to females. Furthermore, males tend to overreport stroke and underreport malignancies and arthritis, whereas females tend to overreport malignancies and arthritis. Both overreporting and underreporting of cardiac disease are more prevalent as people are older. Also, older age is associated with overreporting of stroke, and with underreporting of arthritis. The self-reported presence of mobility limitations is associated with overreporting of all specific diseases studied, except for diabetes mellitus, and its absence is associated with underreporting, except for diabetes mellitus and atherosclerosis. Recent contact with the general practitioner is associated with overreporting of cardiac disease, atherosclerosis, malignancies and arthritis, and with less frequent underreporting of diabetes and arthritis. CONCLUSIONS: Results suggest that patients' self-reports on selected chronic diseases are fairly accurate, with the exceptions of atherosclerosis and arthritis. The associations found with certain patient characteristics may be explained by the tendency of patients to label symptoms, denial by the patient, or inaccuracy of medical records.

Clinimetric properties of a parent report on their offspring's quality of life.

The objective of this study was to assess the reproducibility, construct validity, and responsiveness of the parent report version of the "How are you" (HAY), a quality of life questionnaire for children with a chronic disease. The reproducibility of the HAY was assessed by comparing the scores of two measurement cycles of children with stable asthma. Construct validity was evaluated by testing the differences between scores of the HAY of parents of children with and without asthma and by investigating the correlations between the HAY and instruments supposed to correlate with the HAY. Responsiveness was investigated in parents of children whose clinical status changed clinically relevant between two measurements. The HAY showed acceptable reproducibility. Also the HAY detected anticipated differences in quality of life between parents of asthmatic and healthy children. It furthermore showed acceptable ability to measure change in health status of children with asthma. The parent report version of the HAY shows acceptable reproducibility, supportive evidence for construct validity, and good responsiveness. The measurement of quality of life of asthmatic children and changes therein can truly rely on parental report.

Effects of social support and personal coping resources on depressive symptoms: different for various chronic diseases?

Effects of psychosocial coping resources on depressive symptoms were examined and compared in older persons with no chronic disease or with recently symptomatic diabetes mellitus, lung disease, cardiac disease, arthritis, or cancer. The 719 persons without diseases reported less depressive symptoms than the chronically ill. Direct favorable effects on depressive symptoms were found for having a partner, having many close relationships, greater feelings of mastery, greater self-efficacy expectations, and high self-esteem. Buffer effects were observed for feelings of mastery, having many diffuse relationships, and receiving emotional support. Buffer effects were differential across diseases for emotional support (in cardiac disease and arthritis only) and for diffuse relationships (in lung disease). Receiving instrumental support was associated with more depressive symptoms, especially in diabetes patients.

Do disease specific characteristics add to the explanation of mobility limitations in patients with different chronic diseases? A study in The Netherlands.

STUDY OBJECTIVES: To determine whether disease specific characteristics, reflecting clinical disease severity, add to the explanation of mobility limitations in patients with specific chronic diseases. DESIGN AND SETTING: Cross sectional study of survey data from community dwelling elderly people, aged 55-85 years, in the Netherlands. PARTICIPANTS AND METHODS: The additional explanation of mobility limitations by disease specific characteristics was examined by logistic regression analyses on data from 2830 community dwelling elderly people. MAIN RESULTS: In the total sample, chronic non-specific lung disease, cardiac disease, peripheral atherosclerosis, diabetes mellitus, stroke, arthritis and cancer (the index diseases), were all independently associated with mobility limitations. Adjusted for age, sex, comorbidity, and medical treatment disease specific characteristics that explain the association between disease and mobility mostly reflect decreased endurance capacity (shortness of breath and disturbed night rest in chronic non-specific lung disease, angina pectoris and congestive heart failure in cardiac disease), or are directly related to mobility function (stiffness and lower body complaints in arthritis). For atherosclerosis and diabetes mellitus, disease specific characteristics did not add to the explanation of mobility limitations. CONCLUSIONS: The results provide evidence that, to obtain more detailed information about the differential impact of chronic diseases on mobility, disease specific characteristics are important to take into account.

Direct and buffer effects of social support and personal coping resources in individuals with arthritis.

The direct and buffer effects of various aspects of social support and personal coping resources on depressive symptoms were examined. The study concerned a community-based sample of 1690 older persons aged 55-85 yrs, of whom 719 had no chronic disease, 612 had mild arthritis and 359 had severe arthritis. Persons with arthritis reported more depressive symptoms than persons with no chronic diseases. Irrespective of arthritis, the presence of a partner, having many close social relationships, feelings of mastery and a high self-esteem were found to have direct, favourable effects on psychological functioning. Mastery, having many diffuse social relationships, and receiving emotional support seem to mitigate the influence of arthritis on depressive symptoms, which is in conformity with the buffer hypothesis. Favourable effects of these variables on depressive symptomatology were only, or more strongly, found in persons suffering from severe arthritis.

Psychological status among elderly people with chronic diseases: does type of disease play a part?

Psychological status, including depressive symptoms, anxiety, and mastery, was measured in a community-based sample of 3,076 persons aged 55 to 85 with various chronic diseases. Strong, linear associations were found between the number of chronic diseases and depressive symptoms and anxiety, indicating that psychological distress among elderly people is more apparent in the presence of (more) diseases. Furthermore, in contrast to general assumptions that mastery is a relatively stable state, our results indicate that mastery is affected by having chronic diseases. The 8 groups of chronically ill patients (with cardiac disease, peripheral atherosclerosis, stroke, diabetes, lung disease, osteoarthritis, rheumatoid arthritis, or cancer) did differ in their associations with psychological distress. Psychological distress is most frequently experienced by patients with osteoarthritis, rheumatoid arthritis, and stroke, whereas diabetic and cardiac patients appear to be the least psychologically distressed. Differences in disease characteristics, such as functional incapacitation and illness controllability, may partly explain these observed psychological differences across diseases.

Incidence and management of oral conditions in general practice.

Despite a high community prevalence, little is known about the occurrence of oral conditions in general practice. In an observational study, 354 new cases of oral complaints were recorded in 35 participating practices during a period of six months (cumulative incidence = 6.7 per 1000 per year). The incidence was highest in children under five years of age (21% of all cases). The conditions diagnosed most frequently were aphthous ulceration, oral candidiasis, and herpes simplex infection. Most oral conditions were minor ailments, and could be dealt with by the general practitioner alone.

Vaginal symptoms of unknown aetiology: a study in Dutch general practice.

Vaginal symptoms are frequently presented by women to general practitioners. In many cases, the aetiology of these symptoms remains unknown. This study focused on the factors associated with microbiologically unexplained vaginal symptoms, the course of symptoms and signs in these cases, and factors modifying this course. In a group of 610 women presenting to their general practitioner with vaginal symptoms (itching, irritation, abnormal but non-bloody discharge) the distribution of diagnoses was studied and factors associated with symptoms of unknown aetiology were identified using logistic regression analysis. During a three month follow up, the course of symptoms and signs was studied in 139 women with unexplained vaginal symptoms, using survival analysis methods. It was found that 25% of all the women had symptoms of unknown aetiology. A larger number of these women, compared with women with other diagnoses, were Caucasian, married, more highly educated, used oral contraceptives and reported psychological distress. During the follow-up period, a specific infection was diagnosed in less than 20% of the women with unexplained vaginal symptoms. Over half of the women (54%) recovered within three months. Short duration of symptoms before presentation was associated with a higher probability of recovery. From the study, it was found that many women visiting the general practitioner for vaginal symptoms had no demonstrable microbial disorder. Often these symptoms were transient and disappeared without intervention. Persistent symptoms may call for further examination where somatic, as well as psychosocial, factors should be taken into account.

Shoulder disorders in general practice: prognostic indicators of outcome.

BACKGROUND: Shoulder pain is common in primary health care. Nevertheless, information on the outcome of shoulder disorders is scarce, especially for patients encountered in general practice. AIM: To study the course of shoulder disorders in general practice and to determine prognostic indicators of outcome. METHOD: For this prospective follow-up study, 11 Dutch general practitioners recruited 349 patients with new episodes of shoulder pain. The participants filled out a questionnaire at presentation and further ones after 1, 3, 6 and 12 months; these contained questions on the nature, severity and course of the shoulder complaints. The association between potential prognostic indicators and the status of shoulder complaints (absence or presence of symptoms) was evaluated after one and 12 months of follow-up. RESULTS: After one month, 23% of all patients showed complete recovery; this figure increased to 59% after one year. A speedy recovery seemed to be related to preceding overuse or slight trauma and early presentation. A high risk of persistent or recurrent complaints was found for patients with concomitant neck pain and severe pain during the day at presentation. CONCLUSION: A considerable number of patients (41%) showed persistent symptoms after 12 months. It may be possible to distinguish patients who will show a speedy recovery from those with a high risk of long-standing complaints by determining whether there is a history of slight trauma or overuse, an early presentation or an absence of concomitant neck pain.