Ruling out acute coronary syndrome in primary care with a clinical decision rule and a capillary, high-sensitive troponin I point of care test: study protocol of a diagnostic RCT in the Netherlands (POB HELP).

INTRODUCTION: Chest pain is a common reason for consultation in primary care. To rule out acute coronary syndrome (ACS), general practitioners (GP) refer 40%-70% of patients with chest pain to the emergency department (ED). Only 10%-20% of those referred, are diagnosed with ACS. A clinical decision rule, including a high-sensitive cardiac troponin-I point-of-care test (hs-cTnI-POCT), may safely rule out ACS in primary care. Being able to safely rule out ACS at the GP level reduces referrals and thereby alleviates the burden on the ED. Moreover, prompt feedback to the patients may reduce anxiety and stress. METHODS AND ANALYSIS: The POB HELP study is a clustered randomised controlled diagnostic trial investigating the (cost-)effectiveness and diagnostic accuracy of a primary care decision rule for acute chest pain, consisting of the Marburg Heart Score combined with a hs-cTnI-POCT (limit of detection 1.6 ng/L, 99th percentile 23 ng/L, cut-off value between negative and positive used in this study 3.8 ng/L). General practices are 2:1 randomised to the intervention group (clinical decision rule) or control group (regular care). In total 1500 patients with acute chest pain are planned to be included by GPs in three regions in The Netherlands. Primary endpoints are the number of hospital referrals and the diagnostic accuracy of the decision rule 24 hours, 6 weeks and 6 months after inclusion. ETHICS AND DISSEMINATION: The medical ethics committee Leiden-Den Haag-Delft (the Netherlands) has approved this trial. Written informed consent will be obtained from all participating patients. The results of this trial will be disseminated in one main paper and additional papers on secondary endpoints and subgroup analyses. TRIAL REGISTRATION NUMBERS: NL9525 and NCT05827237.

Exploring why European primary care physicians sometimes do not think of, or act on, a possible cancer diagnosis. A qualitative study.

BACKGROUND: While primary care physicians (PCPs) play a key role in cancer detection, they can find cancer diagnosis challenging, and some patients have considerable delays between presentation and onward referral. AIM: To explore European PCPs' experiences and views on cases where they considered that they had been slow to think of, or act on, a possible cancer diagnosis. DESIGN & SETTING: A multicentre European qualitative study, based on an online survey with open-ended questions, asking PCPs for their narratives about cases when they had missed a diagnosis of cancer. METHOD: Using maximum variation sampling, PCPs in 23 European countries were asked to describe what happened in a case where they were slow to think of a cancer diagnosis, and for their views on why it happened. Thematic analysis was used to analyse the data. RESULTS: A total of 158 PCPs completed the questionnaire. The main themes were as follows: patients' descriptions did not suggest cancer; distracting factors reduced PCPs' cancer suspicions; patients' hesitancy delayed the diagnosis; system factors not facilitating timely diagnosis; PCPs felt that they had acted wrongly; and problems with communicating adequately. CONCLUSION: The study identified six overarching themes that need to be addressed. Doing so should reduce morbidity and mortality in the small proportion of patients who have a significant, avoidable delay in their cancer diagnosis. The 'Swiss cheese' model of accident causation showed how the themes related to each other.

Patients' Experiences, Expectations, Motivations, and Perspectives around Urinary Tract Infection Care in General Practice: A Qualitative Interview Study.

While there are many alternatives to antibiotics for the symptomatic treatment of urinary tract infections (UTIs), their application in practice is limited. Among other things, general practitioners (GPs) often feel pressure from patients to prescribe antibiotics. To gain a better understanding of why this happens and where this pressure originates from, we investigated experiences, expectations, motivations, and perspectives of patients with UTIs in general practice. During this qualitative study we performed 14 semi-structured online interviews among female UTI patients in general practice. Interviews were based on a topic list derived from sensitising concepts. All the interviews were recorded, transcribed, and analysed using a constant comparative technique. Three main categories emerged from the data; (1) experienced versus unexperienced patients with UTI, (2) patient's lack of knowledge, and (3) patients feeling understood. Inexperienced patients consult a general practitioner for both diagnosis and symptom relief, while experienced patients seem to consult specifically to obtain antibiotics. In addition, patients have a lack of knowledge with regard to the diagnosis, treatment, self-care, and cause of UTIs. Finally, patients' satisfaction is increased by involving them more in the process of decision making, so they feel understood and taken seriously. Patients' expectations in UTI management in general practice often arise during their first experience(s) and play a major role in subsequent episodes. In conclusion, preventing misconceptions is especially important in the inexperienced patient group, as this may prevent future overtreatment of UTIs. In addition, involving patients in the decision making process will lead to greater understanding of the GP's treatment choices.

Barriers and facilitators to the implementation of nutrition interventions at primary health care units of Ethiopia: A consolidated framework for implementation research.

Accumulating evidence clearly shows poor implementation of nutrition interventions, in Ethiopia and other African countries, with many missed opportunities in the first 1000 days of life. Even though there are high-impact interventions in this critical period, little is known about the barriers and facilitators influencing their implementation. This paper aims to explore barriers and facilitators for the implementation of nutrition services for small children with a focus on growth monitoring and promotion, iron-folic acid supplementation and nutrition counselling. We conducted a qualitative study in four districts of Ethiopia. The data collection and analysis were guided by the consolidated framework for implementation research (CFIR). A total of 42 key informant interviews were conducted with key stakeholders and service providers. Interviews were transcribed verbatim and coded using CIFR constructs. We found that from 39 constructs of CFIR, 14 constructs influenced the implementation of nutrition interventions. Major barriers included lack of functional anthropometric equipment and high caseload (complexity), poor staff commitment and motivation (organisational incentive and reward), closed health posts (patient need and resource), false reporting (culture), lack of priority for nutrition service (relative priority), poor knowledge among service providers (knowledge and belief about the intervention) and lack of active involvement and support from leaders (leadership engagement). Adaptability and tension for change were the facilitators for the implementation of nutrition interventions. Effective implementation of nutrition interventions at primary health care units requires several actions such as improving the healthcare providers' motivation, improving leadership engagement, and creating a strong system for monitoring, supportive supervision and accountability.

Challenges and opportunities for general practice specific CME in Europe - a narrative review of seven countries.

BACKGROUND: Several changes have led to general practitioners (GPs) working in a more differentiated setting today and being supported by other health professions. As practice changes, primary care specific continuing medical education (CME) may also need to adapt. By comparing different primary care specific CME approaches for GPs across Europe, we aim at identifying challenges and opportunities for future development. METHODS: Narrative review assessing, analysing and comparing CME programs for general practitioners across different north-western European countries (UK, Norway, the Netherlands, Belgium (Flanders), Germany, Switzerland, and France). Templates containing detailed items across seven dimensions of country-specific CME were developed and used. These dimensions are role of primary care within the health system, legal regulations regarding CME, published aims of CME, actual content of CME, operationalisation, funding and sponsorship, and evaluation. RESULTS: General practice specific CME in the countries under consideration are presented and comparatively analysed based on the dimensions defined in advance. This shows that each of the countries examined has different strengths and weaknesses. A clear pioneer cannot be identified. Nevertheless, numerous impulses for optimising future GP training systems can be derived from the examples presented. CONCLUSIONS: Independent of country specific CME programs several fields of potential action were identified: the development of curriculum objectives for GPs, the promotion of innovative teaching and learning formats, the use of synergies in specialist GP training and CME, the creation of accessible yet comprehensive learning platforms, the establishment of clear rules for sponsorship, the development of new financing models, the promotion of fair competition between CME providers, and scientifically based evaluation.

Physician-Targeted Interventions in Antibiotic Prescribing for Urinary Tract Infections in General Practice: A Systematic Review.

Urinary tract infections (UTIs) are the most common reason for women to consult a general practitioner (GP). While UTIs are self-limiting in half of cases, most women are prescribed antibiotics, often in discordance with established guidelines. Researchers have employed different interventions to improve GPs' prescribing behavior, especially for respiratory infections, but it is uncertain whether these are effective for UTI care. Therefore, we performed a systematic review, including (cluster) randomized clinical trials investigating the effect of interventions targeted at GPs to improve antibiotic prescriptions for UTI. From September to December 2021 we searched the Medline, Web of Science, and CENTRAL databases, ultimately including ten studies describing eleven trials. We determined the effect of the interventions on the decision to prescribe and on the choice of antibiotic. Results showed that most studies employed multifaceted interventions, most frequently including audit & feedback and/or educational meetings. Seven out of nine trials that recorded first-choice prescriptions saw an increased proportion of first-choice antibiotics in the intervention groups compared to control groups. The employed interventions also caused a decreased proportion of at least one broad-spectrum antibiotic in five out of six studies that measured broad-spectrum antibiotic prescriptions. However, the total number of antibiotic prescriptions for UTIs increased in four out of eight studies. Therefore, while effective at influencing GPs' prescribing behavior, future interventions should also focus on improving the decision to prescribe at all.

Impact of influenza vaccination on GP-diagnosed COVID-19 and all-cause mortality: a Dutch cohort study.

OBJECTIVES: As clinical presentation and complications of both viruses overlap, it was hypothesised that influenza vaccination was associated with lower general practitioner (GP)-diagnosed COVID-19 rates and lower all-cause mortality rates. STUDY DESIGN: From a primary care population-based cohort in the Netherlands, GP-diagnosed COVID-19 (between 10 March and 22 November 2020) and all-cause mortality events (between 30 December 2019 and 22 November 2020) were recorded. 223 580 persons were included, representing the influenza vaccination 2019 target group (all aged ≥60 years, and those <60 years with a medical indication). Proportional hazards regression analyses evaluated associations between influenza vaccination in 2019 and two outcomes: GP-diagnosed COVID-19 and all-cause mortality. Covariables were sex, age, comorbidities and number of acute respiratory infection primary care consultations in 2019. RESULTS: A slightly positive association (HR 1.15; 95% CI 1.08 to 1.22) was found between influenza vaccination in 2019 and GP-diagnosed COVID-19, after adjusting for covariables. A slightly protective effect for all-cause mortality rates (HR 0.90; 95% CI 0.83 to 0.97) was found for influenza vaccination, after adjusting for covariables. A subgroup analysis among GP-diagnosed COVID-19 cases showed no significant association between influenza vaccination in 2019 and all-cause mortality. CONCLUSIONS: Our hypothesis of a possibly negative association between influenza vaccination in 2019 and GP-diagnosed COVID-19 was not confirmed as we found a slightly positive association. A slightly protective effect on all-cause mortality was found after influenza vaccination, possibly by a wider, overall protective effect on health. Future research designs should include test-confirmed COVID-19 cases and controls, adjustments for behavioural, socioeconomic and ethnic factors and validated cause-specific mortality cases.

Shoulder muscle changes in patients with type 2 diabetes mellitus who have a painful shoulder: a quantitative muscle ultrasound study.

BACKGROUND: It is assumed that in patients with diabetic neuropathy, muscle denervation can result in shoulder disorders. Muscle denervation will lead to changes in muscle architecture, which can be assessed by quantitative muscle ultrasound (QMUS). The aim was to investigate whether increased muscle echogenicity, as a sign of neuropathy, is more often present in patients with shoulder pain who have type 2 diabetes mellitus (T2DM) than in those without. METHODS: Sixty-six patients with T2DM and 23 patients without diabetes mellitus (DM) having shoulder pain were included. Quantitative muscle ultrasound images were obtained bilaterally from the biceps brachii, deltoid, and supra- and infraspinatus muscles. The mean echogenicity (muscle ultrasound grey value) was transformed into z-scores and compared to reference values obtained from 50 healthy participants. Associations between muscle echogenicity and clinical variables were explored. RESULTS: In painful shoulders of both patients with T2DM and patients without DM, mean echogenicity z-scores of all muscles were significantly increased compared to healthy controls. No significant differences in echogenicity between patients with T2DM and those without DM were found. In patients with T2DM, a distal symmetric polyneuropathy was significantly associated with increased echogenicity of all muscles except the infraspinatus muscle. CONCLUSIONS: These findings indicate that patients with painful shoulders, irrespective of having T2DM, seem to have abnormal shoulder muscles. Future studies are needed to elucidate whether neuropathy or other conditions lead to these muscle changes.

Cross-sectional internet survey exploring women's knowledge, attitudes and practice regarding urinary tract infection-related symptoms in the Netherlands.

OBJECTIVES: Urinary tract infections (UTIs) are the most prevalent cause for women to consult a general practitioner (GP) and are commonly treated with (broad-spectrum) empirical antibiotics, even though 50% of UTIs are self-limiting. In this study, we aim to explore women's attitudes and experiences regarding UTIs, in order to determine patients' willingness to accept delayed antibiotic prescriptions. DESIGN: An internet-based cross-sectional survey SETTING: We recruited participants during 2 weeks of March and April in 2020 through several social media platforms. PARTICIPANTS: We obtained 1476 responses, of which 975 were eligible for analysis. RESULTS: We asked women about their knowledge, attitudes and practice regarding UTI-related symptoms. Participants ranked 'confirmation of diagnosis' (43.8%) as the most important reason to consult a GP with urinary symptoms, followed by 'pain relief' (32%), and 'antibiotic prescription' (14.3%). For treatment, 71% of participants reported that their GP prescribed immediate antibiotics, while only 3% received a delayed antibiotic prescription and 1% was advised pain medication. Furthermore, 50% of respondents were aware of the possible self-limiting course of UTIs and 70% would be willing to accept delayed antibiotic treatment, even if a certain diagnosis of UTI was established. Willingness to delay was lower in experienced patients compared to inexperienced patients. CONCLUSIONS: Women are quite receptive to delayed antibiotics as an alternative to immediate antibiotics for UTIs or urinary symptoms. GPs should consider discussing delayed antibiotic treatment more often with women presenting with urinary symptoms.

Coronary calcium scoring as first-line test to detect and exclude coronary artery disease in patients presenting to the general practitioner with stable chest pain: protocol of the cluster-randomised CONCRETE trial.

INTRODUCTION: Identifying and excluding coronary artery disease (CAD) in patients with atypical angina pectoris (AP) and non-specific thoracic complaints is a challenge for general practitioners (GPs). A diagnostic and prognostic tool could help GPs in determining the likelihood of CAD and guide patient management. Studies in outpatient settings have shown that the CT-based coronary calcium score (CCS) has high accuracy for diagnosis and exclusion of CAD. However, the CT CCS test has not been tested in a primary care setting. In the COroNary Calcium scoring as fiRst-linE Test to dEtect and exclude coronary artery disease in GPs patients with stable chest pain (CONCRETE) study, the impact of direct access of GPs to CT CCS will be investigated. We hypothesise that this will allow for early diagnosis of CAD and treatment, more efficient referral to the cardiologist and a reduction of healthcare-related costs. METHODS AND ANALYSIS: CONCRETE is a pragmatic multicentre trial with a cluster randomised design, in which direct GP access to the CT CCS test is compared with standard of care. In both arms, at least 40 GP offices, and circa 800 patients with atypical AP and non-specific thoracic complaints will be included. To determine the increase in detection and treatment rate of CAD in GP offices, the CVRM registration rate is derived from the GPs electronic registration system. Individual patients' data regarding cardiovascular risk factors, expressed chest pain complaints, quality of life, downstream testing and CAD diagnosis will be collected through questionnaires and the electronic GP dossier. ETHICS AND DISSEMINATION: CONCRETE has been approved by the Medical Ethical Committee of the University Medical Center of Groningen. TRIAL REGISTRATION NUMBER: NTR 7475; Pre-results.

Prevalent Morphometrically Assessed Vertebral Fractures in Individuals With Type 2 Diabetes, Prediabetes and Normal Glucose Metabolism: The Maastricht Study.

BACKGROUND: Type 2 diabetes (T2D) is frequently reported to be associated with an increased fracture risk. Epidemiological data on prevalent morphometric vertebral fractures (VFs) in T2D are sparse and even less is known in the prediabetic state. PURPOSE: To determine the association between prevalence and severity of morphometric VFs and glucose metabolism state: normal glucose metabolism (NGM), impaired glucose metabolism (prediabetes) or T2D. METHODS: This study included cross-sectional data from 3625 participants of the Maastricht Study who had a vertebral fracture assessment on lateral Dual Energy X-Ray Absorptiometry images. VFs were classified based on morphometric assessment into mild, moderate and severe VFs (respectively 20-24%, 25-39% or ≥40% reduction in expected vertebral body height). Logistic regression models were used to investigate the association between glucose metabolism status and the prevalence and severity of VFs. Analyses were adjusted for subject characteristics and life-style factors. RESULTS: T2D individuals were older (62.8 ± 7.5 years old) and less often female (30.5%) compared to the NGM group (57.7 ± 8.5 years old, and 58.8% female, respectively). At least one mild, moderate or severe prevalent VF was found in 8.6% of the men and 2.2% of the women in the T2D group, in 9.4% and 8.4% in the prediabetes group and in 9.1% and 4.8% in the NGM group, respectively. After adjustment T2D in women was associated with a lower probability of having a prevalent VF compared to NGM [adjusted OR 0.25 (95% CI 0.09-0.65)], while this was not the case for prediabetes. Furthermore, women with T2D had a significantly lower probability of a prevalent moderate or severe VF [adjusted OR 0.32 (95% CI 0.11-0.96)]. In men there was no significant association between T2D or prediabetes and prevalent VFs. CONCLUSION: Women with T2D had a lower probability of prevalent VFs compared to women with a normal glucose metabolism, while this was not the case for men with T2D and participants with prediabetes.

The Diagnostic and Prognostic Value of Coronary Calcium Scoring in Stable Chest Pain Patients: A Narrative Review.

BACKGROUND: Non-contrast computed tomography (CT) scanning allows for reliable coronary calcium score (CCS) calculation at a low radiation dose and has been well established as marker to assess the future risk of coronary artery disease (CAD) events in asymptomatic individuals. However, the diagnostic and prognostic value in symptomatic patients remains a matter of debate. This narrative review focuses on the available evidence for CCS in patients with stable chest pain complaints. METHOD: PubMed, Embase, and Web of Science were searched for literature using search terms related to three overarching categories: CT, symptomatic chest pain patients, and coronary calcium. The search resulted in 42 articles fulfilling the inclusion and exclusion criteria: 27 articles (n = 38 137 patients) focused on diagnostic value and 23 articles (n = 44 683 patients) on prognostic value of CCS. Of these, 10 articles (n = 21 208 patients) focused on both the diagnostic and prognostic value of CCS. RESULTS: Between 22 and 10 037 patients were included in the studies on the diagnostic and prognostic value of CCS, including 43 % and 51 % patients with CCS 0. The most evidence is available for patients with a low and intermediate pre-test probability (PTP) of CAD. Overall, the prevalence of obstructive CAD (OCAD, defined as a luminal stenosis of ≥ 50 % in any of the coronary arteries) as determined with CT coronary angiography in CCS 0 patients, was 4.4 % (n = 703/16 074) with a range of 0-26 % in individual studies. The event rate for major adverse cardiac events (MACE) ranged from 0 % to 2.1 % during a follow-up of 1.6 to 6.8 years, resulting in a high negative predictive value for MACE between 98 % and 100 % in CCS 0 patients. At increasing CCS, the OCAD probability and MACE risk increased. OCAD was present in 58.3 % (n = 617/1058) of CCS > 400 patients with percentages ranging from 20 % to 94 % and MACE occurred in 16.7 % (n = 175/1048) of these patients with percentages ranging from 6.9 % to 50 %. CONCLUSION: Accumulating evidence shows that OCAD is unlikely and the MACE risk is very low in symptomatic patients with CCS 0, especially in those with low and intermediate PTPs. This suggests a role of CCS as a gatekeeper for additional diagnostic testing. Increasing CCS is related to an increasing probability of OCAD and risk of cardiac events. Additional research is needed to assess the value of CCS in women and patient management in a primary healthcare setting. KEY POINTS: · A CCS of zero makes OCAD in patients at low-intermediate PTP unlikely. · A CCS of zero is related to a very low risk of MACE. · Categories of increasing CCS are related to increasing rates of OCAD and MACE. · Future studies should focus on the diagnostic and prognostic value of CCS in symptomatic women and the role in primary care. CITATION FORMAT: · Koopman MY, Willemsen RT, van der Harst P et al. The Diagnostic and Prognostic Value of Coronary Calcium Scoring in Stable Chest Pain Patients: A Narrative Review. Fortschr Röntgenstr 2022; 194: 257 - 265.

Risk factors of anemia among preschool children in Ethiopia: a Bayesian geo-statistical model.

BACKGROUND: The etiology and risk factors of anemia are multifactorial and varies across context. Due to the geospatial clustering of anemia, identifying risk factors for anemia should account for the geographic variability. Failure to adjust for spatial dependence whilst identifying risk factors of anemia could give spurious association. We aimed to identify risk factors of anemia using a Bayesian geo-statistical model. METHODS: We analyzed the Ethiopian Demographic and Health Survey (EDHS) 2016 data. The sample was selected using a stratified, two- stage cluster sampling design. In this survey, 9268 children had undergone anemia testing. Hemoglobin level was measured using a HemoCue photometer and the results were recorded onsite. Based on the World Health Organization's cut-off points, a child was considered anaemic if their altitude adjusted haemoglobin (Hb) level was less than 11 g/dL. Risk factors for anemia were identified using a Bayesian geo-statistical model, which accounted for spatial dependency structure in the data. Posterior means and 95% credible interval (BCI) were used to report our findings. We used a statistically significant level at 0.05. RESULT: The 9267 children in our study were between 6 and 59 months old. Fifty two percent (52%) of children were males. Thirteen percent (13%) of children were from the highest wealth quintile whereas 23% from the lowest wealth quintile. Most of them lived in rural areas (90%). The overall prevalence of anemia among preschool children was 57% (95% CI: 54.4-59.4). We found that child stunting (OR = 1.26, 95% BCI (1.14-1.39), wasting (OR = 1.35, 95% BCI (1.15-1.57), maternal anemia (OR = 1.61, 95% BCI (1.44-1.79), mothers having two under five children (OR = 1.2, 95% BCI (1.08-1.33) were risk factors associated with anemia among preschool children. Children from wealthy households had lower risk of anemia (AOR = 0.73, 95% BCI (0.62-0.85). CONCLUSION: Using the Bayesian geospatial statistical modeling, we were able to account for spatial dependent structure in the data, which minimize spurious association. Childhood Malnutrition, maternal anemia, increased fertility, and poor wealth status were risk factors of anemia among preschool children in Ethiopia. The existing anaemia control programs such as IFA supplementation during pregnancy should be strengthened to halt intergenerational effect of anaemia. Furthermore, routine childhood anaemia screening and intervention program should be part of the Primary health care in Ethiopia.

Geospatial inequality of anaemia among children in Ethiopia.

Anaemia remains a severe public health problem among children in Ethiopia and targeted approaches, based on the distribution and specific risk factors for that setting are needed to efficiently target health interventions. An analysis was performed using Ethiopia Demographic and Health Survey 2016 data. Blood specimens for anaemia testing were collected from 9268 children aged 6-59 months. A child was considered as anaemic if the bloodhaemoglobin count was less than 11.0 g/dL. We applied Kulldorf's spatial scan statistics and used SaTScanTM to identify locations and estimate cluster sizes. In addition, we ran the local indicator of spatial association and the Getis-Ord Gi* statistics to detect and locate hotspots and multilevel multivariable analysis to identify risk factors for anaemia clustering. More than half of children aged 6-59 months (57%) were found to be anaemic in Ethiopia. We found significant geospatial inequality of anaemia among children and identified clusters (hotspots) in the eastern part of Ethiopia. The odds of anaemia among children found within the identified cluster was 1.5 times higher than children found outside the cluster. Women anaemia, stunting and high fertility were associated with anaemia clustering.

Prevalence of Upper Extremity Musculoskeletal Disorders in Patients with Type 2 Diabetes in General Practice.

Background: One of the lesser recognized complications of diabetes mellitus are musculoskeletal (MSK) complications of the upper and lower extremity. No prevalence studies have been conducted in general practice. Thus, the aim of this study was to investigate the prevalence of upper extremity MSK disorders in patients with type 2 diabetes (T2DM) in the Netherlands. Methods: We conducted a cross-sectional study with two different approaches, namely a representative Dutch primary care medical database study and a questionnaire study among patients with T2DM. Results: In the database study, 2669 patients with T2DM and 2669 non-diabetes patients were included. MSK disorders were observed in 16.3% of patients with T2DM compared to 11.2% of non-diabetes patients (p < 0.001, OR 1.53, 95% CI 1.31, 1.80). In the questionnaire study, 200 patients with T2DM were included who reported a lifetime prevalence of painful upper extremity body sites for at least four weeks of 67.3%. Conclusion: We found that upper extremity MSK disorders have a high prevalence in Dutch patients with T2DM presenting in general practice. The prevalence ranges from 16% based on GP registered disorders and complaints to 67% based on self-reported diagnosis and pain. Early detection and treatment of these disorders may play a role in preventing the development of chronic MSK disorders.

Anaemia and its determinants among young children aged 6-23 months in Ethiopia (2005-2016).

Anaemia in children remains a significant public health threat. Recent numbers from Ethiopia showed that more than two-thirds of children under the age of 2 years were anaemic. This study aimed to investigate the determinants of anaemia throughout Ethiopia over 11 years, making use of the Ethiopian Demographic and Health Survey (EDHS) rounds 2005, 2011 and 2016. The EDHS made it possible to use data on blood tests and detailed questionnaires among infants and young children. Multivariable logistic regression was applied to assess the association of anaemia and different immediate and underlying determinants. A total of 7,324 children aged 6-23 months were included in the analysis, with prevalences of anaemia being 71% in 2005, 61% in 2011 and 72% in 2016. The following determinants were significantly associated with childhood anaemia throughout the entire period: children younger than 1 year, anaemic mothers and those growing up in pastoralist regions. Risk factors such as diet and infections were consistently not significantly associated with anaemia. Given the tremendous adverse health effects of anaemia in young children, urgent action is needed. Hence, this study recommends nationwide multisectoral interventions targeting pastoralist regions, maternal and child health, screening and treatment of risk groups that could reduce the prevalence of anaemia.

What Is the Diagnosis in Patients with Type 2 Diabetes Who Have a Painful Shoulder? Results from a Prospective Cross-Sectional Study.

BACKGROUND: Patients with diabetes mellitus have higher risk of developing shoulder pathology. However, only adhesive capsulitis is addressed in shoulder pain guidelines as a disorder associated with diabetes. Yet, patients with diabetes are at risk of having several other shoulder disorders, including focal neuropathy. Our aim was to quantify the presence of shoulder disorders using physical examination and ultrasound imaging in patients with type 2 diabetes (T2DM) suffering from shoulder pain in general practice. METHODS: In this prospective cross-sectional study, patients with T2DM who had had a painful shoulder for at least four weeks were included. Patients filled out a questionnaire and underwent a physical examination of the shoulders and feet and ultrasound imaging of the shoulder. RESULTS: A total of 66 patients were included, of whom 40.9% (n = 27) had bilateral complaints resulting in 93 symptomatic shoulders. Subacromial pain syndrome was most frequently diagnosed by physical examination (66.6%, 95% CI 51.6-72.0%; p < 0.0001), while ultrasound imaging showed that subacromial disorders were statistically significantly the most prevalent (90.3%, 95% CI 81.9-95.2%). Only two patients (3%) were diagnosed with neuropathic shoulder pain. CONCLUSION: When choosing treatment, general practitioners should be aware that in patients with T2DM the subacromial region is most frequently affected.

Evaluation of the performance of clinical predictors in estimating the probability of pulmonary tuberculosis among smear-negative cases in Northern Ethiopia: a cross-sectional study.

OBJECTIVES: To evaluate the performance of the predictors in estimating the probability of pulmonary tuberculosis (PTB) when all versus only significant variables are combined into a decision model (1) among all clinical suspects and (2) among smear-negative cases based on the results of culture tests. DESIGN: A cross-sectional study. SETTING: Two public referral hospitals in Tigray, Ethiopia. PARTICIPANTS: A total of 426 consecutive adult patients admitted to the hospitals with clinical suspicion of PTB were screened by sputum smear microscopy and chest radiograph (chest X-ray (CXR)) in accordance with the Ethiopian guidelines of the National Tuberculosis and Leprosy Program. Discontinuation of antituberculosis therapy in the past 3 months, unproductive cough, HIV positivity and unwillingness to give written informed consent were the basis of exclusion from the study. PRIMARY AND SECONDARY OUTCOME MEASURES: A total of 354 patients were included in the final analysis, while 72 patients were excluded because culture tests were not done. RESULTS: The strongest predictive variables of culture-positive PTB among patients with clinical suspicion were a positive smear test (OR 172; 95% CI 23.23 to 1273.54) and having CXR lesions compatible with PTB (OR 10.401; 95% CI 5.862 to 18.454). The regression model had a good predictive performance for identifying culture-positive PTB among patients with clinical suspicion (area under the curve (AUC) 0.84), but it was rather poor in patients with a negative smear result (AUC 0.64). Combining all the predictors in the model compared with only the independent significant variables did not really improve its performance to identify culture-positive (AUC 0.84-0.87) and culture-negative (AUC 0.64-0.69) PTB. CONCLUSIONS: Our finding suggests that predictive models based on clinical variables will not be useful to discriminate patients with culture-negative PTB from patients with culture-positive PTB among patients with smear-negative cases.

Primary care practitioners' diagnostic action when the patient may have cancer: an exploratory vignette study in 20 European countries.

OBJECTIVES: Cancer survival rates vary widely between European countries, with differences in timeliness of diagnosis thought to be one key reason. There is little evidence on the way in which different healthcare systems influence primary care practitioners' (PCPs) referral decisions in patients who could have cancer.This study aimed to explore PCPs' diagnostic actions (whether or not they perform a key diagnostic test and/or refer to a specialist) in patients with symptoms that could be due to cancer and how they vary across European countries. DESIGN: A primary care survey. PCPs were given vignettes describing patients with symptoms that could indicate cancer and asked how they would manage these patients. The likelihood of taking immediate diagnostic action (a diagnostic test and/or referral) in the different participating countries was analysed. Comparisons between the likelihood of taking immediate diagnostic action and physician characteristics were calculated. SETTING: Centres in 20 European countries with widely varying cancer survival rates. PARTICIPANTS: A total of 2086 PCPs answered the survey question, with a median of 72 PCPs per country. RESULTS: PCPs' likelihood of immediate diagnostic action at the first consultation varied from 50% to 82% between countries. PCPs who were more experienced were more likely to take immediate diagnostic action than their peers. CONCLUSION: When given vignettes of patients with a low but significant possibility of cancer, more than half of PCPs across Europe would take diagnostic action, most often by ordering diagnostic tests. However, there are substantial between-country variations.

Current status of family medicine in Kenya; family physicians' perception of their role.

BACKGROUND: Family medicine (FM) was introduced in Kenya in 2005. Up to date (August 2019), 42 family physicians have graduated from Kenyan Universities. AIM: The aim of the study was to establish the current state of FM in Kenya and identify areas for more research and actions to support and improve FM in Kenya. SETTING: Interviews were conducted at the different work sites of the participants, four of them in hospitals, one at a University and one in a hotel where a FM conference was held. METHODS: An online questionnaire (response rate = 56%) and six semi-structured interviews were conducted amongst family physicians who completed their studies in Kenya. However, the focus was on the interviews. RESULTS: Family physicians have different ideas of how FM should look like ideally, but all agree that family physicians should be team leaders of a primary healthcare team, taking care of a defined population. Lack of policies, low numbers of family physicians and the misunderstanding of FM by all stakeholders are the major challenges. Sixty-four percent of the participants work in rural areas, and 77% perceive their current work as FM. CONCLUSION: Family medicine must be defined and properly promoted. Various areas have been identified that require further research: assessing required number of family physicians, reasons and solutions for the low number of family physicians, funding possibilities, and research the most suitable definition of a Kenyan family physician.