Prediction of Long-Term Physical, Mental, and Cognitive Problems Following Critical Illness: Development and External Validation of the PROSPECT Prediction Model.

OBJECTIVES: ICU survivors often suffer from long-lasting physical, mental, and cognitive health problems after hospital discharge. As several interventions that treat or prevent these problems already start during ICU stay, patients at high risk should be identified early. This study aimed to develop a model for early prediction of post-ICU health problems within 48 hours after ICU admission. DESIGN: Prospective cohort study in seven Dutch ICUs. SETTING/PATIENTS: ICU patients older than 16 years and admitted for greater than or equal to 12 hours between July 2016 and March 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Outcomes were physical problems (fatigue or ≥ 3 new physical symptoms), mental problems (anxiety, depression, or post-traumatic stress disorder), and cognitive impairment. Patient record data and questionnaire data were collected at ICU admission, and after 3 and 12 months, of 2,476 patients. Several models predicting physical, mental, or cognitive problems and a composite score at 3 and 12 months were developed using variables collected within 48 hours after ICU admission. Based on performance and clinical feasibility, a model, PROSPECT, predicting post-ICU health problems at 3 months was chosen, including the predictors of chronic obstructive pulmonary disease, admission type, expected length of ICU stay greater than or equal to 2 days, and preadmission anxiety and fatigue. Internal validation using bootstrapping on data of the largest hospital ( n = 1,244) yielded a C -statistic of 0.73 (95% CI, 0.70-0.76). External validation was performed on data ( n = 864) from the other six hospitals with a C -statistic of 0.77 (95% CI, 0.73-0.80). CONCLUSIONS: The developed and externally validated PROSPECT model can be used within 48 hours after ICU admission for identifying patients with an increased risk of post-ICU problems 3 months after ICU admission. Timely preventive interventions starting during ICU admission and follow-up care can prevent or mitigate post-ICU problems in these high-risk patients.

Post-intensive care syndrome in primary care: The development of new diseases and primary care services utilisation - a prospective cohort study.

BACKGROUND: Patients experience long-lasting health problems defined as post-intensive care syndrome (PICS) after Intensive Care Unit (ICU) admission. Little is known about PICS in primary care. OBJECTIVES: To investigate whether ICU survivors encounter more new International Classification of Primary Care-2 (ICPC-2) diagnoses and general practitioner (GP) contact compared to patients with similar comorbidity without ICU admission. METHODS: Prospective multicentre cohort study in three Dutch general practices. Numbers of disease-episodes and GP contacts of ICU survivors ≥ 16 years admitted between 2008 and 2017 were extracted from GPs' information systems. A non-ICU reference cohort was matched 1:1 for age, sex, follow-up period and comorbidity groups from patients' medical history. Negative binominal regression analysis was used to compare both cohorts 0-3, 3-6, 6-12 months, 1-2 and 2-5 years after ICU admission and 1 year prior to admission. RESULTS: ICU survivors (n = 199) encountered more new disease-episodes 1 year before (mean 3.97 (95% confidence interval [CI] 3.50-4.52]]; reference 2.36 [1.28-3.17]) to 2-5 years after ICU admission (3.65 [3.15-4.26]; reference 2.86 [2.52-3.22]). ICU survivors also had more GP contacts 1 year before (mean 19.61 [17.31-22.17]; reference 10.02 [7.81-12.38]) to 2-5 years after ICU admission (18.53 [15.58-21.85]; reference 12.03 [10.33-13.91]). Patients with prior ICU admission did not encounter patterns in specific ICPC-2 chapters compared to non-ICU patients. CONCLUSION: Patients admitted to the ICU encounter more new primary care disease-episodes and GP contacts. As patients present their symptoms to their GP first, it is therefore up to the GP to recognise these critical illness-related symptoms.

MiCare study, an evaluation of structured, multidisciplinary and personalised post-ICU care on physical and psychological functioning, and quality of life of former ICU patients: a study protocol of a stepped-wedge cluster randomised controlled trial.

INTRODUCTION: Over 70% of the intensive care unit (ICU) survivors suffer from long-lasting physical, mental and cognitive problems after hospital discharge. Post-ICU care is recommended by international guidelines, but evidence for cost-effectiveness lacks. The aim of this study is to evaluate the clinical effectiveness and cost-effectiveness of structured, multidisciplinary and personalised post-ICU care versus usual care on physical and psychological functioning and health-related quality of life (HRQoL) of ICU survivors, 1- and 2-year post-ICU discharge. METHODS AND ANALYSIS: The MONITOR-IC post-ICU care study (MiCare study) is a multicentre stepped-wedge randomised controlled trial conducted in five hospitals. Adult patients at high risk for critical illness-associated morbidity post-ICU will be selected and receive post-ICU care, including an invitation to the post-ICU clinic 3 months after ICU discharge. A personalised long-term recovery plan tailored to patients' reported outcome measures will be made. 770 (intervention) and 1480 (control) patients will be included. Outcomes are 1- and 2-year HRQoL (EuroQol Instrument (EQ-5D-5L)), physical (fatigue and new physical problems), mental (anxiety, depression and post-traumatic stress disorder), and cognitive symptoms and cost-effectiveness. Medical data will be retrieved from patient records and cost data from health insurance companies. ETHICS AND DISSEMINATION: Due to the lack of evidence, Dutch healthcare insurers do not reimburse post-ICU care. Therefore, evaluation of cost-effectiveness and integration in guidelines supports the evidence. Participation of several societies for physicians, nurses, paramedics, and patients and relatives in the project team increases the support for implementation of the intervention in clinical practice. Patients and relatives will be informed by the patient associations, hospitals and professional associations. Informing healthcare insurers about this project's results is important for the consideration for inclusion of post-ICU care in Dutch standard health insurance. The study is approved by the Radboud University Medical Centre research ethics committee (2021-13125). TRIAL REGISTRATION NUMBER: NCT05066984.

The impact of an intensive care unit admission on the health status of relatives of intensive care survivors: A prospective cohort study in primary care.

BACKGROUND: Relatives of intensive care unit (ICU) survivors may suffer from various symptoms after ICU admittance of their relative, known as post-intensive care syndrome-family (PICS-F). Studies regarding PICS-F have been performed but its impact in primary care is unknown. OBJECTIVES: To explore health problems of relatives of ICU survivors in primary care. METHODS: This is an exploratory prospective cohort study in which we combined data from two hospitals and a primary care research network in the Netherlands. ICU survivors who had been admitted between January 2005 and July 2017 were identified and matched by sex and age with up to four chronically ill (e.g. COPD, cardiovascular disease) patients. In both groups, relatives living in the same household were identified and included in this study. Primary outcome was the number of new episodes of care (International Classification of Primary Care-2) for up to five years. Hazard ratios (HRs) for the total number of new episodes were calculated. RESULTS: Relatives of ICU survivors (n = 267, mean age 38.1 years, 41.0% male) had significantly more new care episodes compared to the reference group (n = 705, mean age 36.3 years, 41.1% male) 1-2 years (median 0.11 vs. 0.08, HR 1.26; 95% confidence interval (CI) 1.03-1.54) and 2-5 years (median 0.18 vs. 0.13, HR 1.28; 95%CI 1.06-1.56) after ICU discharge. No differences were found in the period before ICU admission. CONCLUSION: Relatives of ICU survivors present more morbidity in primary care than relatives of chronically ill patients up to five years after ICU discharge.

Diagnostic Accuracy of Skin Cancer by Family Physicians.

BACKGROUND: Skin cancer is the most common type of cancer worldwide. Family physicians (FPs) need to differentiate between nonmalignant and malignant skin conditions, but the diagnostic accuracy of FPs has never been studied in primary care. AIM: To assess the accuracy of skin cancer diagnoses by FPs. Our secondary aim was to analyze the number of patients with premalignant lesions and examine the diversity of skin-related questions in Dutch primary care. METHOD: This study is a retrospective cohort of all new skin-related health questions between January 1, 2018, and July 1, 2018, in a Dutch primary care registration network with data from 26 FPs in 6 practices, with a follow-up of at least 1 year. The initial FP diagnosis was dichotomized as malignant or nonmalignant and compared in a crosstab to the final diagnosis registered after the follow-up period (reference standard). RESULTS: Our study population included 2952 patients. During the research period, 35 patients received a final diagnosis of skin cancer. The sensitivity and specificity of the FP diagnosis of malignancy was 74.3% (95% confidence interval [CI], 56.7% to 87.5%) and 97.3% (95% CI, 96.7% to 97.8%), the positive predictive value and negative predictive value was 21.5% (95% CI, 17.2% to 26.5%) and 99.7% (95% CI, 99.5% to 99.8%), respectively. Seventy-two patients were diagnosed with a premalignant lesion. Included patients received 141 different diagnoses. CONCLUSION: The calculated diagnostic accuracy of FPs is high and shows that FPs are especially accurate in excluding malignancy. This research shows the variety of skin problems in primary care and shows that the FP can deliver safe and effective dermatologic care.

Mediation of emotional and external eating between dieting and food intake or BMI gain in women.

OBJECTIVE: Dieting to control body weight is often associated with weight gain, particularly so in women; however, the underlying mechanisms are unclear. In a series of studies on women, we examined whether the relationship between dieting and weight gain can be explained by (serial) mediation of emotional eating (EE) and/or subsequent external eating (EX). METHODS: In a pilot study (116 women), we first assessed this (serial) mediation between dieting or dietary restraint and actual food consumption in the laboratory. In Study 1, a four-year follow up on patients with newly diagnosed type 2 diabetes (51 women), we assessed this (serial) mediation between dietary restraint and change in BMI and intake of energy (Kcal; Food Frequency Questionnaire). In Study 2, a three-year follow up study in a representative Dutch sample (287 women), we assessed this (serial) mediation between dieting and change in BMI. RESULTS: There was consistent support for (serial) mediation: In the pilot study, frequency of dieting and dietary restraint were both indirectly associated with grams of crackers eaten through EE and EX. In study 1, dietary restraint had a significant (95% CI) indirect association with subsequent change in measured BMI and a marginally (90% CI) significant indirect association with intake of energy through EE and EX. In study 2, EE marginally (90% CI) acted as a mediator between frequency of dieting and subsequent self-reported change in BMI. In the subsample of overweight women (n = 146) frequency of dieting was indirectly associated with subsequent self-reported change in BMI through EE and EX. CONCLUSION: The possibility that female dieters may gain weight through EE and/or subsequent EX should be taken into account when treating women with overweight or obesity.

Alpha-glucosidase inhibitors for prevention or delay of type 2 diabetes mellitus and its associated complications in people at increased risk of developing type 2 diabetes mellitus.

BACKGROUND: Alpha-glucosidase inhibitors (AGI) reduce blood glucose levels and may thus prevent or delay type 2 diabetes mellitus (T2DM) and its associated complications in people at risk of developing of T2DM. OBJECTIVES: To assess the effects of AGI in people with impaired glucose tolerance (IGT), impaired fasting blood glucose (IFG), moderately elevated glycosylated haemoglobin A1c (HbA1c) or any combination of these. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform, and the reference lists of systematic reviews, articles and health technology assessment reports. The date of the last search of all databases was December 2017. SELECTION CRITERIA: We included randomised controlled trials (RCTs), with a duration of one year or more, comparing AGI with any pharmacological glucose-lowering intervention, behaviour-changing intervention, placebo or no intervention in people with IFG, IGT, moderately elevated HbA1c or combinations of these. DATA COLLECTION AND ANALYSIS: Two review authors read all abstracts and full-text articles or records, assessed quality and extracted outcome data independently. One review author extracted data, which were checked by a second review author. We resolved discrepancies by consensus or involvement of a third review author. For meta-analyses we used a random-effects model with assessment of risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, using 95% confidence intervals (CIs) for effect estimates. We assessed the overall quality of the evidence by using the GRADE instrument. MAIN RESULTS: For this update of the Cochrane Review (first published 2006, Issue 4) we included 10 RCTs (11,814 participants), eight investigating acarbose and two investigating voglibose, that included people with IGT or people "at increased risk for diabetes". The trial duration ranged from one to six years. Most trials compared AGI with placebo (N = 4) or no intervention (N = 4).Acarbose reduced the incidence of T2DM compared to placebo: 670 out of 4014 people (16.7%) in the acarbose groups developed T2DM, compared to 812 out of 3994 people (20.3%) in the placebo groups (RR 0.82, 95% CI 0.75 to 0.89; P < 0.0001; 3 trials; 8008 participants; moderate-certainty evidence). One trial including participants with coronary heart disease and IGT contributed 64% of cases for this outcome. Acarbose reduced the risk of T2DM compared to no intervention: 7 out 75 people (9.3%) in the acarbose groups developed T2DM, compared to 18 out of 65 people (27.7%) in the no-intervention groups (RR 0.31, 95% CI 0.14 to 0.69; P = 0.004; 2 trials; 140 participants; very low-certainty evidence).Acarbose compared to placebo did not reduce or increase the risk of all-cause mortality (RR 0.98, 95% CI 0.82 to 1.18; P = 0.86; 3 trials; 8069 participants; very low-certainty evidence), cardiovascular mortality (RR 0.88; 95% CI 0.71 to 1.10; P = 0.26; 3 trials; 8069 participants; very low-certainty evidence), serious adverse events (RR 1.12, 95% CI 0.97 to 1.29; P = 0.13; 2 trials; 6625 participants; low-certainty evidence), non-fatal stroke (RR 0.50, 95% CI 0.09 to 2.74; P = 0.43; 1 trial; 1368 participants; very low-certainty evidence) or congestive heart failure (RR of 0.87; 95% CI 0.63 to 1.12; P = 0.40; 2 trials; 7890 participants; low-certainty evidence). Acarbose compared to placebo reduced non-fatal myocardial infarction: one out of 742 participants (0.1%) in the acarbose groups had a non-fatal myocardial infarction compared to 15 out of 744 participants (2%) in the placebo groups (RR 0.10, 95% CI 0.02 to 0.53; P = 0.007; 2 trials; 1486 participants; very low-certainty evidence). Acarbose treatment showed an increased risk of non-serious adverse events (mainly gastro-intestinal events), compared to placebo: 751 of 775 people (96.9%) in the acarbose groups experienced an event, compared to 723 of 775 people (93.3%) in the placebo groups (RR 1.04; 95% CI 1.01 to 1.06; P = 0.0008; 2 trials; 1550 participants). Acarbose compared to no intervention showed no advantage or disadvantage for any of these outcome measures (very low-certainty evidence).One trial each compared voglibose with placebo (1780 participants) or diet and exercise (870 participants). Voglibose compared to placebo reduced the incidence of T2DM: 50 out of 897 participants (5.6%) developed T2DM, compared to 106 out of 881 participants (12%) in the placebo group (RR 0.46, 95% CI 0.34 to 0.64; P < 0.0001; 1 trial; 1778 participants; low-certainty evidence). For all other reported outcome measures there were no clear differences between voglibose and comparator groups. One trial with 90 participants compared acarbose with diet and exercise and another trial with 98 participants reported data on acarbose versus metformin. There were no clear differences for any outcome measure between these two acarbose interventions and the associated comparator groups.None of the trials reported amputation of lower extremity, blindness or severe vision loss, end-stage renal disease, health-related quality of life, time to progression to T2DM, or socioeconomic effects. AUTHORS' CONCLUSIONS: AGI may prevent or delay the development of T2DM in people with IGT. There is no firm evidence that AGI have a beneficial effect on cardiovascular mortality or cardiovascular events.

Incidence, course and risk factors of head injury: a retrospective cohort study.

OBJECTIVES: To assess the incidence of head injury and predictors of complication across the care continuum. DESIGN: Retrospective cohort study using data from a research network. We calculated the incidence of overall head injury in a longitudinal cohort covering 1-year interval (31 369 patient-years), and the incidence of complicated head injury in a longitudinal cohort covering 10 years interval (220 352 patient-ears). Incidence rates were calculated per 1000 patient-years with 95% CI using the Mid-P exact test. We calculated ORs to assess potential risk factors for a complicated head injury. SETTING: A practice-based research network covering a population of >30 000 patients. PARTICIPANTS: All patients listed in practices within the research network during the years 2005-2014. MAIN OUTCOME MEASURES: Incidence of (complicated) head injury and predictors for clinical complications. RESULTS: The incidence of overall head injury was 22.1 per 1000 person-years and the incidence of a complicated course following head injury was 0.16 per 1000 person-years. The following determinants were risk factors for a complicated course: high energy trauma, bicycle accident, traffic accident in general, use of anticoagulants, alcohol intoxication, age above 60 years and low Glasgow Coma Scale at initial presentation. A complicated course was very unlikely when the patients' first encounter with a healthcare professional was in primary care (OR 0.03, 95% CI 0.01 to 0.07). CONCLUSIONS: Complication after head injury are rarely seen in general practice. Patients who do experience complications are often easily identifiable as requiring specialist care. A more reserved referral policy for general practice may be desirable, suggesting that current guidelines are too defensive.

Development and Validation of Search Filters to Identify Articles on Family Medicine in Online Medical Databases.

Physicians and researchers in the field of family medicine often need to find relevant articles in online medical databases for a variety of reasons. Because a search filter may help improve the efficiency and quality of such searches, we aimed to develop and validate search filters to identify research studies of relevance to family medicine. Using a new and objective method for search filter development, we developed and validated 2 search filters for family medicine. The sensitive filter had a sensitivity of 96.8% and a specificity of 74.9%. The specific filter had a specificity of 97.4% and a sensitivity of 90.3%. Our new filters should aid literature searches in the family medicine field. The sensitive filter may help researchers conducting systematic reviews, whereas the specific filter may help family physicians find answers to clinical questions at the point of care when time is limited.

Incidence of neuralgic amyotrophy (Parsonage Turner syndrome) in a primary care setting--a prospective cohort study.

OBJECTIVE: Neuralgic amyotrophy is considered a rare peripheral nervous system disorder but in practice seems grossly under recognized, which negatively affects care for these patients. In this study we prospectively counted the one-year incidence rate of classic neuralgic amyotrophy in a primary care setting. METHODS: In a prospective cohort study during the year 2012 we registered all new cases of neck, shoulder or arm complaints from two large primary care centers serving a population of 14,118. Prior to study, general practitioners received a short training on how to diagnose classic neuralgic amyotrophy. Neuralgic amyotrophy was defined according to published criteria irrespective of family history. Only patients with a classic phenotype were counted as definite cases. After inclusion, patients with suspected neuralgic amyotrophy who had not yet seen a neurologist were offered neurologic evaluation for diagnostic confirmation. RESULTS: Of the 492 patients identified with new onset neck, shoulder or arm complaints, 34 were suspected of having neuralgic amyotrophy. After neurologic evaluation the diagnosis was confirmed in 14 patients. This amounts to a one-year incidence rate for classic neuralgic amyotrophy of 1 per 1000. CONCLUSIONS: Our findings suggest that neuralgic amyotrophy is 30-50 times more common than previously thought. Unawareness of the disorder and its clinical presentation seems the most likely explanation for this difference. An incidence rate of 1 per 1000 and the long-term sequelae many patients suffer warrant more vigilance in diagnosing the disorder, to pave the way for timely treatment and prevent complications.

[Incidence of neuralgic amyotrophy in a primary care setting: a prospective cohort study]. / Neuralgische amyotrofie in de eerste lijn: prospectief cohortonderzoek naar de incidentie.

OBJECTIVE: To assess the incidence of classic neuralgic amyotrophy (NA) in a primary care setting. DESIGN: Prospective cohort study. METHOD: During the year 2012 we registered all new cases of neck, shoulder or arm symptoms from two large primary care centres serving a population of 14,118. Prior to commencing the study, general practitioners attended a short training session on how to diagnose classic NA. After inclusion, patients in whom general practitioners suspected NA were offered a neurologic assessment for diagnostic confirmation. RESULTS: Of the 492 patients identified with new onset of neck, shoulder or arm symptoms, 34 were suspected of having NA. Neurologic evaluation confirmed the diagnosis in 14 patients. For the Netherlands, this translates to an incidence of 1 in 1,000. CONCLUSION: Our findings suggest that NA is 30-50 times more common than previously thought; in the Netherlands, this would mean 17,000 instead of 500 new cases each year. Lack of awareness of the disorder and its clinical presentation seems the most likely explanation for this difference. Since NA may lead to sustained symptoms and functional limitations in the chronic phase, increased attention is urgently required to improve diagnostics and treatment.

[Sulphonylurea derivatives or insulin with metformin?]. / Sulfonylureumderivaat of insuline bij metformine?

If pharmacological treatment of glycaemia with metformin in patients with type 2 diabetes fails, a second agent is advised, however, the optimal choice is unclear. Most guidelines suggest the addition of sulphonylurea (SU) derivatives as the first option, but sometimes insulin is preferred as there have been doubts concerning the cardiovascular safety of SUs. From a large Veterans Administration (VA) registry study, Roumie et al. extracted patients on metformin who received additional treatment with either SU (majority) or insulin, and compared the number of cardiovascular endpoints over the subsequent 7-year period. The number of endpoints was higher in the metformin+insulin group than in the metformin+SU group, with a relative risk of 1.3. The authors conclude that when compared with the addition of SU the addition of insulin to metformin is associated with an elevated risk of a cardiovascular endpoint. While the authors have performed multiple adjustments for potential differences in the two treatment groups, this is in fact a retrospective cohort study and hence selection bias cannot be excluded. Nevertheless, the results suggest that the current guidelines/practice of adding SU to metformin is at least as safe as adding insulin and should not be changed.

Adenosine-diphosphate (ADP) receptor antagonists for the prevention of cardiovascular disease in type 2 diabetes mellitus.

BACKGROUND: Cardiovascular disease (CVD) is the most prevalent complication of type 2 diabetes with an estimated 65% of people with type 2 diabetes dying from a cause related to atherosclerosis. Adenosine-diphosphate (ADP) receptor antagonists like clopidogrel, ticlopidine, prasugrel and ticagrelor impair platelet aggregation and fibrinogen-mediated platelet cross-linking and may be effective in preventing CVD. OBJECTIVES: To assess the effects of adenosine-diphosphate (ADP) receptor antagonists for the prevention of cardiovascular disease in type 2 diabetes mellitus. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (issue 2, 2011), MEDLINE (until April 2011) and EMBASE (until May 2011). We also performed a manual search, checking references of original articles and pertinent reviews to identify additional studies. SELECTION CRITERIA: Randomised controlled trials comparing an ADP receptor antagonist with another antiplatelet agent or placebo for a minimum of 12 months in patients with diabetes. In particular, we looked for trials assessing clinical cardiovascular outcomes. DATA COLLECTION AND ANALYSIS: Two review authors extracted data for studies which fulfilled the inclusion criteria, using standard data extraction templates. We sought additional unpublished information and data from the principal investigators of all included studies. MAIN RESULTS: Eight studies with a total of 21,379 patients with diabetes were included. Three included studies investigated ticlopidine compared to aspirin or placebo. Five included studies investigated clopidogrel compared to aspirin or a combination of aspirin and dipyridamole, or compared clopidogrel in combination with aspirin to aspirin alone. All trials included patients with previous CVD except the CHARISMA trial which included patients with multiple risk factors for coronary artery disease. Overall the risk of bias of the trials was low. The mean duration of follow-up ranged from 365 days to 913 days.Data for diabetes patients on all-cause mortality, vascular mortality and myocardial infarction were only available for one trial (355 patients). This trial compared ticlopidine to placebo and did not demonstrate any statistically significant differences for all-cause mortality, vascular mortality or myocardial infarction. Diabetes outcome data for stroke were available in three trials (31% of total diabetes participants). Overall pooling of two (statistically heterogeneous) studies showed no statistically significant reduction in the combination of fatal and non-fatal stroke (359/3194 (11.2%) versus 356/3146 (11.3%), random effects odds ratio (OR) 0.81; 95% confidence interval (CI) 0.44 to 1.49) for ADP receptor antagonists versus other antiplatelet drugs. There were no data available from any of the trials on peripheral vascular disease, health-related quality of life, adverse events specifically for patients with diabetes, or costs. AUTHORS' CONCLUSIONS: The available evidence for ADP receptor antagonists in patients with diabetes mellitus is limited and most trials do not report outcomes for patients with diabetes separately. Therefore, recommendations for the use of ADP receptor antagonists for the prevention of CVD in patients with diabetes are based on available evidence from trials including patients with and without diabetes. Trials with diabetes patients and subgroup analyses of patients with diabetes in trials with combined populations are needed to provide a more robust evidence base to guide clinical management in patients with diabetes.

Measurement properties of questionnaires measuring continuity of care: a systematic review.

BACKGROUND: Continuity of care is widely acknowledged as a core value in family medicine. In this systematic review, we aimed to identify the instruments measuring continuity of care and to assess the quality of their measurement properties. METHODS: We did a systematic review using the PubMed, Embase and PsycINFO databases, with an extensive search strategy including 'continuity of care', 'coordination of care', 'integration of care', 'patient centered care', 'case management' and its linguistic variations. We searched from 1995 to October 2011 and included articles describing the development and/or evaluation of the measurement properties of instruments measuring one or more dimensions of continuity of care (1) care from the same provider who knows and follows the patient (personal continuity), (2) communication and cooperation between care providers in one care setting (team continuity), and (3) communication and cooperation between care providers in different care settings (cross-boundary continuity). We assessed the methodological quality of the measurement properties of each instrument using the COSMIN checklist. RESULTS: We included 24 articles describing the development and/or evaluation of 21 instruments. Ten instruments measured all three dimensions of continuity of care. Instruments were developed for different groups of patients or providers. For most instruments, three or four of the six measurement properties were assessed (mostly internal consistency, content validity, structural validity and construct validity). Six instruments scored positive on the quality of at least three of six measurement properties. CONCLUSIONS: Most included instruments have problems with either the number or quality of its assessed measurement properties or the ability to measure all three dimensions of continuity of care. Based on the results of this review, we recommend the use of one of the four most promising instruments, depending on the target population Diabetes Continuity of Care Questionnaire, Alberta Continuity of Services Scale-Mental Health, Heart Continuity of Care Questionnaire, and Nijmegen Continuity Questionnaire.

Generalizability of systematic reviews of the effectiveness of health care interventions to primary health care: concepts, methods and future research.

BACKGROUND: There is a push to make clinical decision making more evidence based and patient oriented. However, current systematic reviews are limited by the lack of consideration of generalizability. OBJECTIVE: To develop a guide for investigators (systematic reviewers) on how to adapt the methodology of a systematic review to facilitate the exploration of the results to primary care. METHODS: We reviewed the method guidelines of five organizations and working groups. Then, we conducted a search of literature in PubMed for articles on external validity of systematic. Based on the literature, we developed general steps to incorporate generalizability in systematic reviews and then integrated main primary care themes as outlined in WONCA definition of primary care and the definition of person-centred medicine across those steps. RESULTS: We identified a wide variety of approaches to address the issue of generalizability in systematic reviews. We extracted four major primary care themes from the two definitions of primary care and person-centred medicine that we mapped across the methods of generalizability. We suggested a two-step approach: Step 1 planning the scope of a review using four-layer schematic model and Step 2 to follow four steps to incorporate the concept of generalizability to primary care in the review. CONCLUSIONS: Systematic reviewers can take several steps to improve the generalizability of their review to primary care. However, more research is needed to determine which approach provides better results than others.

Diagnostic accuracy of the ID Migraine: a systematic review and meta-analysis.

OBJECTIVE: The purpose of this systematic review with meta-analysis is to determine the diagnostic accuracy of the identification of migraine (ID Migraine) as a decision rule for identifying patients with migraine. BACKGROUND: The ID Migraine screening tool is designed to identify patients with migraine in primary care settings. Several studies have validated the ID Migraine across various clinical settings, including primary care, neurology departments, headache clinics, dental clinics, ear, nose, and throat (ENT) and ophthalmology. METHODS: A systematic literature search was conducted to identify all studies validating the ID Migraine, with the International Headache Criteria as the reference standard. The methodological quality of selected studies was assessed using the Quality of Diagnostic Accuracy Studies tool. All selected studies were combined using a bivariate random effects model. A sensitivity analysis was also conducted, pooling only those studies using representative patient groups (primary care, neurology departments, and headache clinics) to determine the potential influence of spectrum bias on the results. RESULTS: Thirteen studies incorporating 5866 patients are included. The weighted prior probability of migraine across the 13 studies is 59%. The ID Migraine is shown to be useful for ruling out rather than ruling in migraine, with a greater pooled sensitivity estimate (0.84, 95% confidence interval 0.75-0.90) than specificity (0.76, 95% confidence interval 0.69-0.83). A negative ID Migraine score reduces the probability of migraine from 59% to 23%. The sensitivity analysis reveals similar results. CONCLUSIONS: This systematic review quantifies the diagnostic accuracy of the ID Migraine as a brief, practical, and easy to use diagnostic tool for Migraine. Application of the ID Migraine as a diagnostic tool is likely to improve appropriate diagnosis and management of migraine sufferers.

Predicting acute uncomplicated urinary tract infection in women: a systematic review of the diagnostic accuracy of symptoms and signs.

BACKGROUND: Acute urinary tract infections (UTI) are one of the most common bacterial infections among women presenting to primary care. However, there is a lack of consensus regarding the optimal reference standard threshold for diagnosing UTI. The objective of this systematic review is to determine the diagnostic accuracy of symptoms and signs in women presenting with suspected UTI, across three different reference standards (10(2) or 10(3) or 10(5) CFU/ml). We also examine the diagnostic value of individual symptoms and signs combined with dipstick test results in terms of clinical decision making. METHODS: Searches were performed through PubMed (1966 to April 2010), EMBASE (1973 to April 2010), Cochrane library (1973 to April 2010), Google scholar and reference checking.Studies that assessed the diagnostic accuracy of symptoms and signs of an uncomplicated UTI using a urine culture from a clean-catch or catherised urine specimen as the reference standard, with a reference standard of at least ≥ 10(2) CFU/ml were included. Synthesised data from a high quality systematic review were used regarding dipstick results. Studies were combined using a bivariate random effects model. RESULTS: Sixteen studies incorporating 3,711 patients are included. The weighted prior probability of UTI varies across diagnostic threshold, 65.1% at ≥ 10(2) CFU/ml; 55.4% at ≥ 10(3) CFU/ml and 44.8% at ≥ 10(2) CFU/ml ≥ 10(5) CFU/ml. Six symptoms are identified as useful diagnostic symptoms when a threshold of ≥ 10(2) CFU/ml is the reference standard. Presence of dysuria (+LR 1.30 95% CI 1.20-1.41), frequency (+LR 1.10 95% CI 1.04-1.16), hematuria (+LR 1.72 95%CI 1.30-2.27), nocturia (+LR 1.30 95% CI 1.08-1.56) and urgency (+LR 1.22 95% CI 1.11-1.34) all increase the probability of UTI. The presence of vaginal discharge (+LR 0.65 95% CI 0.51-0.83) decreases the probability of UTI. Presence of hematuria has the highest diagnostic utility, raising the post-test probability of UTI to 75.8% at ≥ 10(2) CFU/ml and 67.4% at ≥ 10(3) CFU/ml. Probability of UTI increases to 93.3% and 90.1% at ≥ 10(2) CFU/ml and ≥ 10(3) CFU/ml respectively when presence of hematuria is combined with a positive dipstick result for nitrites. Subgroup analysis shows improved diagnostic accuracy using lower reference standards ≥ 10(2) CFU/ml and ≥ 10(3) CFU/ml. CONCLUSIONS: Individual symptoms and signs have a modest ability to raise the pretest-risk of UTI. Diagnostic accuracy improves considerably when combined with dipstick tests particularly tests for nitrites.

Medically unexplained symptoms, somatisation disorder and hypochondriasis: course and prognosis. A systematic review.

OBJECTIVE: To study the course of medically unexplained symptoms (MUS), somatisation disorder, and hypochondriasis, and related prognostic factors. Knowledge of prognostic factors in patients presenting persistent MUS might improve our understanding of the naturalistic course and the identification of patients with a high risk of a chronic course. METHODS: A comprehensive search of Medline, PsycInfo, CINAHL, and EMBASE was performed to select studies focusing on patients with MUS, somatisation disorder, and hypochondriasis, and assessing prognostic factors. Studies focusing on patients with single-symptom unexplained disorder or distinctive functional somatic syndromes were excluded. A best-evidence synthesis for the interpretation of results was used. RESULTS: Only six studies on MUS, six studies on hypochondriasis, and one study on abridged somatisation could be included. Approximately 50% to 75% of the patients with MUS improve, whereas 10% to 30% of patients with MUS deteriorate. In patients with hypochondriasis, recovery rates vary between 30% and 50%. In studies on MUS and hypochondriasis, we found some evidence that the number of somatic symptoms at baseline influences the course of these conditions. Furthermore, the seriousness of the condition at baseline seemed to influence the prognosis. Comorbid anxiety and depression do not seem to predict the course of hypochondriasis. CONCLUSIONS: Due to the limited numbers of studies and their high heterogeneity, there is a lack of rigorous empirical evidence to identify relevant prognostic factors in patients presenting persistent MUS. However, it seems that a more serious condition at baseline is associated with a worse outcome.

Prevalence of zebras in general practice: data from the Continuous Morbidity Registration Nijmegen.

OBJECTIVE: To explore the prevalence of rare diseases in the Continuous Morbidity Registration (CMR) Nijmegen, and to discuss methodological difficulties in the study of rare diseases in general practice. METHODS: We selected all diseases with a prevalence <0.5/1000 patients/year between 1986 and 2006 in the CMR, and we compared the results with rare diseases in the Orphanet database of rare diseases. RESULTS: We retrieved 71 codes of rare diseases: 15 referred to trauma or intoxications; the remaining 51 could be subdivided into malignancies, specific infections, diseases of short duration, and chronic diseases. Twenty (36%) of these 56 diseases were also listed in the Orphanet database (mostly malignancies and chronic diseases). CONCLUSION: Although in the literature emphasis is placed on rare chronic diseases, the general practitioner is also confronted with many rare diseases of shorter duration. The CMR is not yet feasible for studying diseases with an extremely low prevalence.