Vitamin D supplementation for nonspecific musculoskeletal pain in non-Western immigrants: a randomized controlled trial.

PURPOSE: Many non-Western immigrants report musculoskeletal pains that are hard to treat. We studied the effect of high-dose vitamin D(3) on nonspecific persistent musculoskeletal complaints in vitamin D-deficient non-Western immigrants and assessed correlation of pain patterns with benefit. METHODS: We conducted a semi-crossover randomized controlled trial between February 2008 and February 2010 in primary care in 84 non-Western immigrants visiting their general practitioner for nonspecific musculoskeletal pain. At baseline, patients were randomized to placebo or vitamin D (150,000 IU vitamin D(3) orally); at week 6, patients in the original vitamin D group were randomized a second time to receive vitamin D (again) or to switch to placebo, whereas patients in the original placebo group were all switched to vitamin D. The main outcome was self-assessed change in pain after the first 6 weeks. RESULTS: Patients in the vitamin D group were significantly more likely than their counterparts in the placebo group to report pain relief 6 weeks after treatment (34.9% vs 19.5%, P = .04). The former were also more likely to report an improved ability to walk stairs (21.0% vs 8.4%, P = .008). Pain pattern was not correlated with the success of treatment. In a nonsignificant trend, patients receiving vitamin D over 12 weeks were more likely to have an improvement than patients receiving it over 6 weeks. CONCLUSIONS: There is a small positive effect 6 weeks after high-dose vitamin D(3) on persistent nonspecific musculoskeletal pain. Future research should focus on longer follow-up, higher supplementation doses, and mental health.

Management decisions in nontraumatic complaints of arm, neck, and shoulder in general practice.

UNLABELLED: OBJECTIVE We wanted to evaluate associations between diagnosis and characteristics of the patient, complaint, and general practitioner (GP), as well as 6 common management decisions, in patients with nontraumatic arm, neck, and shoulder complaints at the time of the first consultation with their physician. METHODS: We undertook an observational cohort study set in 21 Dutch general practices, including 682 patients with nontraumatic complaints of arm, neck, and shoulder. The outcome measure was application (yes/no) of a specific management option: watchful waiting, additional diagnostic tests, prescription of medication, corticosteroid injection, referral for physiotherapy, and referral for medical specialist care. RESULTS: Separate multilevel analyses showed that overall, the diagnostic category, having long duration of complaints, and reporting many functional limitations were most frequently associated with the choice of a management option. For watchful waiting, only complaint variables played a role (long duration of complaints, high complaint severity, many functional limitations, recurrent complaint). All these variables were negatively associated with watchful waiting. When opting for 1 of the 5 other management options, several physician characteristics played a role as well. Less clinical experience was associated with additional diagnostic tests and referral to a medical specialist. GPs working in a solo practice more frequently referred to a medical specialist. GPs working in a rural area more frequently referred for physiotherapy. Female GPs prescribed medication less frequently. Physicians with special interest in musculoskeletal complaints gave corticosteroid injections more frequently. CONCLUSIONS: Diagnostic category, long duration of complaints, and high functional limitations were key variables in management decisions with these complaints. In addition, several physician characteristics played a role as well.

Inhaled sodium cromoglycate for asthma in children.

BACKGROUND: Sodium cromoglycate has been recommended as maintenance treatment for childhood asthma for many years. Its use has decreased since 1990, when inhaled corticosteroids became popular, but it is still used in many countries. OBJECTIVES: To determine the efficacy of sodium cromoglycate compared to placebo in the prophylactic treatment of children with asthma. SEARCH STRATEGY: We searched the Cochrane Airways Group Trials Register (October 2007), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2007), MEDLINE (January 1966 to November 2007), EMBASE (January 1985 to November 2007) and reference lists of articles. We also contacted the pharmaceutical company manufacturing sodium cromoglycate. In 2007 we updated the review. SELECTION CRITERIA: All double-blind, placebo-controlled randomised trials, which addressed the effectiveness of inhaled sodium cromoglycate as maintenance therapy, studying children aged 0 up to 18 years with asthma. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality and extracted data. We pooled study results. MAIN RESULTS: Of 3500 titles retrieved from the literature, 24 papers reporting on 23 studies could be included in the review. The studies were published between 1970 and 1997 and together included 1026 participants. Most were cross-over studies. Few studies provided sufficient information to judge the concealment of allocation. Four studies provided results for the percentage of symptom-free days. Pooling the results did not reveal a statistically significant difference between sodium cromoglycate and placebo. For the other pooled outcomes, most of the symptom-related outcomes and bronchodilator use showed statistically significant results, but treatment effects were small. Considering the confidence intervals of the outcome measures, a clinically relevant effect of sodium cromoglycate cannot be excluded. The funnel plot showed an under-representation of small studies with negative results, suggesting publication bias. AUTHORS' CONCLUSIONS: There is insufficient evidence to be sure about the efficacy of sodium cromoglycate over placebo. Publication bias is likely to have overestimated the beneficial effects of sodium cromoglycate as maintenance therapy in childhood asthma.

What is the clinical course of acute ankle sprains? A systematic literature review.

BACKGROUND: Ankle sprains are one of the most common musculoskeletal injuries. In order to evaluate the effectiveness of therapeutic interventions and to guide management decisions, it is important to have clear insight of the course of recovery after an acute lateral ankle injury and to evaluate potential factors for nonrecovery and re-sprains. METHODS: A database search was conducted in MEDLINE, CINAHL, PEDro, EMBASE, and the Cochrane Controlled trial register. Included were observational studies and controlled trials with adult subjects who suffered from an acute lateral ankle sprain that was conventionally treated. One of the following outcomes had to be described: pain, re-sprains, instability, or recovery. Two reviewers independently assessed the methodological quality of each included study. One reviewer extracted relevant data. RESULTS: In total, 31 studies were included, from which 24 studies were of high quality. There was a rapid decrease in pain reporting within the first 2 weeks. Five percent to 33% of patients still experienced pain after 1 year, while 36% to 85% reported full recovery within a period of 3 years. The risk of re-sprains ranged from 3% to 34% of the patients, and re-sprain was registered in periods ranging from 2 weeks to 96 months postinjury. There was a wide variation in subjective instability, ranging from 0% to 33% in the high-quality studies and from 7% to 53% in the low-quality studies. One study described prognostic factors and indicated that training more than 3 times a week is a prognostic factor for residual symptoms. CONCLUSIONS: After 1 year of follow-up, a high percentage of patients still experienced pain and subjective instability, while within a period of 3 years, as much as 34% of the patients reported at least 1 re-sprain. From 36% up to 85% of the patients reported full recovery within a period of 3 years.

Measles, mumps and rubella infections and atopic disorders in MMR-unvaccinated and MMR-vaccinated children.

Vaccinations have been incriminated in the increase of atopic disorders. Especially the measles-mumps-rubella (MMR) vaccination is often refused by people having a notion that these infectious diseases are beneficial for a healthy development of a child's immune system. This practice endangers herd immunity and is the cause of repeated outbreaks. As the clinical course of infections and also its possible impact on the development of atopy may be different in vaccinated and unvaccinated individuals, we explored in vaccinated and unvaccinated children associations of MMR infection with atopic disorders. Using data from a previously conducted study on the relationship between the diphtheria-tetanus-pertussis-(inactivated) poliomyelitis vaccination in the first year of life and atopic disorders, the study population of 1872 8-12-yr-old was divided as children MMR-unvaccinated and children MMR-vaccinated in the first year of life. Within each group the association between MMR infections and atopic disorders (both as reported by the parents) was assessed. We found a statistically significant positive association between measles infection and 'any atopic disorder' [adjusted odds ratio, OR (95% confidence interval, CI): 1.77 (1.20-2.61)] in the MMR-vaccinated group, mainly because of the relationship with eczema. For rubella there was a negative association with eczema and food allergy in the unvaccinated group: adjusted OR (95% CI): 0.57 (0.38-0.85) and 0.23 (0.07-0.76), respectively. All other associations were not statistically significant. We found a positive relationship between measles infection and any atopy in a group of MMR-vaccinated children and a negative association between rubella infection and eczema and food allergy in unvaccinated children. However, we cannot conclude that these relationships are causal. The negative association with rubella may be an artefact. This study shows no evidence for any protective effects from MMR diseases for the development of atopy and therefore supports conclusions found elsewhere that childhood vaccinations do not cause atopy.

Reported pertussis infection and risk of atopy in 8- to 12-yr-old vaccinated and non-vaccinated children.

Pertussis infection has been suspected to be a potential causal factor in the development of atopic disease because of the effect of pertussis immunization on specific IgE antibodies. Although several studies found a positive association between pertussis infection and atopic disorders, this relationship has not yet been studied in a population stratified by vaccination status. To assess the association between pertussis infection and atopic disorders in pertussis-unvaccinated children and in pertussis-vaccinated children. Using data from a previously conducted study on the relationship between the diphtheria-tetanus-pertussis-(inactivated) poliomyelitis vaccination in the first year of life and atopic disorders, the study population of 1872 8-12 yr old was divided into children pertussis-unvaccinated and children pertussis-vaccinated in the first year of life. Within each group, the association between pertussis infection and atopic disorders (both as reported by the parents) was assessed. In the unvaccinated group, there were no significant associations between pertussis infection and atopic disorders. In the vaccinated group, all associations between pertussis infection and atopic disorders were positive, the associations with asthma [odds ratio (OR) = 2.24, 95% confidence interval (CI(95%)): 1.36-3.70], hay fever (OR = 2.35, CI(95%): 1.46-3.77) and food allergy (OR = 2.68, CI(95%): 1.48-4.85) being significant. There was a positive association between pertussis infection and atopic disorders in the pertussis vaccinated group only. From the present study, it cannot be concluded whether this association is causal or due to reverse causation.

Kinesiophobia in patients with non-traumatic arm, neck and shoulder complaints: a prospective cohort study in general practice.

BACKGROUND: Complaints of arm, neck and shoulder are common in Western societies. Of those consulting a general practitioner (GP) with non-traumatic arm, neck or shoulder complaints, about 50% do not recover within 6 months. Kinesiophobia (also known as fear of movement/(re)injury) may also play a role in these complaints, as it may lead to avoidance behaviour resulting in hypervigilance to bodily sensations, followed by disability, disuse and depression. However, in relation to arm, neck and shoulder complaints little is known about kinesiophobia and its associated variables. Therefore this study aimed to: describe the degree of kinesiophobia in patients with non-traumatic complaints of arm, neck and shoulder in general practice; to determine whether mean scores of kinesiophobia change over time in non-recovered patients; and to evaluate variables associated with kinesiophobia at baseline. METHODS: In this prospective cohort study set in general practice, consulters with a first or new episode of non-traumatic arm, neck or shoulder complaints (aged 18-64 years) entered the cohort. Baseline data were collected on kinesiophobia using the Tampa Scale for Kinesiophobia, the 13-item adjusted version: TSK-AV, and on patient-, complaint-, and psychosocial variables using self-administered questionnaires. The mean TSK-AV score was calculated. In non-recovered patients the follow-up TSK-AV scores at 6 and 12 months were analyzed with the general linear mixed model. Variables associated with kinesiophobia at baseline were evaluated using multivariate linear regression analyses. RESULTS: The mean TSK-AV score at baseline was 24.8 [SD: 6.2]. Among non-recovered patients the mean TSK-AV score at baseline was 26.1 [SD: 6.6], which remained unchanged over 12- months follow-up period. The strongest associations with kinesiophobia were catastrophizing, disability, and comorbidity of musculoskeletal complaints. Additionally, having a shoulder complaint, low social support, high somatization and high distress contributed to the kinesiophobia score. CONCLUSION: The mean TSK-AV score in our population seems comparable to those in other populations in primary care. In patients who did not recover during the 12- month follow-up, the degree of kinesiophobia remained unchanged during this time period. The variables associated with kinesiophobia at baseline appear to be in line with the fear-avoidance model.

MRI follow-up of posttraumatic bone bruises of the knee in general practice.

OBJECTIVE: Our purpose was to study the natural course of bone bruises in posttraumatic knees and to describe possible determinants of this course. SUBJECTS AND METHODS: Prospective MRI follow-up data were gathered for patients with bone bruises after sustained knee trauma. Follow-up ceased when the bone bruise could no longer be discerned or after 1 year of follow-up. For each patient we studied the relationships between time to healing of all bone bruises and the explanatory variables age, sex, obesity, workload, sports load, number of bone bruises, osteoarthritis, and concomitant knee lesions using survival analyses. We also investigated the relationships between resolution of individual bone bruises and lesion type, size and location, and the explanatory variables at 6 months and at 12 months separately, using logistic regression analyses for repeated measurements and generalized estimating equations. RESULTS: In 80 patients, 157 bone bruises were found. The estimated median healing time was 42.1 weeks. Healing was prolonged in patients having a higher number of bone bruises and in the presence of osteoarthritis. Resolution of individual bone bruises was prolonged in the presence of osteoarthritis and greater age. Reticular lesions were less likely to be present after 6 months than other bone bruise types. None of the remaining tested variables had prognostic value. CONCLUSION: Median healing time of bone bruises is 42.1 weeks. Prognosis is particularly influenced by the presence of osteoarthritis. Age, type of bone bruise, and number of bruises also have prognostic value.

Sublingual immunotherapy with grass pollen is not effective in symptomatic youngsters in primary care.

BACKGROUND: Sublingual immunotherapy (SLIT) is considered safer and more convenient than subcutaneous therapy and therefore has been proposed as especially suitable for children and in primary care. Most efficacy studies in children lack power to be conclusive, and all have been performed in referral centers. OBJECTIVE: To investigate the efficacy of SLIT with grass pollen allergen in children and adolescents with rhinoconjunctivitis in a primary care setting. METHODS: Youngsters aged 6-18 years with hay fever were enrolled from general practices and randomly assigned to receive placebo or grass pollen mix for 2 years. The primary outcome was the mean daily total symptom score (scale 0-15) comprising sneezing, itching nose, watery running nose, nasal blockage, and itching eyes during the months May-August of the second treatment year. RESULTS: Out of 204 youngsters randomized, 168 entered the intention-to-treat analysis (91 verum, 77 placebo). The mean daily total symptom score did not differ between participants allocated to verum and those allocated to placebo (difference for verum minus placebo: -0.08, 95%CI, -0.66-0.50; P = .78). No differences were found for rescue medication-free days, disease-specific quality of life, and overall evaluation of the treatment effect. Local side effects were more frequent in the verum group (39% vs 17% of participants; P = .001). CONCLUSION: Sublingual immunotherapy with grass pollen in a primary care setting is not effective in children and adolescents. CLINICAL IMPLICATIONS: Currently, SLIT cannot be recommended for general practitioners as a therapeutic modality in youngsters with grass pollen allergy.

Clinical consequences of posttraumatic bone bruise in the knee.

BACKGROUND: Bone bruise is often seen in posttraumatic knees, but the clinical relevance is unclear. HYPOTHESIS: The presence of bone bruise is associated with increased pain severity in patients with sustained knee trauma. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: We collected prospective data of 132 patients visiting their general practitioner after sustained knee trauma. Patients with bone bruise underwent a magnetic resonance imaging follow-up study that was discontinued when the bone bruise could no longer be discerned or after 1 year of follow-up. Bone bruise was assessed on magnetic resonance imaging, and pain severity was scored on a numeric rating scale (0-10) at baseline, and at 3, 6, and 12 months after trauma. The presence of bone bruise and pain severity (over time) were compared using linear regression analyses for repeated measurements. Adjustment was made for possible confounders: presence of meniscal tears, cruciate or collateral ligament ruptures, severe effusion, osteoarthritis, obesity, age, gender, work load, and sports load. RESULTS: At baseline as well as during follow-up, bone bruise was associated with a slightly higher pain score. The differences, however, were very small (adjusted difference in pain severity 0.34 or less) and not statistically significant nor clinically relevant. CONCLUSION: There is no statistically significant relationship, nor a clinically relevant relationship, between the presence of bone bruise and pain severity in patients with sustained knee injury in general practice.

Association between skin diseases and severe bacterial infections in children: case-control study.

BACKGROUND: Sepsis or bacteraemia, however rare, is a significant cause of high mortality and serious complications in children. In previous studies skin disease or skin infections were reported as risk factor. We hypothesize that children with sepsis or bacteraemia more often presented with skin diseases to the general practitioner (GP) than other children. If our hypothesis is true the GP could reduce the risk of sepsis or bacteraemia by managing skin diseases appropriately. METHODS: We performed a case-control study using data of children aged 0-17 years of the second Dutch national survey of general practice (2001) and the National Medical Registration of all hospital admissions in the Netherlands. Cases were defined as children who were hospitalized for sepsis or bacteraemia. We selected two control groups by matching each case with six controls. The first control group was randomly selected from the GP patient lists irrespective of hospital admission and GP consultation. The second control group was randomly sampled from those children who were hospitalized for other reasons than sepsis or bacteraemia. We calculated odds ratios and 95% confidence intervals (CI). A two-sided p-value less than 0.05 was considered significant in all tests. RESULTS: We found odds ratios for skin related GP consultations of 3.4 (95% CI: [1.1-10.8], p = 0.03) in cases versus GP controls and 1.4 (95% CI: [0.5-3.9], p = 0.44) in cases versus hospital controls. Children younger than three months had an odds ratio (cases/GP controls) of 9.2 (95% CI: [0.81-106.1], p = 0.07) and 4.0 (95% CI: [0.67-23.9], p = 0.12) among cases versus hospital controls. Although cases consulted the GP more often with skin diseases than their controls, the probability of a GP consultation for skin disease was only 5% among cases. CONCLUSION: There is evidence that children who were admitted due to sepsis or bacteraemia consulted the GP more often for skin diseases than other children, but the differences are not clinically relevant indicating that there is little opportunity for GPs to reduce the risk of sepsis and/or bacteraemia considerably by managing skin diseases appropriately.

Body mass index, sexual behaviour, and sexually transmitted infections: an analysis using the NHANES 1999-2000 data.

BACKGROUND: Factors determining human sexual behaviour are not completely understood, but are important in the context of sexually transmitted disease epidemiology and prevention. Being obese is commonly associated with a reduced physical attractiveness but the associations between body mass index, sexual behaviour and the risk of acquiring sexually transmitted infections has never been studied. METHODS: The National Health and Nutrition Examination Survey (NHANES) files of 1999-2000 were used. Linear regression was used to relate the reported number of sex partners in the last year and lifetime to Body Mass Index (BMI). Logistic regression was used to relate Herpes Simplex Virus type II (HSV-2) antibodies to BMI and other variables. RESULTS: Data on 979 men and 1250 women were available for analysis. Obese (mean number of partners for men:1.12, women: 0.93) and overweight (mean for men: 1.38, women: 1.03) individuals reported fewer partners than individuals of normal BMI (mean for men: 2.00, women: 1.15) in the last year (p < .0.01 & p < 0.05 for men, p < 0.05 & n.s. for women). The same relationship held for lifetime partners in men (mean 11.94, 18.80, and 22.08 for obese, overweight and normal BMI respectively (p < 0.05 & n.s. for obese and overweight vs normal respectively), but not in women (mean 7.96, 4.77, and 5.24 respectively). HSV-2 antibodies were significantly correlated with the number of lifetime partners in both men and women, with the odds of being HSV-2 positive increasing by 0.6% (p < 0.01) and 2.7% (p < 0.01) for men and women respectively. HSV-2 antibodies increased with age, even after adjustment for lifetime partners (p < 0.01). Being obese (HSV-2 prevalence 15.9 and 34.9% for men and women respectively) or overweight (HSV-2 prevalence 16.7 and 29.3 for men and women respectively) was not associated with HSV-2 antibodies (HSV-2 prevalence for normal BMI: 15.6 and 23.2% respectively), independent of whether the association was adjusted for life time sexual partners or not. There was evidence of substantial misreporting of sexual behaviour. CONCLUSION: Obese and overweight individuals, especially men, self report fewer sex partners than individuals of normal weight, but surprisingly this is not reflected in their risk of HSV-2 infection. HSV-2 antibodies provide information not contained in self-reported number of partners and may better estimate sexual risk than self-reported behaviour.

Do Dutch doctors communicate differently with immigrant patients than with Dutch patients?

The aim of this study was to gain deeper insight into relational aspects of the medical communication pattern in intercultural consultations at GP practices in the Netherlands. We ask whether there are differences in the verbal interaction of Dutch GPs with immigrant and Dutch patients. Data were drawn from 144 adult patient interviews and video observations of consultations between the patients and 31 Dutch GPs. The patient group consisted of 61 non-Western immigrants (Turkish, Moroccan, Surinamese, Antillean, Cape Verdian) and 83 Dutch participants. Affective and instrumental aspects of verbal communication were assessed using Roter's Interaction Analysis System (RIAS). Patients' cultural background was assessed by ethnicity, language proficiency, level of education, religiosity and cultural views (in terms of being more traditional or more modern). Consultations with the non-Western immigrant patients (especially those from Turkey and Morocco) were well over 2 min shorter, and the power distance between GPs and these patients was greater when compared to the Dutch patients. Major differences in verbal interaction were observed on the affective behavior dimensions, but not on the instrumental dimensions. Doctors invested more in trying to understand the immigrant patients, while in the case of Dutch patients they showed more involvement and empathy. Dutch patients seemed to be more assertive in the medical conversation. The differences are discussed in terms of patients' ethnic background, cultural views (e.g. practicing a religion) and linguistic barriers. It is concluded that attention to cultural diversity does matter, as this leads to different medical communication patterns. A two-way strategy is recommended for improving medical communication, with implications for both doctor and patient behavior.