[Power in the consulting room]. / Macht in de spreekkamer.

Three physicians reflect on the theme 'power in the consulting room', but in fact they are mostly discussing disempowerment. In this article we discuss strategies involved in the physician's power over patients and factors that limit these powers.

[A series about the value of physical examination]. / Een serie over de waarde van lichamelijk onderzoek.

This article is the introduction to a new series in the Nederlands Tijdschrift voor Geneeskunde about the value of physical examination. Associated with this series, on the website (www.ntvg.nl) there are chapters of the new textbook on physical examination and films about carrying out physical examinations. Although physical examination is an essential part of the diagnostic process, often little attention is paid to the correct execution of the examination and there is insufficient knowledge of the value of the findings. The diagnostic process usually involves analysing all the information from the patient's history and a physical examination. However, research has only been done on the value of specific tests and even that is very limited. The most important measure we use for the results of a physical examination is the likelihood ratio, which shows how the likelihood of presence or absence of a disease changes depending on the examination results.

[Two-thirds of doctors are female, but ever still behind]. / Twee derde van de artsen vrouw, maar nog steeds op achterstand.

At present, two-thirds of the medical students in The Netherlands are women. However, the problems of combining a medical education with the responsibilities of motherhood, and the inaccessibility of medical top positions for women, are as serious as they were ten years ago at the 65th anniversary of the Dutch Association of Medical Women (VNVA). There is a serious need for medical education to become more 'woman-friendly'--and 'man-friendly' for that matter. For healthcare workers, it should be feasible to combine having children with a career. In addition, research into gender-specific health differences should be facilitated. Women, in particular, should take their responsibility in this respect, and be aware of the achievements of their pioneering predecessors. Last but not least: the Dutch Journal of Medicine needs to adapt. It needs to address a new audience, in which the male readers aged 50 and over have been largely replaced by female physicians in their thirties with children.

[The dawn of a smoke-free leisure industry in The Nederlands]. / Aan de vooravond van een rookvrije horeca in Nederland.

From the 1st of July 2008 the Dutch smoking ban for public spaces will be extended to hotels, restaurants and bars. The ban is a result of a 2003 Health Council report in which it was concluded that the annual incidence of deaths due to passive smoking is considerable. Based on these numbers, smoking in public spaces is prohibited since 2004. In a society where smoking in public spaces is prohibited, the harm of passive smoking will decrease. In this issue of The Nederlands Tijdschrit voor Geneeskunde (Dutch Journal of Medicine) a number of articles are dedicated to the subject of smoking.

[Hippocrates in the age of reality television]. / Hippocrates in het tijdperk van de 'reality-tv'.

At the end of their studies, physicians take the Hippocratic Oath. Medical and societal changes have meant that the oath has been altered over time. The oath still stipulates that the privacy of the patient should be respected. These days there is increased pressure on physicians and institutions to breach the duty of professional confidentiality. However, physicians themselves should also consider being more careful when talking about their patients outside the consulting room. They should definitely be aware oftheir responsibilities when participating in a reality series on television. In addition, medical information that is disclosed on Internet videos may negatively affect patients and physicians. Medical openness is commendable, but negligence may lead to loss of respect.

WITHDRAWN: Drugs for treating giardiasis.

BACKGROUND: There can be a high rate of recurrence of disease after initial drug treatment for giardiasis. These drugs also have a range of adverse effects. OBJECTIVES: The objective of this review was to assess the effects of drug treatments for giardiasis. SEARCH STRATEGY: We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL, MEDLINE, EMBASE, Current Contents, and reference lists of articles. SELECTION CRITERIA: Randomised and quasi-randomised trials of drug therapy for giardiasis compared with placebo or another drug. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data. MAIN RESULTS: Thirty-four trials were included. Only one trial was without serious methodological flaws. Compared with placebo, drug treatment was associated with an improved cure rate (odds ratio 11.51, 95% confidence interval 2.29 to 57.98). Metronidazole treatment longer than three days had a better parasitological cure rate than other long treatment courses (odds ratio 2.41, 95% confidence interval 1.31 to 4.44), but there was significant heterogeneity between the trials. Available evidence has not detected a difference in cure between single dose therapy and longer treatment courses (odds ratio 0.33, 95% confidence interval 0.08 to 1.34). Within the single dose regimens, the available evidence did not demonstrate a difference in parasitological cure rate between tinidazole and other short therapies (odds ratio 3.39, 95% confidence interval 0.95 to 12.04), but had a higher clinical cure rate (odds ratio 5.33, 95% 2.66 to 10.67). AUTHORS' CONCLUSIONS: A single dose of tinidazole appears to give the highest clinical cure rate for giardiasis with relatively few adverse effects.

Drugs for treating giardiasis.

BACKGROUND: There can be a high rate of recurrence of disease after initial drug treatment for giardiasis. These drugs also have a range of adverse effects. OBJECTIVES: The objective of this review was to assess the effects of drug treatments for giardiasis. SEARCH STRATEGY: We searched the Cochrane Infectious Diseases Group trials register, the Cochrane Controlled Trials Register, Medline and Embase, Current Contents, reference lists of articles. SELECTION CRITERIA: Randomised and quasi-randomised trials of drug therapy for giardiasis compared with placebo or another drug. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data. MAIN RESULTS: Thirty-four trials were included. Only one trial was without serious methodological flaws. Compared with placebo, drug treatment was associated with an improved cure rate (odds ratio 11.5, 95% confidence interval 2.3 to 58). Metronidazole treatment longer than three days had a better parasitological cure rate than other long treatment courses (odds ratio 2.4, 95% confidence interval 1.3 to 4.4), but there was significant heterogeneity between the trials. Single dose therapy appeared equally effective as longer treatment courses (odds ratio 0.33, 95% confidence interval 0.08 to 1.34). Within the single dose regimens, tinidazole had a comparable parasitological cure rate to other short therapies (odds ratio 3.4, 95% confidence interval 0.95 to 12), but had a higher clinical cure rate (odds ratio 5.3, 95% 2.7-10.7). REVIEWER'S CONCLUSIONS: A single dose of tinidazole appears to give the highest clinical cure rate for giardiasis with relatively few adverse effects.

Value of breast imaging in women with painful breasts: observational follow up study.

OBJECTIVES: To determine the value of breast imaging in patients with localised or diffuse pain in the breast in whom physical examination shows no abnormalities. DESIGN: Observational follow up study. SETTING: Radiology department of a teaching hospital in the Netherlands. SUBJECTS: Altogether 987 women referred for radiological breast imaging because of pain alone and a control group of 987 asymptomatic women referred for a screening mammogram. MAIN OUTCOME MEASURES: Correlation of the radiological findings with clinical and pathological findings over two years of follow up. RESULTS: Radiological examination of the painful breast(s) showed the following: normal findings in 854 (86.5%) women, benign abnormalities in 85 (8.6%; mainly small cysts or mastopathy), abnormalities that were probably benign in 36 (3.6%), suspicious findings in 8 (0.8%), and malignancy in 4 (0.4%). Biopsy of the painful area was performed in 10 of the 939 women with normal findings or benign abnormalities, in two of 36 women with radiological abnormalities that were probably benign, and in all women with suspicious or malignant findings. Only the four lesions that had been classified radiologically as malignant were found to be malignant at surgery. The prevalence of breast cancer was similar in symptomatic and control women. CONCLUSIONS: Breast imaging in women who present with pain alone is of value only in providing reassurance--no abnormalities are usually found in the painful area, radiological abnormalities classified as benign do not generally have any clinical consequences, and the prevalence of cancer is low in these women. Biopsy of the painful area should be performed only where radiological findings are suspicious.

Nonpalpable, probably benign breast lesions in general practice: the role of follow-up mammography.

A nonpalpable, probably benign lesion is frequently detected on mammograms. The aim of this paper was to determine the role of follow-up mammography as an alternative to surgical biopsy of these lesions, in patients from a general practice population. In a prospective study we estimated the compliance rate of general practitioners and patients with the recommendations for mammographic follow-up of nonpalpable, probably benign lesions. Reasons for noncompliance, the value of a reminder and the probability of malignancy were determined.

[Mammographic surveillance of breast cancer patient relatives; implementation of guidelines formulated by the Netherlands College of General Practitioners]. / Herhalingsmammografie bij belaste familieanamnese; naleving van de standaard van het Nederlands Huisartsen Genootschap.

OBJECTIVE: To determine the implementation of the guidelines for mammographic screening of breast cancer relatives formulated by the Dutch College of General Practitioners (NHG), in daily practice. DESIGN: Prospective, descriptive. SETTING: Kennemer Gasthuis, location EG, Haarlem, the Netherlands. METHODS: For all asymptomatic women referred for mammography to our department of radiology by their general practitioners between January 1, 1992 and August 1, 1995 because of a family history of breast cancer, who had normal or benign radiological findings and fulfilled the NHG criteria (aged 35 years or older with a first degree family history of breast cancer), we advised a repeat mammogram within 1-2 years. After 2 years we checked in the hospital information system whether or not a patient had undergone repeat mammography in the Kennemer Gasthuis; in case of non-reattendance at this hospital general practitioners were asked by questionnaire, and if necessary by telephone, if follow-up mammography had been performed elsewhere. RESULTS: Out of the 510 referred women, 405 (79.4%) met the NHG criteria. In 370 the radiological findings were 'normal' or 'benign' and the follow-up data were complete. Of these 370 women 201 (54.3%) underwent a repeat mammogram within two years. This examination was performed more often if breast cancer of a first degree relative had been diagnosed premenopausally (126/208 = 60.6%) rather than postmenopausally (75/162 = 46.3%; 95% confidence interval for the difference: 3.6-25.0). CONCLUSION: General practitioners in 50% of the cases complied with the recommendations for regular mammographic screening of breast cancer relatives. Their compliance may be increased by introduction of simple procedures into the computerized system for identification of risk factors and a systematic planning of screening examinations.

Dietary advice for acute diarrhoea in general practice: a pilot study.

BACKGROUND: Although there is no evidence that diet shortens acute diarrhoea, doctors tend to give dietary advice. AIM: To test the effects of eating and drinking normally on the duration of acute diarrhoea and on the feeling of well-being. METHOD: Randomized single-blinded, controlled trial in urban and semi-urbanized areas. Patients aged 3-70 years suffering with diarrhoea at least three times on the preceding day, lasting no more than five days, were eligible. Two regimes were randomly allocated to practices. In the intervention group, the advice was to eat everything one liked and to drink more. The control group was advised to follow a strict regime of fasting for 24 hours and was subsequently given specified limitations. RESULTS: No significant differences between the 44 patients in the intervention group and the 27 in the control group were found for the duration of watery diarrhoea (median 14 versus 13 hours), or the total number of evacuations (2 versus 2.5). Among the items concerning well-being, only nausea (51% versus 23%) showed a significant difference. CONCLUSION: In this pilot study, the null hypothesis that both treatments will show equal results cannot be confirmed or rejected because of the small number of participants. Despite our efforts, we included fewer patients than expected. This might be due to the data-forms, which were rather complicated and voluminous for both, including doctors and participants.

Sensitivity of microscopy versus enzyme immunoassay in the laboratory diagnosis of giardiasis.

The substitution of enzyme immunoassay (EIA) techniques for microscopy as a screening tool for Giardia lamblia infection was assessed. Paired stool samples obtained within a ten-day period from 366 patients with persistent diarrhea were examined by microscopy. In addition, two commercially available Giardia lamblia-specific EIAs were performed. Compared with microscopy, EIA for copro-antigen detection was more sensitive, based on examination of either one or two stool samples. Repeated examinations increased the number of cases detected, more so for microscopy than EIA. The negative predictive values of the two EIAs performed on the first stool sample were 98.7% and 97.8%. The results show that EIA for detection of copro-antigens in a single stool sample may be almost as sensitive for identifying Giardia infection as repeated microscopy on two sequential stool samples.

A systematic review on the treatment of giardiasis.

To assess the efficacy of treatment of parasitological excretion of cysts and trophozoites and symptoms of patients with giardiasis, a systematic review of published randomized clinical trials was conducted through extensive searches in Medline, Embase and Current Contents from 1966 till 1996 as well as manual reviews of 28 journals. The methodological quality of all trials was assessed by guidelines of the Cochrane Collaboration. Thirty-one trials were included, only one of which had no serious methodological flaws. The mean score of parasitological examination was 4.8 out of a possible 15. There was a considerable effect in cure rate of treatment versus placebo (odds 9.3, 95% CI 4.69-18.4), but all 3 trials in this comparison had serious flaws. Metronidazole treatment over more than 3 days seems to achieve a better parasitological cure rate than other long treatment courses (pooled odds 2.6, 95% 1.7-3.8), but trials are clinically and statistically heterogeneous. Single-dose therapy is as effective as longer treatment courses (pooled odds 0.67, 95% 0.31-1.44). Within the single-dose regimens tinidazole (2 g) reaches a higher parasitological cure rate than other short therapies (pooled odds 55, 95% CI 3.7-8.3) with relatively few side-effects. Placebo-controlled trials with parasitological and clinical outcomes are needed.

Sensitivity, specificity and predictive values of breast imaging in the detection of cancer.

In an observational follow-up study we determined whether the combined use of mammography and breast ultrasonography is an appropriate diagnostic tool to select patients with symptomatic breast disease who need additional pathological evaluation. Mammography and ultrasound were used as complementary diagnostic modalities in 3014 consecutively referred and mainly symptomatic patients. Sensitivity, specificity, predictive values and likelihood ratios were calculated according to standard procedures. Virtually complete follow-up was obtained by correlating the radiological diagnosis with clinical records, final pathological findings, records from the Cancer Register and data from questionnaires sent to the general practitioners of all the referred patients. After an average follow-up period of 30 months, the sensitivity for breast cancer detection was 92.0% and the specificity 97.7%. A positive predictive value of 68.0%, a negative predictive value of 99.6%, a positive likelihood ratio of 40 and a negative likelihood ratio of 0.08 were found. The mean diagnostic delay as a result of false negative examinations was 9 months (range 0-20 months). We conclude that breast imaging in routine daily practice, consisting of the integral use of mammography and ultrasonography, is an appropriate tool in the detection of cancer and should be included in the work-up of symptomatic breast disease.

Mammographic surveillance of asymptomatic breast cancer relatives in general practice: rate of re-attendance and GP- and patient-related barriers.

BACKGROUND: Several guidelines have been formulated for mammographic screening of breast cancer relatives. No studies have examined the adherence of GPs and their patients to these recommendations. OBJECTIVES: We aimed to determine the rate of re-attendance of breast cancer relatives for mammographic screening requested by GPs and specify the barriers for non-attending follow-up mammography. METHODS: The study included all asymptomatic women aged 35 years or older with a first-degree family history of breast cancer, referred for mammography to our department of radiology by their GP between 1 January 1992 and 1 September 1994. Reasons for not re-attending mammography within 2 years were obtained by sending a questionnaire to GPs and, if necessary, telephone calls to GPs or their patients. The questionnaire was accompanied by a reminder, in which we advised re-attendance. The number of women who still underwent repeated mammographic screening within the 2 months following the reminder was determined. RESULTS: In 123 out of 234 patients (52.6%) follow-up mammography had been performed within 2 years. Barriers to undergoing follow-up mammography were GP-related in 70.3% of cases and patient-related in 29.7%. Of the 111 non-re-attenders, 52 (47.7%) still underwent follow-up mammography within 2 months after the reminder. This examination was performed more often if the barriers to re-attendance were GP-related rather than patient-related (57.7% versus 24.2%, 95% confidence interval (CI) 13.0-53.9). Significantly more patients re-attended after the reminder if the GP-related barrier was an insufficient retrieval system rather than disagreement with mammography guidelines (81.3% versus 20.0%, 95% CI 40.4-82.0). CONCLUSIONS: Many breast cancer relatives did not undergo regular mammographic screening. Non-re-attendance resulted from a limited degree of acceptance and implementation of the screening recommendations by physicians as well as reluctance of the patient to adhere to such recommendations. A reminder, generated by a radiology department, may increase the performance of follow-up mammography.

Comparison of fresh versus sodium acetate acetic acid formalin preserved stool specimens for diagnosis of intestinal protozoal infections.

The use of sodium acetate acetic acid formalin (SAF)-preserved stool specimens was compared with that of nonpreserved specimens for the recovery of intestinal protozoa. A total of 247 patients, 170 with diarrhea of more than one week's duration and 77 refugees, were asked to collect a stool specimen. Each specimen was placed into two vials, one empty, the other containing SAF fixative. Laboratory investigations included microscopic examination of the concentrated sediment and direct wet smears from both types of stool specimens and the microscopic examination of a permanent stained smear from the unsedimented, SAF-preserved stool specimens. Examination of SAF-preserved stool specimens revealed intestinal protozoa in 149 of the 247 patients. With the conventional procedure using unpreserved stool specimens, intestinal protozoa were found in 89 of the 247 patients. The results show that the examination of SAF-preserved stool specimens, consisting of the microscopic examination of both the concentrated sediment and the permanent stained smear from the unsedimented material, increases the chance of recovering intestinal protozoa as compared to the conventional procedure.

Do out-of-office laboratory tests affect diagnoses in general practice?

OBJECTIVE: To find out whether the GP diagnosis changed by out-of-office laboratory test results and whether his diagnosis became more certain. DESIGN: Descriptive study. SETTING: Dutch survey of morbidity and interventions in general practice: stratified random sample of 161 GPs with a total list of 335,000 patients. SUBJECTS: 2,081 episodes of illness with at least one consultation with clinical chemistry, haematology, or serology tests and at least one follow-up consultation. MAIN OUTCOME MEASUREMENTS: Change in ICPC component or chapter between the consultation in which a laboratory test was ordered and the follow up contact; change in exact ICPC code in cases with important diseases (infectious diseases, haematological disorders, endocrine abnormalities, auto-immune processes and malignancies (n = 330)); change in certainty of a diagnosis and change in somatic/psychosocial orientation. RESULTS: After laboratory tests done in the first consultation the ICPC component changed in 46% of the diagnoses. Of the diagnoses made in first consultations without laboratory tests 41% changed in the follow up consultation. The diagnosis after laboratory tests was the same as before in 51% of the consultations with important diseases. Certainty about a diagnosis increased significantly after laboratory tests (p < 0.001). An abnormal laboratory result did not affect the clinical certainty of the general practitioner or the percentage of altered diagnoses. CONCLUSION: The usefulness of tests should be assessed not only in terms of the number of diagnoses changed or of the percentage of abnormal results, but also in terms of the changed certainty concerning a diagnosis.

[Underestimation of intestinal protozoa as a cause of diarrhea in family practice]. / Onderschatting van darmprotozoa als oorzaak van diarree in de huisartspraktijk.

OBJECTIVE: To assess the frequency of intestinal protozoa in stool samples of patients with diarrhoea in general practice. SETTING: General practitioners' laboratory in Haarlem, Netherlands. DESIGN: Descriptive study. METHOD: During one year (1 February 1992 to 31 January 1993) all stool samples from patients with diarrhoea visiting a general practitioner were examined according to a standard protocol consisting of bacterial and protozoal examination. RESULTS: Among 1703 stool examinations requested by general practitioners and performed according to the protocol, pathogenic protozoa were found in 10.8% and pathogenic bacteria in 8.6%. Of the 184 patients who tested positive for pathogenic protozoa 156 harboured Giardia lamblia, 22 Entamoeba histolytica and 6 Cryptosporidium spp. Pathogenic protozoa were predominantly found in patients with diarrhoea persisting for longer than 1 week and in cases with intermittent diarrhoea. In patients with acute diarrhoea (duration < 1 week) we predominantly found pathogenic bacteria (Campylobacyter jejuni). If the search for protozoa in the stool samples would not have been performed routinely, 34% of the pathogenic protozoa (Giardia lamblia) would not have been found. CONCLUSION: Intestinal infections with protozoa are not rare in general practice. It seems worthwhile to perform protozoal examination of the stool samples in case of persistent diarrhoea.