Hand and wrist problems in general practice--patient characteristics and factors related to symptom severity.

OBJECTIVES: Hand and wrist problems are common, but little is known about characteristics of patients consulting the general practitioner (GP) for these problems. The objectives are: (i) to describe wrist and hand problems presented to the GP in terms of severity of symptoms, and their impact on physical, emotional and social functioning; (ii) to describe patient and disease characteristics across different diagnostic categories; and (iii) to study factors related to the severity of hand or wrist problems. METHODS: Patients consulting their GP with hand or wrist problems were sent a questionnaire containing questions on socio-demographic variables, characteristics of the complaint, physical activity and psychosocial factors. The GP recorded information on symptoms, signs and medical diagnosis. We studied the cross-sectional association between a variety of factors and severity of hand or wrist problems, using the Symptom Severity Scale as the outcome measure. RESULTS: Mean age of the 267 participants was 49.3 yrs and 74% were female. The three most frequently recorded diagnoses were osteoarthritits (17%), tenosynovitis (16%) and nerve entrapment (12%). The characteristics of patients varied slightly across diagnostic categories. Patients who did not have paid work, had longer duration of symptoms, diagnosis of entrapment, higher pain intensity, higher body mass index and higher scores on worrying reported significantly higher scores on severity of hand or wrist problems (P-value <0.10). CONCLUSION: Primary care patients with hand or wrist problems report pain and reduced function. Impact on other aspects of perceived health is limited. Severity seems to be associated with socio-demographic, physical and psychosocial factors, more than with medical diagnosis.

[Guideline 'Cardiovascular Risk Management']. / Richtlijn 'cardiovasculair risicomanagement'.

The aim of the clinical practice guideline 'Cardiovascular risk management' is an integral approach to all relevant risk factors for cardiovascular disease (CVD) caused by atherothrombosis. Patients with CVD, diabetes mellitus type 2 (DM2), elevated blood pressure or cholesterol, men of 50 years or older who smoke and women of 55 years or older who smoke are eligible for assessment of relevant risk factors for CVD. All high-risk patients should receive lifestyle counselling. In patients with CVD the use of acetylsalicylic acid and often, depending on the specific disease, a beta-blocker or an angiotensin converting enzyme (ACE) inhibitor are recommended. The use of a statin is recommended if the LDL-cholesterol concentration is > or = 2.5 mmol/l. In patients with DM2, the use of statins is recommended if LDL-cholesterol is > or = 2.5 mmol/l and use of a blood pressure lowering drug with a systolic blood pressure > or = 140 mmHg, as well as glucose lowering drugs. In patients without CVD and DM2, the need for drug treatment will be determined by estimation of the absolute 10-year mortality risk of CVD. Treatment is recommended if this risk exceeds 10%. The treatment and follow-up plan will be determined individually, depending on the risk profile, morbidity, comorbidity and patient's preferences.

[From the Cochrane Library and Diabetes Care: self-monitoring of blood glucose probably an effective way to improve glycaemic control in patients with type 2 diabetes not taking insulin]. / Uit de Cochrane Library en Diabetes Care: zelfcontrole van bloedglucosewaarden bij diabetes mellitus type 2 zonder gebruik van insuline waarschijnlijk effectieve methode om glykemische instelling te verbeteren.

Self-monitoring of blood glucose has been found to be effective for patients with type I diabetes and for patients with type 2 diabetes taking insulin. There is much debate on the effectiveness of self-monitoring of blood glucose in the management of patients with type 2 diabetes who are not taking insulin. A systematic review of 6 randomised controlled trials comparing self-monitoring of blood glucose with standard care, self-monitoring of urine glucose, or both showed that self-monitoring of blood glucose may be effective in improving glycaemic control in patients with type 2 diabetes who are not using insulin. There was scant data on patient-related outcomes, such as quality of life, well being and satisfaction. Therefore, more large long-term studies of high quality are needed.

[The practice guideline 'Heart failure' (first revision) from the Dutch College of General Practitioners; a response from the perspective of general practice]. / De standaard 'hartfalen' (eerste herziening) van het Nederlands Huisartsen Genootschap; reactie vanuit de huisartsgeneeskunde.

The practice guideline 'Heart failure' from the Dutch College of General Practitioners will be a source of support for the general practitioner/family physician. Its clear set of diagnostic steps helps the general practitioner to assess heart failure in patients with breathlessness, fatigue, decreased exercise tolerance or ankle swelling. Testing plasma concentrations of natriuretic peptides plays a new and central diagnostic role. This guideline differs from the previous one in another important aspect. Based on many RCT's and reviews the authors have succeeded in developing a detailed but balanced treatment protocol for heart-failure patients in general practice. However, adverse effects from co- and multi-medication in the growing number of frail elderly may reduce the patients' compliance.

Frequent attenders in general practice: problem solving treatment provided by nurses [ISRCTN51021015].

BACKGROUND: There is a need for assistance from primary care mental health workers in general practice in the Netherlands. General practitioners (GPs) experience an overload of frequent attenders suffering from psychological problems. Problem Solving Treatment (PST) is a brief psychological treatment tailored for use in a primary care setting. PST is provided by nurses, and earlier research has shown that it is a treatment at least as effective as usual care. However, research outcomes are not totally satisfying. This protocol describes a randomized clinical trial on the effectiveness of PST provided by nurses for patients in general practice. The results of this study, which currently being carried out, will be presented as soon as they are available. METHODS/DESIGN: This study protocol describes the design of a randomized controlled trial to investigate the effectiveness and cost-effectiveness of PST and usual care compared to usual care only. Patients, 18 years and older, who present psychological problems and are frequent attenders in general practice are recruited by the research assistant. The participants receive questionnaires at baseline, after the intervention, and again after 3 months and 9 months. Primary outcome is the reduction of symptoms, and other outcomes measured are improvement in problem solving skills, psychological and physical well being, daily functioning, social support, coping styles, problem evaluation and health care utilization. DISCUSSION: Our results may either confirm that PST in primary care is an effective way of dealing with emotional disorders and a promising addition to the primary care in the UK and USA, or may question this assumption. This trial will allow an evaluation of the effects of PST in practical circumstances and in a rather heterogeneous group of primary care patients. This study delivers scientific support for this use and therefore indications for optimal treatment and referral.

Self-monitoring of blood glucose in patients with type 2 diabetes mellitus who are not using insulin.

BACKGROUND: Self-monitoring of blood glucose (SMBG) has been found to be effective for patients with type 1 diabetes and for patients with type 2 diabetes using insulin. There is much debate on the effectiveness of SMBG as a tool in the self-management for patients with type 2 diabetes who are not using insulin. OBJECTIVES: The objective of this review was to assess the effects of SMBG in patients with type 2 diabetes mellitus who are not using insulin. SEARCH STRATEGY: Studies were obtained from searches of multiple electronic bibliographic databases supplemented with hand searches of references of retrieved articles. Date of last search: September 2004. SELECTION CRITERIA: We included randomised controlled trails investigating the effects of SMBG compared with usual care and/or with self-monitoring of urine glucose in patients with type 2 diabetes who where not using insulin. Included studies should have used at least one of the following outcome measures: glycaemic control, quality of life, well-being, patient satisfaction, or hypoglycaemic episodes. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data from included studies and assessed study quality. Data from the studies were compared to decide whether they were sufficiently homogeneous to pool in a meta-analysis. MAIN RESULTS: Six randomised controlled trials were included in the review. Four trials compared SMBG with usual care, one trial compared SMBG with self-monitoring of urine glucose and there was one three-armed trial comparing SMBG with self-monitoring of urine glucose and usual care. Because of the differences in patient characteristics, interventions and outcomes between the studies, it was not possible to perform a meta-analysis. The methodological quality of studies was low. Two of the six studies reported a significant lowering effect of self-monitoring of blood glucose on HbA1c. However, one of these studies had a co-intervention with education on diet and lifestyle. There were few data on the effects of other outcomes and these effects were not statistically significant. AUTHORS' CONCLUSIONS: From this review we concluded that self-monitoring of blood glucose might be effective in improving glycaemic control in patients with type 2 diabetes who are not using insulin. To assess the potential beneficial effects of SMBG in these patients a large and well-designed randomised controlled trial is required. This long-term trial should also investigate patient-related outcomes like quality of life, well-being and patient satisfaction, and provide adequate education to the patient to allow SMBG to be effective.

Efficacy of temazepam in frequent users: a series of N-of-1 trials.

BACKGROUND: Benzodiazepines are frequently prescribed for sleep disturbances. However, benzodiazepines are associated with side effects, and may be ineffective when used for a prolonged period of time. OBJECTIVES: To investigate for individual patients whether placebo was as effective as temazepam, or whether 10 mg was as effective as 20 mg temazepam, and whether these results influenced their future temazepam use. METHODS: A series of randomized double-blind N-of-1 trials were conducted in general practices in The Netherlands for patients who were using temazepam regularly. Each patient received five pairs of treatments consisting of one week of temazepam (10 or 20 mg) and one week of the control intervention (placebo or 10 mg temazepam). Per pair, the sequence of treatments was randomized. Main outcome measures were: time to fall asleep, and the individual main complaint. RESULTS: Twelve out of 15 patients completed their trial. In three patients there was no difference, in five a large difference, and in four a small difference in favour of temazepam. At follow-up, seven patients had stopped or reduced their temazepam use. CONCLUSION: The results regarding the efficacy of temazepam varied across patients. N-of-1 trials seem to be valuable in patients who are motivated to stop or reduce their temazepam use. They clearly demonstrate the efficacy of temazepam, and may give patients additional confidence to discontinue regular hypnotic use. The value of N-of-1 trials for patients who are less motivated is unclear, as the size of treatment effect does not seem to influence future hypnotic use.

[The practice guideline 'Peripheral vascular disease' (first revision) from the Dutch College of General Practitioners: a response from the perspective of general practice]. / De standaard 'Perifeer arterieel vaatlijden' (eerste herziening) van het Nederlands Huisartsen Genootschap; reactie vanuit de huisartsgeneeskunde.

The practice guideline 'Peripheral vascular disease' (PVD) from the Dutch College of General Practitioners will certainly be of benefit to the Dutch general practitioner. Its limited set of simple diagnostic steps can help the general practitioner to assess or exclude PVD in patients with intermittent claudication. The inclusion of a pretest-posttest probability scheme enhances a clear diagnostic process. This guideline differs from the previous one in one important aspect. This guideline deals not only with the specific management of peripheral arterial disease but also with the management of cardiovascular risk in general. In this way the guideline follows the recently changed international attitude reflected in the European Guidelines on cardiovascular disease prevention. Smoking cessation and exercise therapy continues to be the cornerstone as well as the stumbling block of management of most cases of PVD in general practice; a challenge for every general practitioner.

Dementia: predictors of diagnostic accuracy and the contribution of diagnostic recommendations.

OBJECTIVES: To explore and quantify the relative contribution of guideline recommendations and other determinants in the family physicianamprsquos diagnostic work-up of patients suspected of dementia. STUDY DESIGN: We prospectively studied 64 family physicians in an Eastern district in the Netherlands who diagnosed dementia according to the national Dutch guidelines in primary care. Their diagnoses were compared with the reference standard embodied by the memory clinic team of the University Medical Center Nijmegen. POPULATION: The physicians evaluated 107 patients older than 55 years suspected of having dementia. OUTCOMES MEASURED: Predictive values of various clinical and demographic parameters were measured in both univariate and multivariate logistic regression analyses. RESULTS: Activities of daily living (ADL) dependency (odds ratio [OR] = 5.3, P =.03), years since symptoms first started (OR = 1.84, P =.03), and the presence of somatic comorbidity (OR = 0.48, P =.02) independently contributed to the prediction of the presence or absence of dementia. The area under the receiver-operating characteristic (ROC) curve for these 3 variables together was 0.79. The ROC area of the family physiciansamprsquo diagnosis to determine the final diagnosis was 0.74. The number of recommendations applied did not additionally contribute to the assessment of the final diagnosis. CONCLUSIONS: The diagnostic accuracy of the family physician was reasonable. For family physicians, ADL dependency is a better predictor of dementia than cognitive impairment. Family physicians should be aware of diagnostic difficulties in patients with somatic comorbidity. We were unable to confirm the diagnostic value of many of the recommendations of dementia guidelines.

Clinical effectiveness of conventional influenza vaccination in asthmatic children.

Influenza immunization rates among young asthmatics remain unsatisfactory due to persistent concern about the impact of influenza and the benefits of the vaccine. We assessed the effectiveness of the conventional inactivated trivalent sub-unit influenza vaccine in reducing acute respiratory disease in asthmatic children. We conducted a two-season retrospective cohort study covering the 1995-6 and 1996-7 influenza outbreaks in 22 computerized primary care practices in The Netherlands. In total, 349 patients aged between 0 and 12 years meeting clinical asthma-criteria were included; 14 children were lost to follow-up in the second season. The occurrence of physician-diagnosed acute respiratory disease episodes including influenza-like illness, pneumonia. bronchitis, bronchiolitis, asthma exacerbation and acute otitis media in vaccinated and unvaccinated children were compared after adjustments for age, prior health care and medication use. The occurrence of acute respiratory disease in unvaccinated children was 28% and 24% in the 1995-6 and 1996-7 season, respectively, and was highest in children under 6 years of age (43%). The overall pooled clinical vaccine effectiveness was 27% (95% confidence interval -7 to 51%, P = 0.11) after adjustments. A statistically higher vaccine protectiveness of 55% (95% CI 20-75%, P = 0.01) was observed among asthmatics under 6 years of age compared with -5% in older children (95% CI -81 to 39%). The occurrence of acute respiratory disease among asthmatic children during influenza epidemics is very high, notably in the youngest. Influenza vaccination may reduce morbidity in asthmatic infants and pre-school children. However, larger, preferably experimental, studies are needed to establish the benefits of vaccination, notably in older asthmatic children.