Performance of a simplified HEART score and HEART-GP score for evaluating chest pain in urgent primary care.

BACKGROUND: Chest pain is a common symptom in urgent primary care. The distinction between urgent and non-urgent causes can be challenging. A modified version of the HEART score, in which troponin is omitted ('simplified HEART') or replaced by the so-called 'sense of alarm' (HEART-GP), may aid in risk stratification. METHOD: This study involved a retrospective, observational cohort of consecutive patients evaluated for chest pain at a large-scale, out-of-hours, regional primary care facility in the Netherlands, with 6­week follow-up for major adverse cardiac events (MACEs). The outcome of interest is diagnostic accuracy, including positive predictive value (PPV) and negative predictive value (NPV). RESULTS: We included 664 patients; MACEs occurred in 4.8% (n = 32). For  simplified HEART and HEART-GP, we found C­statistics of 0.86 (95% confidence interval (CI) 0.80-0.91) and 0.90 (95% CI 0.85-0.95), respectively. Optimal diagnostic accuracy was found for a simplified HEART score ≥2 (PPV 9%, NPV 99.7%), HEART-GP score ≥3 (PPV 11%, NPV 99.7%) and HEART-GP score ≥4 (PPV 16%, NPV 99.4%). Physicians referred 157 patients (23.6%) and missed 6 MACEs. A simplified HEART score ≥2 would have picked up 5 cases, at the expense of 332 referrals (50.0%, p < 0.001). A HEART-GP score of ≥3 and ≥4 would have detected 5 and 3 MACEs and led to 293 (44.1%, p < 0.001) and 186 (28.0%, p = 0.18) referrals, respectively. CONCLUSION: HEART-score modifications including the physicians' 'sense of alarm' may be used as a risk stratification tool for chest pain in primary care in the absence of routine access to troponin assays. Further validation is warranted.

Survivorship care for cancer patients in primary versus secondary care: a systematic review.

BACKGROUND: Cancer survivorship care is traditionally performed in secondary care. Primary care is often involved in cancer management and could therefore play a more prominent role. PURPOSE: To assess outcomes of cancer survivorship care in primary versus secondary care. METHODS: A systematic search of MEDLINE and EMBASE was performed. All original studies on cancer survivorship care in primary versus secondary care were included. A narrative synthesis was used for three distinctive outcomes: (1) clinical, (2) patient-reported, and (3) costs. RESULTS: Sixteen studies were included: 7 randomized trials and 9 observational studies. Meta-analyses were not feasible due to heterogeneity. Most studies reported on solid tumors, like breast (N = 7) and colorectal cancers (N = 3). Clinical outcomes were reported by 10 studies, patient-reported by 11, and costs by 4. No important differences were found on clinical and patient-reported outcomes when comparing primary- with secondary-based care. Some differences were seen relating to the content and quality of survivorship care, such as guideline adherence and follow-up tests, but there was no favorite strategy. Survivorship care in primary care was associated with lower societal costs. CONCLUSIONS: Overall, cancer survivorship care in primary care had similar effects on clinical and patient-reported outcomes compared with secondary care, while resulting in lower costs. IMPLICATIONS FOR CANCER SURVIVORS: Survivorship care in primary care seems feasible. However, since the design and outcomes of studies differed, conclusive evidence for the equivalence of survivorship care in primary care is still lacking. Ongoing studies will help provide better insights.

A single dose of doxycycline after an ixodes ricinus tick bite to prevent Lyme borreliosis: An open-label randomized controlled trial.

OBJECTIVES: A single dose of doxycycline after a tick bite can prevent the development of Lyme borreliosis in North America, but extrapolation to Europe is hampered by differences in Borrelia burgdorferi sensu lato genospecies and tick species. We assessed the efficacy of prophylaxis after a tick bite in Europe. METHODS: We conducted an open-label randomized controlled trial, administering a single dose of 200 mg doxycycline within 72 h after removing an attached tick from the skin, compared to no treatment. Potential participants ≥ 8 years of age who reported a recent tick bite online were invited for the study. After informed consent, they were randomly assigned to either the prophylaxis or the no-treatment group. Participants in the prophylaxis group were asked to visit their general practitioner to administer the antibiotics. All participants were followed up by online questionnaires. Our primary outcome was the development of physician-confirmed Lyme borreliosis in a modified-intention-to-treat analysis. This study is registered in the Netherlands Trial Register (NTR3953) and is closed. RESULTS: Between April 11, 2013, and June 10, 2015, 3538 potential participants were randomized, of whom 1689 were included in the modified-intention-to-treat analysis. 10 cases of Lyme borreliosis were reported out of 1041 participants (0.96%) in the prophylaxis group, and 19 cases out of 648 no-treatment participants (2.9%), resulting in a relative risk reduction of 67% (95% CI 31 - 84%), and a number-needed-to-treat of 51 (95% CI 29 - 180). No serious adverse events were reported. CONCLUSIONS: This primary care-based trial provides evidence that a single dose of doxycycline can prevent the development of Lyme borreliosis after an Ixodes ricinus tick bite.

Information needs and information seeking behaviour of patients during follow-up of colorectal cancer in the Netherlands.

PURPOSE: Adequately informing patients is considered crucial in cancer care, but need for information and information seeking behaviour of colorectal cancer (CRC) patients in the Netherlands are currently not well known. METHODS: In a prospective study, patients participating in a specialty, hospital-based follow-up program completed three consecutive surveys over a 6-month period to analyse their information need and information seeking behaviour. RESULTS: Patients (n = 259) felt well informed about their treatment (86%), disease (84%), and follow-up program (80%), but less well informed about future expectations (49%), nutrition (43%), recommended physical activity (42%), and heredity of cancer (40%). The need for more information on these subjects remained constant over the first five postoperative years. Patients who were younger, who had undergone chemotherapy, or who had comorbid conditions needed more information on several subjects. One in three patients searched for information themselves, mostly on the Internet. One in four patients consulted a health care provider for information, mostly their GP. Younger and more educated patients more often searched for information themselves, while patients undergoing chemotherapy more often consulted the hospital nurse. Information seeking behaviour remained constant over time. CONCLUSIONS: This study showed where current information provision is perceived as adequate and on which subject improvements can be made. It identifies information seeking behaviour and proposes ways to personalize information provision. IMPLICATIONS FOR CANCER SURVIVORS: The GP is most frequently consulted for information; involving GPs in CRC follow-up could improve information provision on several subjects for several patients.

[Dilemma: to test or not to test for Lyme borreliosis in general practice]. / Dilemma: wel of niet testen op lymeziekte in de huisartsenpraktijk?

There is no such thing as a perfect diagnostic test and the value of a test depends on the situation in which the test is being used. Here, we discuss two options for dealing with the diagnostic process for Lyme borreliosis in general practice. One option is to manage, treat or refer according to clinical signs and symptoms, in accordance with Dutch practice guidelines. The other option is to use laboratory tests to guide further patient management (treatment or referral). The choice depends on currently unknown factors, such as the pre-test probability of Lyme disease in patients presenting to general practitioners. Furthermore, clarity is required about how to proceed after a positive or negative test result. The consequences of a false test result will depend on the patient's status, possible alternative diagnoses and treatment options. Both physician and patient should be aware of the shortcomings of diagnostic tests.

Colorectal cancer patients' preferences for type of caregiver during survivorship care.

PURPOSE: Colorectal cancer (CRC) survivors are currently included in a secondary care-led survivorship care programme. Efforts are underway to transfer this survivorship care to primary care, but met with some reluctance by patients and caregivers. This study assesses (1) what caregiver patients prefer to contact for symptoms during survivorship care, (2) what patient factors are associated with a preferred caregiver, and (3) whether the type of symptom is associated with a preferred caregiver. METHODS: A cross-sectional study of CRC survivors at different time points. For 14 different symptoms, patients reported if they would consult a caregiver, and who they would contact if so. Patient and disease characteristics were retrieved from hospital and general practice records. RESULTS: Two hundred and sixty patients participated (response rate 54%) of whom the average age was 67, 54% were male. The median time after surgery was seven months (range 0-60 months). Patients were divided fairly evenly between tumour stages 1-3, 33% had received chemotherapy. Men, patients older than 65 years, and patients with chronic comorbid conditions preferred to consult their general practitioner (GP). Women, patients with stage 3 disease, and patients that had received chemotherapy preferred to consult their secondary care provider. For all symptoms, patients were more likely to consult their GP, except for (1) rectal blood loss, (2) weight loss, and (3) fear that cancer had recurred, in which case they would consult both their primary and secondary care providers. Patients appreciated all caregivers involved in survivorship care highly; with 8 out of 10 points. CONCLUSIONS: CRC survivors frequently consult their GP in the current situation, and for symptoms that could alarm them to a possible recurrent disease consult both their GP and secondary care provider. Patient and tumour characteristics influence patients' preferred caregiver.

Follow-up of colon cancer patients; causes of distress and need for supportive care: Results from the ICARE Cohort Study.

BACKGROUND: Colon cancer survivors experience physical and psychosocial problems that are currently not adequately addressed. This study investigated distress in patients after curative surgery for colon cancer and studied how this corresponds with the need for supportive care. METHODS: Prospective cohort of patients with stage I-III colon carcinoma, treated with curative intent, currently in follow-up at 6 different hospitals. A survey recorded symptoms, experienced problems, and (un)expressed needs. Satisfaction with supportive care was recorded. RESULTS: Two hundred eighty four patients were included; 155 males and 129 females, with a mean age of 68 years (range 33-95), and a median follow-up of 7 months. 227 patients completed the survey. Patients experienced a median of 23 symptoms in the week before the survey, consisting of a median of 10 physical, 8 psychological and 4 social symptoms. About a third of these symptoms was felt to be a problem. Patients with physical problems seek supportive care in one in three cases, while patients with psychosocial problems only seek help in one in eight cases. Patients who recently finished treatment, finished adjuvant chemotherapy, or had a stoma, had more symptoms and needed more help in all domains. Patients most frequently consulted general practitioners (GPs) and surgeons, and were satisfied with the help they received. CONCLUSION: Colon cancer survivors experience many symptoms, but significantly fewer patients seek help for a psychosocial problem than for a physical problem. Consultations with supportive care are mainly with GPs or surgeons, and both healthcare providers are assessed as providing satisfying care.

Qualitative point-of-care D-dimer testing compared with quantitative D-dimer testing in excluding pulmonary embolism in primary care.

BACKGROUND: General practitioners can safely exclude pulmonary embolism (PE) by using the Wells PE rule combined with D-dimer testing. OBJECTIVE: To compare the accuracy of a strategy using the Wells rule combined with either a qualitative point-of-care (POC) D-dimer test performed in primary care or a quantitative laboratory-based D-dimer test. METHODS: We used data from a prospective cohort study including 598 adults suspected of PE in primary care in the Netherlands. General practitioners scored the Wells rule and carried out a qualitative POC test. All patients were referred to hospital for reference testing. We obtained quantitative D-dimer test results as performed in hospital laboratories. The primary outcome was the prevalence of venous thromboembolism in low-risk patients. RESULTS: Prevalence of PE was 12.2%. POC D-dimer test results were available in 582 patients (97%). Quantitative test results were available in 401 patients (67%). We imputed results in 197 patients. The quantitative test and POC test missed one (0.4%) and four patients (1.5%), respectively, with a negative strategy (Wells ≤ 4 points and D-dimer test negative) (P = 0.20). The POC test could exclude 23 more patients (4%) (P = 0.05). The sensitivity and specificity of the Wells rule combined with a POC test were 94.5% and 51.0% and, combined with a quantitative test, 98.6% and 47.2%, respectively. CONCLUSIONS: Combined with the Wells PE rule, both tests are safe to use in excluding PE. The quantitative test seemed to be safer than the POC test, albeit not statistically significant. The specificity of the POC test was higher, resulting in more patients in whom PE could be excluded.

Common alternative diagnoses in general practice when deep venous thrombosis is excluded.

BACKGROUND: In patients initially suspected of deep venous thrombosis (DVT) the diagnosis can be confirmed in approximately 10 to 30% of cases. For the majority of patients this means that eventually an alternative diagnosis is assigned. OBJECTIVE: To assess the frequency distribution of alternative diagnoses and subsequent management of patients in primary care after initial exclusion of DVT. In addition, assess the value of ultrasound examination for the allocation of alternative diagnoses. METHODS: Data were recorded by general practitioners alongside a diagnostic study in primary care in the Netherlands (AMUSE). Additional data were retrieved from a three-month follow-up questionnaire. A descriptive analysis was performed using these combined data. RESULTS: The most prevalent diagnoses were muscle rupture (18.5%), chronic venous insufficiency (CVI) (14.6%), erysipelas/cellulitis (12.6%) and superficial venous thrombosis (SVT) (10.9%). Alternative diagnoses were based mainly on physical examination; ultrasound examination (US) did not improve the diagnostic yield for the allocation of alternative diagnoses. In about 30% of all cases, a wait and see approach was used (27 to 41%). During the three-month follow-up nine patients were diagnosed with venous thromboembolic disease, three of which occurred in patients with the working diagnosis of SVT (p=0.026). CONCLUSIONS: We found that after exclusion of DVT in general practice a wait and see policy in the primary care setting is uneventful for almost one third of patients, but with the alternative diagnosis of SVT, patients may require closer surveillance since we found a significant association with thrombosis in these patients.

Efficacy of diagnostic tools for detecting cardiac arrhythmias: systematic literature search.

BACKGROUND/OBJECTIVES: Symptoms suggestive of cardiac arrhythmias are a challenge to the diagnosis. Physical examination and a 12-lead ECG are of limited value, as rhythm disturbances are frequently of a paroxysmal nature. New technologies facilitate a more accurate diagnosis. The objective of this study was to review the medical literature in an effort to define a guide to rational diagnostic testing. METHODS: Primary studies on the use of a diagnostic tool in the evaluation of palpitations were searched in MEDLINE, and EMBASE with an additional reference check. RESULTS: TWO TYPES OF STUDIES WERE FOUND: descriptive and experimental studies, which compared the yield of two or more devices or diagnostic strategies. Holter monitors seemed to have less diagnostic yield (33 to 35%) than event recorders. Automatically triggered recorders detect more arrhythmias (72 to 80%) than patient-triggered devices (17 to 75%). Implantable devices are used for prolonged monitoring periods in patients with infrequent symptoms or unexplained syncope. CONCLUSION: The choice of the device depends on the characteristics of the symptoms and the patient. Due to methodological shortcomings of the included studies no evidence-based diagnostic strategy can be proposed. (Neth Heart J 2010;18:543-51.).

Cost-effectiveness of ruling out deep venous thrombosis in primary care versus care as usual.

BACKGROUND: Referral for ultrasound testing in all patients suspected of DVT is inefficient, because 80-90% have no DVT. OBJECTIVE: To assess the incremental cost-effectiveness of a diagnostic strategy to select patients at first presentation in primary care based on a point of care D-dimer test combined with a clinical decision rule (AMUSE strategy), compared with hospital-based strategies. PATIENTS/METHODS: A Markov-type cost-effectiveness model with a societal perspective and a 5-year time horizon was used to compare the AMUSE strategy with hospital-based strategies. Data were derived from the AMUSE study (2005-2007), the literature, and a direct survey of costs (2005-2007). RESULTS OF BASE-CASE ANALYSIS: Adherence to the AMUSE strategy on average results in savings of euro138 ($185) per patient at the expense of a very small health loss (0.002 QALYs) compared with the best hospital strategy. The iCER is euro55 753($74 848). The cost-effectiveness acceptability curves show that the AMUSE strategy has the highest probability of being cost-effective. RESULTS OF SENSITIVITY ANALYSIS: Results are sensitive to decreases in sensitivity of the diagnostic strategy, but are not sensitive to increase in age (range 30-80), the costs for health states, and events. CONCLUSION: A diagnostic management strategy based on a clinical decision rule and a point of care D-dimer assay to exclude DVT in primary care is not only safe, but also cost-effective as compared with hospital-based strategies.

Diagnosis of conjunctivitis in primary care: comparison of two different culture procedures.

BACKGROUND: In general practice, infectious conjunctivitis is a common and mostly (64%) self-limiting disorder. In case of an aberrant course or severe symptoms, a general practitioner may take a culture. Direct inoculation is considered the reference standard, but usually a swab is sent to a laboratory. OBJECTIVES: To compare the diagnostic performance of the swab, transported by surface mail with direct inoculation. METHODS: 19 general practitioners took two samples of the conjunctiva from 88 patients with symptoms suggestive of infectious conjunctivitis by rolling a cotton swab across the conjunctiva of the lower fornix. One swab was used to inoculate three agar plates directly, while the other was sent in a Stuart medium to the laboratory and inoculated at the time of arrival. The numbers of positive cultures of both methods were compared. RESULTS: A pathogen was found in 31 of 88 samples (35% (95% CI 26 to 46)). Surprisingly, the number of positive cultures was higher for the Stuart medium (27/88) than for direct inoculation (23/88). The difference was 4.5% (90% CI 0 to 12, p = 0.388; one-sided McNemar test for paired proportions). In five of the 19 samples that were positive in both tests, the cultured pathogens were different. CONCLUSIONS: The Stuart medium detected more bacteria than direct inoculation. The lower 90% CI, testing non-inferiority at p = 0.05, indicates that it is unlikely that the Stuart medium misses any positive cultures compared with direct inoculation.

[Changes in the medical curriculum in Mongolia]. / Veranderingen in de medische opleiding in Mongolië.

Since 1996, general practitioners from the universities in Amsterdam, Groningen and Leeds (England) have been involved in restructuring the medical curriculum in Mongolia. The Mongolians desired a problem-based and integrated new curriculum that would be suitable for training generalists. We started by training Mongolian teachers in modern pedagogic developments and in multidisciplinary consultation. The new curriculum started in 1999 and after a cumbersome start, integration was achieved, the library was completely renewed and equipped for self-study and rural opportunities were created so that medical students could acquire practical experience outside of the university hospital. The new curriculum is a step in the direction of training doctors who will be able to function independently in the new Mongolian health-care system.