Association of Anemia with Clinical Symptoms Commonly Attributed to Anemia-Analysis of Two Population-Based Cohorts.

BACKGROUND: Fatigue, dyspnea, and lack of energy and concentration are commonly interpreted as indicative of symptomatic anemia and may thus play a role in diagnostic and therapeutic decisions. OBJECTIVE: To investigate the association between symptoms commonly attributed to anemia and the actual presence of anemia. METHODS: Data from two independent cohorts of the Study of Health in Pomerania (SHIP) were analyzed. Interview data, laboratory data, and physical examination were individually linked with claims data from the Association of Statutory Health Insurance Physicians. A complete case analysis using logistic regression models was performed to evaluate the association of anemia with symptoms commonly attributed to anemia. The models were adjusted for confounders such as depression, medication, insomnia, and other medical conditions. RESULTS: A total of 5979 participants (53% female, median age 55) were included in the analysis. Of those, 30% reported fatigue, 16% reported lack of energy, 16% reported lack of concentration, and 29% reported dyspnea and/or weakness. Anemia was prevalent in about 6% (379). The symptoms were more prevalent in participants with anemia. However, participants with anemia were older and had a poorer health status. There was no association in multivariate logistic regression models between the symptoms fatigue, lack of concentration, dyspnea, and/or weakness and anemia. Anemia was associated (OR: 1.45; 95% CI: 1.13-1.86) with lack of energy in the multivariate analysis. Other factors such as depression, insomnia, and medication were more strongly associated with the symptoms. CONCLUSION: The clinical symptoms commonly attributed to anemia are unspecific and highly prevalent both in non-anemic and anemic persons. Even in the presence of anemia, other diagnoses should be considered as causes such as depression, heart failure, asthma, and COPD, which are more closely associated with the symptoms. Further diagnostic research is warranted to explore the association of symptoms in different subgroups and settings in order to help clinical decision making.

Monitoring and management of chronic kidney disease in ambulatory care - analysis of clinical and claims data from a population-based study.

BACKGROUND: Although chronic kidney disease (CKD) is highly prevalent in the general population, little research has been conducted on CKD management in ambulatory care. Objective was to assess management and quality of care by evaluating CKD coding in ambulatory care, patient diagnosis awareness, frequency of monitoring and whether appropriate patients are referred to nephrology. METHODS: Clinical data from the population-based cohort Study of Health in Pomerania (SHIP-START) were matched with claims data of the Association of Statutory Health Insurance Physicians. Quality of care was evaluated according international and German recommendations. RESULTS: Data from 1778 participants (56% female, mean age 59 years) were analysed. 10% had eGFR < 60 ml/min/1.73m2 (mean age 74 years), 15% had albuminuria. 21% had CKD as defined by KDIGO. 20% of these were coded and 7% self-reported having CKD. Coding increased with GFR stage (G3a 20%, G3b 61%, G4 75%, G5 100%). Serum creatinine and urinary dip stick testing were billed in the majority of all participants regardless of renal function. Testing frequency partially surpassed recommendations. Nephrology consultation was billed in few cases with stage G3b-G4. CONCLUSION: CKD coding increased with stage and was performed reliably in stages ≥ G4, while CKD awareness was low. Adherence to monitoring and referral criteria varied, depending on the applicability of monitoring criteria. For assessing quality of care, consent on monitoring, patient education, referral criteria and coordination of care needs to be established, accounting for patient related factors, including age and comorbidity. TRIAL REGISTRATION: This study was prospectively registered as DRKS00009812 in the German Clinical Trials Register (DRKS).

Referral criteria for chronic kidney disease: implications for disease management and healthcare expenditure-analysis of a population-based sample.

BACKGROUND: Clinical practice guidelines recommend specialist referral according to different criteria. The aim was to assess recommended and observed referral rate and health care expenditure according to recommendations from: • Kidney Disease Improving Global Outcomes (KDIGO,2012) • National Institute for Health and Care Excellence (NICE,2014) • German Society of Nephrology/German Society of Internal Medicine (DGfN/DGIM,2015) • German College of General Practitioners and Family Physicians (DEGAM,2019) • Kidney failure risk equation (NICE,2021) METHODS: Data of the population-based cohort Study of Health in Pomerania were matched with claims data. Proportion of subjects meeting referral criteria and corresponding health care expenditures were calculated and projected to the population of Mecklenburg-Vorpommern. RESULTS: Data from 1927 subjects were analysed. Overall proportion of subjects meeting referral criteria ranged from 4.9% (DEGAM) to 8.3% (DGfN/DGIM). The majority of patients eligible for referral were ≥ 60 years. In subjects older than 60 years, differences were even more pronounced, and rates ranged from 9.7% (DEGAM) to 16.5% (DGfN/DGIM). Estimated population level costs varied between €1,432,440 (DEGAM) and €2,386,186 (DGfN/DGIM). From 190 patients with eGFR < 60 ml/min, 15 had a risk of end stage renal disease > 5% within the next 5 years. CONCLUSIONS: Applying different referral criteria results in different referral rates and costs. Referral rates exceed actually observed consultation rates. Criteria need to be evaluated in terms of available workforce, resources and regarding over- and underutilization of nephrology services.

[Perspective of General Practitioners on Management of Non-dialysis Chronic Kidney Disease - a Qualitative Study]. / Management der nicht dialysepflichtigen chronischen Niereninsuffizienz aus hausärztlicher Sicht ­ eine qualitative Studie.

BACKGROUND: Chronic Kidney Disease (CKD) is a common diagnosis in older age due to age dependent kidney function decline, as well as an increase in causative diseases like diabetes mellitus and arterial hypertension. The condition knows a long asymptomatic phase in the early stages, and only a small part of the patient will progress to end stage renal disease requiring renal replacement therapy. Patients with CKD are generally managed by General Practitioners (GPs). OBJECTIVES: The aim of the study was to evaluate the perspectives of German GPs on management of patients with non-dialysis CKD. METHODS: There were 5 focus group discussions with a maximum of 5 GPs (n = 22). The material was recorded and transcribed to be analyzed by content analysis. RESULTS: The most important treatment measures at the CKD were the optimization of causative diseases, medication adjustment and referral for nephrologist consultation. GPs stressed the individual management of their CKD patients. CONCLUSION: GPs reported that their decisions about CKD management were based on Individual patient factors such as high age or multimorbidity.

The Management of Non-Dialysis-Dependent Chronic Kidney Disease in Primary Care.

BACKGROUND: Approximately 10% of adults in Germany have chronic kidney disease (CKD). The prevalence of CKD among patients being cared for by general practitioners is approximately 30%, and its prevalence in nursing homes is over 50%. An S3 guideline has been developed for the management of CKD in primary care. METHODS: The guideline is based on publications retrieved by a systematic search of the literature for international guidelines published in the period 2013-2017, and additional searches on specific questions. It was created by the German College of General Practitioners and Family Physicians (Deutsche Gesellschaft für Allgemeinmedizin und Familienmedizin, DEGAM) and consented with the German Societies of Nephrology and Internal Medicine (DGfN, DGIM) and patient representation. RESULTS: Upon the initial diagnosis of CKD (glomerular filtration rate [GFR] <60 mL/ min), the patient's blood pressure and urinary albumin-to-creatinine ratio (ACR) should be measured, and the urine should be examined for hematuria. Monitoring intervals are determined on an individual basis depending on the stage of disease and the patient's general state of health and personal preferences. Nephrological consultation should be obtained if the GFR is less than 30 mL/min, if CKD is initially diagnosed (GFR 30-59 mL/min) in the presence of persistent hematuria without any urological explanation or of albinuria in stage A2 or higher, if the patient has refractory hypertension requiring three or more antihypertensive drugs, or if the renal disease is rapidly progressive. The threshold for referring a patient should be kept low for persons under age 50; persons over age 70 should be referred only if warranted in consideration of their comorbidities and individual health goals. CONCLUSION: The main elements of the treatment of CKD are the treatment of hypertension and diabetes and the modification of lifestyle factors. An innovation from the primary care practioner's perspective is the assessment of albuminuria with the albumin-to-creatinine ratio.

Fairness and objectivity of a multiple scenario objective structured clinical examination.

Introduction: The aim of the Objective Structured Clinical Examination (OSCE) is a standardized and fair assessment of clinical skills. Observing second clinical year medical students during a summative OSCE assessing a General Practice clerkship, we noticed that information exchange with peers led to a progressively faster and overly focused management of simulations. Therefore, we established a Multiple Scenario-OSCE (MS-OSCE) where all students had to manage the same chief complaint at a station but it's underlying scenarios being randomly changed during students' rotation through their parcours. We wanted to ensure they fully explore differential diagnosis instead of managing their task influenced by shared information. We wanted to assess if a MS-OSCE violates the assumption of objectivity and fairness given that students are not tested with the same scenarios. Methods: We developed and piloted five OSCE stations (chest pain, abdominal pain, back pain, fatigue and acute cough) with two or three different underlying scenarios each. At each station these scenarios randomly changed from student to student. Performance was assessed with a checklist and global rating. The effect of scenarios and raters on students' grades was assessed calculating the intraclass correlation coefficient with a fixed effect two level linear model. Results: A total of 169 students and 23 raters participated in the MS-OSCE. The internal consistency over all stations was 0.65 by Cronbach's alpha. The difference of the mean grades between the scenarios of a given chief complaint ranged from 0.03 to 0.4 on a 1 to 5 grading scale. The effect of scenarios on the variance of the final grades at each station ranged from 4% to 9% and of raters from 20% to 50% when adjusted for students' skills. Conclusions: The effect of different scenarios on the grades was relevant but small compared to the effect of raters on grades. Improving rater training is more important to ensure objectivity and fairness of MS-OSCE than providing the same scenario to all students.

Nephrologists' perspectives on ambulatory care of patients with non-dialysis chronic kidney disease - A qualitative study.

Little is known on the perspectives of nephrologists on managing non-dialysis patients with chronic kidney disease (CKD). The purpose of this qualitative study was to explore the experiences and perspectives of nephrologists regarding the interface with general practitioners (GP) and GPs' management of patients with non-dialysis CKD, so that barriers to cooperation and need for improved management can be identified. Twenty semi-structured interviews were conducted for this qualitative study. The interviews were audio-recorded and coded to be analysed. The concept of knowledge systems served as a sensitising concept. Optimising underlying diseases, medication adaptation and patient awareness of CKD were regarded as the most important treatment measures in CKD management. Differing views exist on who should be responsible for lifestyle interventions, patient education and timing of referral. Nephrologists generally preferred the referral of patients with high progression risk and co-treatment models in which daily care was performed by GP, but some preferred referral of all patients with early CKD and some nephrologists stated that patient care should be in the hands of nephrologists entirely in case of CKD. Doctor-patient communication predominantly remained within the medical-scientific knowledge system whereas patients' everyday knowledge systems were rarely considered. While stressing optimisation of laboratory values, diabetes and hypertension, patients' perspectives and shared decision-making to identify and prioritise patients' individual health goals were rarely considered by nephrologists. Instead, most nephrologists regarded educating patients and GPs as an important part of their professional role. Defining the interface between GPs and nephrologists, with specific recommendations on when to refer and which tasks each professional group should perform can lead to standardisation and improved interdisciplinary management of CKD patients. Addressing patients' everyday knowledge systems can be valuable in formulating and prioritising health goals with patients.

Diagnosis and management of non-dialysis chronic kidney disease in ambulatory care: a systematic review of clinical practice guidelines.

BACKGROUND: Chronic kidney disease (CKD) is age-dependent and has a high prevalence in the general population. Most patients are managed in ambulatory care. This systematic review provides an updated overview of quality and content of international clinical practice guidelines for diagnosis and management of non-dialysis CKD relevant to patients in ambulatory care. METHODS: We identified guidelines published from 2012-to March 2018 in guideline portals, databases and by manual search. Methodological quality was assessed with the Appraisal of Guidelines for Research and Evaluation II instrument. Recommendations were extracted and evaluated. RESULTS: Eight hundred fifty-two publications were identified, 9 of which were eligible guidelines. Methodological quality ranged from 34 to 77%, with domains "scope and purpose" and "clarity of presentation" attaining highest and "applicability" lowest scores. Guidelines were similar in recommendations on CKD definition, screening of patients with diabetes and hypertension, blood pressure targets and referral of patients with progressive or stage G4 CKD. Definition of high risk groups and recommended tests in newly diagnosed CKD varied. CONCLUSIONS: Guidelines quality ranged from moderate to high. Guidelines generally agreed on management of patients with high risk or advanced CKD, but varied in regarding the range of recommended measurements, the need for referrals to nephrology, monitoring intervals and comprehensiveness. More research is needed on efficient management of patients with low risk of CKD progression to end stage renal disease.

[Local Allergic Reaction to Subcutaneous Treatment with Procaine in a Patient with Shoulder Pain - a Case Study]. / Lokale allergische Reaktion nach subkutaner Applikation von Procain bei einem Patienten mit Schulterschmerzen ­ Fallbericht.

HISTORY: A 53-year-old man presented at the general practitioner's office with 2 weeks of existing shoulder pain without radiation. On physical examination, no abnormalities were found, except for left-sided tension of the shoulder muscles. FINDINGS AND DIAGNOSIS: Because of the expected self-limiting nature of the complaints, no further tests were conducted. Based on shoulder pain with local muscle tension, the working diagnosis cervicobrachialgia was adopted. THERAPY AND COURSE: The pain was treated with local subcutaneous administration of procaine. 4 days later, the patient presented with distinct patches of urticaria at the injection sites, which regressed spontaneously over the course of 2 weeks. DISCUSSION: Allergic reactions occuring after treatment with procaine are rare, but can be life-threatening if systemic or afflicting vital structures.Patients should be informed about the importance of the allergy in relation to medical procedures, such as dental treatment, and about cross-reactivity with other medication.

[Drug Prescribing for Patients with Chronic Kidney Disease in General Practice: a Cross-Sectional Study]. / Arzneimittelverordnung bei Patienten mit chronischer Niereninsuffizienz in der hausärztlichen Versorgung.

BACKGROUND: Many drugs require dose adjustment or are contraindicated in patients with chronic kidney disease (CKD) to avoid adverse events. The aims of this study were to assess if medication was appropriately dose adjusted in patients with CKD in primary care, to identify medications that were frequently prescribed inappropriately and to identify factors predicting mal-prescription. METHODS: We conducted a cross-sectional observational study in 34 general practioners' offices, assessing the medication of patients with CKD stage ≥ 3 according to the corresponding pharmaceutical product information. Additional information was extracted from recommendations of scientific societies and regulatory authorities. Contraindicated and overdosed medications were identified. Predictive factors for inadequate prescribing were analyzed with multiple logistic regression. RESULTS: 589 patients (Ø 78 years, 63 % female) with CKD stage ≥ 3 were included. A total of 5102 medications were extracted from the medication sheets (94,6 % regular, 5,4 % "as needed"). 4,2 % were judged as being inadequate according to pharmaceutical information (2,1 % contraindicated, 2,1 % overdosed). 173 patients (29 %) had ≥ 1 inadequate prescription. The proportion of inadequate prescriptions fell to 3,5 % after adjustment for the most recent recommendations of scientific societies and regulatory authorities. Most frequent inappropriate prescriptions were ACE-inhibitors, diuretics, oral antidiabetic drugs, methotrexate and potassium supplements. Most important predictors for inadequate prescriptions were CKD stage ≥ 3b and number of medications. CONCLUSION: A quarter of all patients had a least one inadequate prescription. The overall proportion of inadequately prescribed drugs was low. Adjustment for recommendations by scientific societies and regulatory authorities further reduced the number of inadequate prescriptions. Valid data on the clinical relevance of inadequate prescriptions is scarce and further research is required. Because of the time and effort needed to assess all medications, future quality improvement projects should focus on CKD stage ≥ 3b, patients with polypharmacy and crucial medication.

Seminar program for postgraduate specialty training in general practice: proposal for a 5-year thematic catalogue.

Introduction: In different German regions, seminar programs have been conducted for General practice residents. In each region, selection and teaching of learning content is conducted in a different manner. So far, no structured, standardized curriculum has been implemented nationwide. We have investigated, if the development of a common 5-year program of learning topics is conceivable between the different university departments of General practice in Germany. Method: The seminar program working group of the DEGAM (German College of General Practitioners and Family Physicians) has conducted an online survey based on information gathered via preliminary telephone conference (n=7; physicians with postgraduate teaching experience) among all German university departments of General Practice and two non-university teaching institutions, identified via the internet. 884 topics were extracted from 14 Seminar programs. The topics were entered in a database, discussed and categorized: Practice management/practice work flow/standardized documentation forms/quality management (n=33 topics), common acute and chronic diseases, including disease management programs (n=29 topics), communication, neurological, psychological and psychiatric consultations (n=24 topics), common medical problems, including eye, ear, nose, throat, skin and pediatric problems (n=99 Topics) family physicians general approach, including epidemiology, shared decision making, test of time (n=42 Topics). These topics have been rated for priority and desirable number of teaching-units. Results: A catalogue of 111 topics was designed, encompassing 160 teaching units. There is a suggestion of wide topics collections plus an add-on catalogue. Conclusion: A proposal for a 5-year-thematic catalogue for postgraduate training of general practice residents in Germany has been developed. This newly developed curriculum has the potential to improve knowledge and skills that have not been covered during in-house and ambulatory general practice residencies.

Efficacy of AMC/DCBA lozenges for sore throat: A systematic review and meta-analysis.

BACKGROUND: Lozenges containing Amylmetacresol and 2,4-Dichlorobenzylalcohol (AMC/DCBA, eg Strepsils® ) are marketed as a remedy for acute sore throat. This over-the-counter formulation has antiseptic and local anaesthetic qualities. OBJECTIVES: The objective of this systematic review and meta-analysis is to evaluate the efficacy and safety of AMC/DCBA for the relief of pain associated with acute uncomplicated sore throat. METHODS: A systematic review of Literature was conducted using databases Medline, Embase and Cochrane to identify randomised controlled trials comparing AMC/DCBA against placebo or alternative local treatment options for acute uncomplicated sore throat. An additional hand search was performed. Two reviewers independently assessed citations for relevance, inclusion criteria and risk of bias. Meta-analysis was performed on included trials and standardised mean differences (SMD; dCohen ) with 95% confidence intervals (CIs) were calculated. RESULTS: The literature search yielded 77 citations, 3 of which met the inclusion criteria. AMC/DCBA lozenges (0.6 mg Amylmetacresol, 1.2 mg 2, 4-Dichlorobenzylalcohol) were compared with unflavoured, non-medicated lozenges. The AMC/DCBA formulation additionally contained lidocaine in one and flavouring additives in another trial. A total of 660 adults participated in the included trials. Primary outcome was reduction in pain intensity against baseline, 2 hours after intervention compared with placebo group. Fixed effects meta-analysis resulted in a standardised mean difference in pain intensity of -0.6 (-0.75; -0.45) on an 11-point ordinal rating scale, favouring the AMC/DCBA lozenges. Secondary outcomes were sore throat relief, difficulty swallowing and throat numbness. No serious side effects were reported, whereas mild side effects like headache, cough, nasal congestion and irritation of the oral cavity, were reported in up to 16% of subjects in both groups. All included trials were sponsored by a manufacturer of AMC/DCBA containing lozenges. CONCLUSIONS: Lozenges with AMC/DCBA can be a safe treatment option to relieve pain in patients with uncomplicated sore throat looking for local treatment options and valuing the modest additional effect compared with non-medicated lozenges. Registration: PROSPERO CRD42015008826.

[Management of Patients with CKD in Clinical Practice]. / Chronische Nierenerkrankungen ­ was der Praktiker wissen sollte.

Chronic kidney disease (CKD) affects between 3 and 17 % of the population in Europe, especially elderly persons. CKD is a clinical syndrome which may develop in patients with e. g. diabetes mellitus, arterial hypertension or autoimmune diseases. A poorer renal function - especially in old age - is to be considered irrespective of the medication. Many antibiotics and painkillers require dose adjustments. Therapy should be done in a manner which is suitable for indication. Polypharmacy should be avoided as far as possible. Diuretics and RAAS inhibitors are useful drugs in therapy of CKD. Changes of lifestyle are important, so as weight reduction, restriction of salt and fructose, sufficient drinking, strict control of blood glucose, blood pressure and hypercholesterolaemia. Additional acute lesions have to be avoided ("acute-on-chronic renal failure").