Evaluation of practice nurses' management of paediatric psychosocial problems in general practice.

BACKGROUND: Child mental health services are under major pressure worldwide. In the Netherlands, Youth Mental Health Practice Nurses (YMHPNs) have been introduced in general practice to improve access to care. In this study, we evaluated care delivered by YMHPNs. METHODS: We used medical records of a population-based cohort (21 717 children, 0-17 years). Characteristics of children consulting a YMHPN, type of problem, care delivered by YMHPNs and referrals were assessed using quantitative content analysis. RESULTS: Records of 375 children (mean age 12.9 years, 59.2% girl) were analysed. These children were often in their adolescence (57.3% was between 13 and 17 years), and more often female than male (59.2% vs 40.8%). YMHPNs had a median of four consultations (IQR 2-7) with the child. YMHPNs managed a variety of psychosocial problems. YMHPNs managed 22.4% of children without need of referral, 52.0% were eventually referred for additional care. 13.3% of children dropped out during the treatment trajectory. In the remaining 12.3% of children, the treatment trajectory was stopped because the child was already attending specialized services, the treatment trajectory was still ongoing or the medical record was inconclusive. CONCLUSIONS: YMHPNs successfully managed one in four children with psychosocial problems without need for referral. Nevertheless, most children were eventually referred for additional care.

Patellofemoral pain in general practice: the incidence and management.

BACKGROUND: Patellofemoral pain (PFP) is a nontraumatic knee problem primarily observed in physically active adolescents. The objective of this study was to determine the incidence and management of PFP in children and adolescents in general practice. METHODS: A retrospective cohort study was conducted using a regional primary care database containing full electronic health records of over 300,000 patients. Patients with a new PFP diagnosis between the years 2013 and 2019 were extracted using a search algorithm based on International Classification of Primary Health Care coding and search terms in free text. Data on the management of PFP were manually checked and analysed. In addition, a sub-analysis for chronic and nonchronic PFP patients was performed. RESULTS: The mean incidence of PFP over the study period was 3.4 (95% CI 3.2-3.6) per 1,000 person years in the age group of 7-24 years. Girls had a higher incidence rate (4.6 [95% CI 4.3-5.0]) compared to boys (2.3 [95% CI 2.1-2.5]). Peak incidence was at age 13 years for both sexes. The most commonly applied management strategy was advice (55.1%), followed by referral to physiotherapy (28.2%), analgesics prescription (10.4%), and referral to the orthopaedic surgeon (8.9%). No differences were found in age, sex, and treatment between chronic and nonchronic PFP patients. CONCLUSIONS: The average Dutch general practitioner sees approximately 1.4 new child or adolescent with PFP per year. Overall management strategies were in concordance with current Dutch general practice guideline on nontraumatic knee problems. More insight should be gained in the population with chronic complaints.

Epidemiology and management of hepatitis B and C in primary care in the Netherlands: data from the Rijnmond Primary Care database.

BACKGROUND: The Dutch guideline for general practitioners (GPs) advises biannual surveillance of hepatitis B (HBV) patients and referral of every hepatitis C (HCV) patient. We aimed to study the prevalence, incidence, and the management of hepatitis B and C in primary care. METHODS: This is a retrospective cohort study using the Rijnmond Primary Care database (RPCD), including health care data of medical records of GPs of approximately 200,000 patients in the area of Rotterdam, the Netherlands. Patient records were selected based on laboratory results, International Classification of Primary Care (ICPC) codes, and free-text words. RESULTS: In total, 977 patients were included: 717 HBV, 252 HCV, and 8 HBV/HCV coinfected patients. Between 2013 and 2019, the prevalence of HBV and HCV declined from 5.21 to 2.99/1,000 person-years (PYs) and 1.50 to 0.70/1,000 PYs, respectively. We observed that the majority of the patients had been referred to a medical specialist at least once (71% HBV and 89% HCV patients). However, among chronic patients, we observed that 36.2% of the HBV patients did not receive adequate surveillance by their GP (≥2 alanine aminotransferase checks within 3 years) or a medical specialist. In addition, 44.4% of the HCV patients had no record about successful antiviral treatment. CONCLUSIONS: This study demonstrated a declining prevalence in viral hepatitis B and C in primary care in the Netherlands. However, a substantial part of the patients did not receive adequate surveillance or antiviral therapy. It is therefore crucial to involve GPs in case finding and in follow-up after treatment.

Patient perspectives on telemedicine during the COVID-19 pandemic: a mixed-methods community-based study.

BACKGROUND: Detailed community-based perspectives on patient experiences with telemedicine are currently lacking, yet essential to assess clinical applicability of telemedicine during and beyond pandemics, alike COVID-19. The aim of this study was to expose patient perspectives on virtual compared to in-person consultations, including determinants of these preferences. METHODS: We invited 5864 participants of the population-based Rotterdam Study to fill in a validated questionnaire using both close-ended and free-text questions. The questionnaire was sent on 30 July 2020, following a period of lockdowns and closures of non-essential workplaces. It assessed preferences for physician contact, healthcare utilisation, socioeconomic factors, and overall health. Those who experienced at least one virtual consultation (telephone or video call) between March 2020 and the beginning of July 2020 were asked whether those consultations were more, equally or less pleasant than in-person consultations, and to detail their experiences through free-text comments. These narrative data were examined using thematic analysis. RESULTS: 4514 participants completed the questionnaire (response rate 77.0%, 58.7% women, mean age 70.8 ± 10.5 years). 1103 participants (24.4%) reported having had experience with virtual consultations. Half of these participants considered virtual consultations less pleasant than in-person consultations (N = 556; 50.4%), while 11.5% found it more pleasant. In total, we coded free-text comments of 752 participants. Prominent themes behind patient preferences for virtual or in-person consultations were lack of nonverbal communication, lack of physical examination, consultation scheduling, personal circumstances, and the presence of somatic and/or language barriers. CONCLUSIONS: Based on the experiences of a large elderly patient population, we showed that preference for virtual or in-person consultations is dependent on personal and situational variety, and their interplay. Healthcare providers should consider patients' complex care needs and evaluate the potential added value of nonverbal communication and physical examination before scheduling a virtual consultation.

Sex-specific patterns and lifetime risk of multimorbidity in the general population: a 23-year prospective cohort study.

BACKGROUND: Multimorbidity poses a major challenge for care coordination. However, data on what non-communicable diseases lead to multimorbidity, and whether the lifetime risk differs between men and women are lacking. We determined sex-specific differences in multimorbidity patterns and estimated sex-specific lifetime risk of multimorbidity in the general population. METHODS: We followed 6,094 participants from the Rotterdam Study aged 45 years and older for the occurrence of ten diseases (cancer, coronary heart disease, stroke, chronic obstructive pulmonary disease, depression, diabetes, dementia, asthma, heart failure, parkinsonism). We visualised participants' trajectories from a single disease to multimorbidity and the most frequent combinations of diseases. We calculated sex-specific lifetime risk of multimorbidity, considering multimorbidity involving only somatic diseases (1) affecting the same organ system, (2) affecting different organ systems, and (3) multimorbidity involving depression. RESULTS: Over the follow-up period (1993-2016, median years of follow-up 9.2), we observed 6334 disease events. Of the study population, 10.3% had three or more diseases, and 27.9% had two or more diseases. The most frequent pair of co-occurring diseases among men was COPD and cancer (12.5% of participants with multimorbidity), the most frequent pair of diseases among women was depression and dementia (14.9%). The lifetime risk of multimorbidity was similar among men (66.0%, 95% CI: 63.2-68.8%) and women (65.1%, 95% CI: 62.5-67.7%), yet the risk of multimorbidity with depression was higher for women (30.9%, 95% CI: 28.4-33.5%, vs. 17.5%, 95% CI: 15.2-20.1%). The risk of multimorbidity with two diseases affecting the same organ is relatively low for both sexes (4.2% (95% CI: 3.2-5.5%) for men and 4.5% (95% CI: 3.5-5.7%) for women). CONCLUSIONS: Two thirds of people over 45 will develop multimorbidity in their remaining lifetime, with women at nearly double the risk of multimorbidity involving depression than men. These findings call for programmes of integrated care to consider sex-specific differences to ensure men and women are served equally.

The use and safety of corticosteroid injections for shoulder pain in general practice: a retrospective cohort study.

BACKGROUND: Guidelines for shoulder pain in general practice recommend treatment with corticosteroid injections (CSI) if initial pain management fails. However, little is known about the actual use and safety of CSIs in treatment by general practitioners (GP). OBJECTIVE: The objective of this study was to gain insight into the use and safety of CSIs for patients with a new episode of shoulder pain in general practice. METHODS: A retrospective cohort study was conducted using a healthcare database containing the electronic medical records of approximately 200,000 patients in general practice. A search algorithm was constructed to identify patients with a new episode of shoulder pain between January 2012 and December 2017. Data on the use of CSIs in 2 random samples (n = 1,000) were manually validated for a 12-month period after the diagnosis. RESULTS: In total, 26% of the patients with a new episode of shoulder pain received a CSI. The patient's age (OR 1.03, 95% CI 1.02-1.04) and a history of shoulder pain (OR 1.52, 95% CI 1.13-2.12) were significantly associated with the administration of a CSI. Half of the patients received the CSI in the first consultation. The patient's age was positively associated with the likelihood of receiving the CSI in the first consultation (OR 1.01, 95% CI 1.00-1.02). No serious adverse reactions were recorded by the GP. CONCLUSION: In contrast to the guidelines, CSIs were frequently administered in the first consultation. Older patients and patients with a history of shoulder pain were more likely to receive a CSI for shoulder pain.

Prevalence and determinants of healthcare avoidance during the COVID-19 pandemic: A population-based cross-sectional study.

BACKGROUND: During the Coronavirus Disease 2019 (COVID-19) pandemic, the number of consultations and diagnoses in primary care and referrals to specialist care declined substantially compared to prepandemic levels. Beyond deferral of elective non-COVID-19 care by healthcare providers, it is unclear to what extent healthcare avoidance by community-dwelling individuals contributed to this decline in routine healthcare utilisation. Moreover, it is uncertain which specific symptoms were left unheeded by patients and which determinants predispose to healthcare avoidance in the general population. In this cross-sectional study, we assessed prevalence of healthcare avoidance during the pandemic from a patient perspective, including symptoms that were left unheeded, as well as determinants of healthcare avoidance. METHODS AND FINDINGS: On April 20, 2020, a paper COVID-19 survey addressing healthcare utilisation, socioeconomic factors, mental and physical health, medication use, and COVID-19-specific symptoms was sent out to 8,732 participants from the population-based Rotterdam Study (response rate 73%). All questionnaires were returned before July 10, 2020. By hand, prevalence of healthcare avoidance was subsequently verified through free text analysis of medical records of general practitioners. Odds ratios (ORs) for avoidance were determined using logistic regression models, adjusted for age, sex, and history of chronic diseases. We found that 1,142 of 5,656 included participants (20.2%) reported having avoided healthcare. Of those, 414 participants (36.3%) reported symptoms that potentially warranted urgent evaluation, including limb weakness (13.6%), palpitations (10.8%), and chest pain (10.2%). Determinants related to avoidance were older age (adjusted OR 1.14 [95% confidence interval (CI) 1.08 to 1.21]), female sex (1.58 [1.38 to 1.82]), low educational level (primary education versus higher vocational/university 1.21 [1.01 to 1.46), poor self-appreciated health (per level decrease 2.00 [1.80 to 2.22]), unemployment (versus employed 2.29 [1.54 to 3.39]), smoking (1.34 [1.08 to 1.65]), concern about contracting COVID-19 (per level increase 1.28 [1.19 to 1.38]) and symptoms of depression (per point increase 1.13 [1.11 to 1.14]) and anxiety (per point increase 1.16 [1.14 to 1.18]). Study limitations included uncertainty about (perceived) severity of the reported symptoms and potentially limited generalisability given the ethnically homogeneous study population. CONCLUSIONS: In this population-based cross-sectional study, 1 in 5 individuals avoided healthcare during lockdown in the COVID-19 pandemic, often for potentially urgent symptoms. Healthcare avoidance was strongly associated with female sex, fragile self-appreciated health, and high levels of depression and anxiety. These results emphasise the need for targeted public education urging these vulnerable patients to timely seek medical care for their symptoms to mitigate major health consequences.

The incidence and management of shoulder complaints in general practice: a retrospective cohort study.

BACKGROUND: Shoulder pain is the third most common musculoskeletal complaint in primary care. The international guidelines for general practitioners (GPs) recommend a stepwise treatment of shoulder pain. Little is known about the actual distribution of these treatments in current practice. OBJECTIVE: To gain insight in the incidence and current management of shoulder complaints in Dutch general practice. METHODS: A retrospective cohort study was conducted using a health care database containing the full electronic medical records of approximately 200 000 patients in Dutch general practice. A search algorithm was constructed to identify incident cases of shoulder complaints from January 2012 to December 2017. Data on the management of shoulder complaints were manually validated in a random sample of 1000 cases. RESULTS: The overall incidence of shoulder complaints was 30.3 (95% confidence interval 29.9-30.7) per 1000 person-years. More than half of the patients (58.6%) consulted their GP only once, 44.4% two times or more and 19.7% three times or more. For most patients (58.1%), the GP applied a wait-and-see policy or prescription of oral medication in the first consultation. However, no less than 42.9% of the patients were referred or received an injection already in the first consultation. CONCLUSIONS: There is a wide variety of treatments for shoulder complaints applied by the GP. Some patients are referred or received an injection already in the first consultation. The stepwise approach recommended by the guideline, might not always be applicable due to the diversity of patient- and shoulder characteristics presented in general practice.

Prevalence of spinal pathology in patients presenting for lumbar MRI as referred from general practice.

BACKGROUND: The use of magnetic resonance imaging (MRI) as initial imaging for back pain has increased in general practice. However, few data are available on the characteristics of these referred patients. The objective of this study was to describe the baseline characteristics and MRI findings of patients presenting for a lumbar MRI examination as referred by their GP. METHODS: Patients presenting for a lumbar MRI examination as referred by their GP were recruited at the MRI Center. The MRI radiology reports were scored for the presence of disc bulging, disc herniation, nerve root compression, spinal stenosis, spondylolisthesis and serious pathologies. Information on patients' characteristics, characteristics of the complaints and red flags were derived from questionnaires. Cross-sectional differences between patients with and without specific MRI findings were analyzed. RESULTS: A total of 683 low back pain (LBP) patients were included; mean age was 49.9 (range 19-80) years and 53% was male. Mean back pain severity score was 6.6 (SD 2.0) and 67% of the patients reported having chronic LBP. In total, 374 patients (55%) reported sciatica complaints for at least 6 weeks. Of all MRI reports, 69% mentioned signs of nerve root compression. Serious pathologies were reported in 3% of the patients. In total, 94% of patients had abnormal MRI findings. CONCLUSIONS: Almost all patients presenting for a lumbar MRI examination as referred by their GP had abnormal MRI findings. In total, 55% of the patients reported persistent sciatica in which imaging is recommended according to international guidelines.

The added prognostic value of MRI findings for recovery in patients with low back pain in primary care: a 1-year follow-up cohort study.

PURPOSE: Information on the prognostic value of MRI findings in low back pain patients in primary care is lacking. The objective of this study is to investigate the added prognostic value of baseline MRI findings over known prognostic factors for recovery at 12-month follow-up in patients with low back pain referred to MRI by their general practitioner. METHODS: Patients referred by their general practitioner for MRI of the lumbar spine were recruited at the MRI Center. The questionnaires at baseline and at 3 and 12-months follow-up included potential clinical predictors from history taking and the outcome recovery. The MRI radiology reports were scored. Analysis was performed in 3 steps: derivation of a predictive model including characteristics of the patients and back pain only (history taking), including reported MRI findings only, and the addition of reported MRI findings to the characteristics of the patients and back pain. RESULTS: At 12-months follow-up 53% of the patients reported recovery (n = 683). Lower age, better attitude/beliefs regarding back pain, acute back pain, presence of neurological symptoms of the leg(s), and presence of non-continuous back pain were significantly associated with recovery at 12-months follow-up: area under the curve (AUC) 0.77. Addition of the MRI findings resulted in an AUC of 0.78. CONCLUSIONS: At 12-months follow-up, only 53% of these patients with low back pain referred for MRI in general practice reported recovery. Five clinic baseline characteristics were associated with recovery at 12-months follow-up; adding the MRI findings did not result in a stronger prediction of recovery.

Children and young people's consultation rates for psychosocial problems between 2016 and 2021 in the Netherlands.

BACKGROUND: Worldwide, there are concerns about declining mental health of children and young people (CYP). OBJECTIVES: To examine trends in GP consultation rates for psychosocial problems and the impact of the COVID-19 pandemic. METHODS: We performed a population-based cohort study using electronic GP records of CYP (0-24 years) living in the Rotterdam metropolitan area between 2016 and 2021. We calculated monthly consultation rates for psychosocial problems, stratified by age group and sex. We used negative binomial models to model the pre-COVID-19 trend, and estimate expected rates post-COVID-19 onset. We modelled the effect of COVID-19 infection rate and school closure on consultation rates per sex and age group. RESULTS: The cohort increased from 64801 to 92093 CYP between January 2016 and December 2021. Median age was 12.5 years and 49.3% was female. Monthly consultation rates increased from 2,443 to 4,542 consultations per 100,000 patient months over the six years. This trend (RR 1.009, 95%CI 1.008-1.011) started well before the COVID-19 pandemic. Consultation rates of adolescent girls and young women increased most strongly. Between March and May 2020, there was a temporary reduction in consultation rates, whereupon these returned to expected levels. COVID-19 infection rate and school closures showed small but significant associations with consultation rates for psychosocial problems but this did not affect the overall trend. Although consultation rates for psychosocial problems increased, this increment was stable over the entire study period. CONCLUSION: The COVID-19 pandemic did not significantly increase consultation rates for psychosocial problems in CYP. The consultation rates increased, especially in adolescent girls and young women.

CYP' consultation rates for psychosocial problems within general practice almost doubled between 2016 and 2021 in the Rotterdam metropolitan area, the Netherlands.This increase was steady over time and was not affected by the COVID-19 pandemic.Consultation rates in general practice for psychosocial problems increased most strongly in adolescent girls and young women.

The prevalence, incidence and management of low back pain with radiating leg pain in Dutch general practice: A population-based cohort study in the Rijnmond Primary Care Database.

BACKGROUND: Radiating leg pain is common in patients with low back pain (LBP). In this study, we aimed to determine the prevalence and incidence of LBP with radiating leg pain in Dutch general practice, and to describe the prescribed medications and requested imaging diagnostics. METHODS: The Rijnmond Primary Care Database containing over 500,000 primary care patients was used to select patients ≥18 years with LBP with radiating leg pain between 2013 and 2021. Data on patient characteristics, LBP episodes, prescribed medication and requested imaging in the first 3 months of an episode was extracted. Descriptive statistics were used to present patient characteristics and diagnostic/therapeutic interventions. RESULTS: A total of 27,695 patients were included. The total number of LBP with radiating leg pain episodes in these patients was 36,268. In 2021, the incidence and prevalence were 19.1 and 25.7 per 1000 patient years, respectively. In 60% of patients, the episode duration was shorter than 1 month. In 62% of the episodes, patients visited the general practitioner (GP) one to two times. In 59% of the episodes, at least one medication was prescribed, non-steroidal anti-inflammatory drugs (NSAIDs) being the most common one (45%). In approximately 11% of the episodes, additional diagnostic imaging was requested. CONCLUSION: LBP with radiating leg pain is common in Dutch general practice patients. About 2/3rd were prescribed pain medications. Dutch request few to none diagnostic imaging for these patients which is in line with clinical practice guidelines. SIGNIFICANCE: In this new study, we have gained insights into the incidence and prevalence of LBP with radiating leg pain in Dutch general practice. Both remained fairly stable over the study period of 9 years (2013-2021). Overall, the care burden regarding seeking contact with the GPs and the requested diagnostics seem not to be that high. In 62% of the care episodes, there were one or two consultations with the GP, and in 11% of the episodes a diagnostic imaging was requested. Pain medications frequently prescribed (i.e. 2/3rd of the episodes), with NSAIDs being the most common ones.

Blood pressure measurements for diagnosing hypertension in primary care: room for improvement.

BACKGROUND: In the adult population, about 50% have hypertension, a risk factor for cardiovascular disease and subsequent premature death. Little is known about the quality of the methods used to diagnose hypertension in primary care. OBJECTIVES: The objective was to assess the frequency of use of recognized methods to establish a diagnosis of hypertension, and specifically for OBPM, whether three distinct measurements were taken, and how correctly the blood pressure levels were interpreted. METHODS: A retrospective population-based cohort study using electronic medical records of patients aged between 40 and 70 years, who visited their general practitioner (GP) with a new-onset of hypertension in the years 2012, 2016, 2019, and 2020. A visual chart review of the electronic medical records was used to assess the methods employed to diagnose hypertension in a random sample of 500 patients. The blood pressure measurement method was considered complete if three or more valid office blood pressure measurements (OBPM) were performed, or home-based blood pressure measurements (HBPM), the office- based 30-minute method (OBP30), or 24-hour ambulatory blood pressure measurements (24 H-ABPM) were used. RESULTS: In all study years, OBPM was the most frequently used method to diagnose new-onset hypertension in patients. The OBP-30 method was used in 0.4% (2012), 4.2% (2016), 10.6% (2019), and 9.8% (2020) of patients respectively, 24 H-ABPM in 16.0%, 22.2%, 17.2%, and 19.0% of patients and HBPM measurements in 5.4%, 8.4%, 7.6%, and 7.8% of patients, respectively. A diagnosis of hypertension based on only one or two office measurements occurred in 85.2% (2012), 87.9% (2016), 94.4% (2019), and 96.8% (2020) of all patients with OBPM. In cases of incomplete measurement and incorrect interpretation, medication was still started in 64% of cases in 2012, 56% (2016), 60% (2019), and 73% (2020). CONCLUSION: OBPM is still the most often used method to diagnose hypertension in primary care. The diagnosis was often incomplete or misinterpreted using incorrect cut-off levels. A small improvement occurred between 2012 and 2016 but no further progress was seen in 2019 or 2020. If hypertension is inappropriately diagnosed, it may result in under treatment or in prolonged, unnecessary treatment of patients. There is room for improvement in the general practice setting.

Disk degeneration of the upper lumbar disks is associated with hip pain.

PURPOSE: A possible cause of hip pain is the presence of radiating pain from the higher lumbar spine. Identification of factors associated with hip pain arising from the lumbar spine would aid the physician. The first step in identifying possible factors is to look at the association between hip pain and osteoarthritis of the lumbar spine. METHODS: In an open population based study of people 55 years and older (Rotterdam study), 2,819 lumbar radiographs were scored for the presence and severity of individual radiographic features of disk degeneration. Hip osteoarthritis was scored on anteroposterior pelvic radiographs, and questionnaires including self-reported hip pain were taken. Logistic regression adjusted for possible confounders was used to determine the association between self-reported hip pain and the individual radiographic features of lumbar disk degeneration. RESULTS: The presence of dis space narrowing grade ≥1 at level L1/L2 was significantly associated with hip pain in the last month (men OR = 2.0; 95 % CI 1.1-3.8 and women OR = 1.7; 95 % CI 1.1-2.5). The presence of disk space narrowing grade ≥1 at level L2/L3 was only significantly associated with hip pain in women. The strength of the associations increased for self-reported chronic hip pain, especially in men (L1/L2 OR = 2.5; 95 % CI 1.3-5.0). The presence of disk space narrowing at the lower levels (L3/L4/L5/S1) was not significantly associated with hip pain. CONCLUSION: Our data provide evidence for an association between hip pain and disk space narrowing at disk level L1/L2 and L2/L3. In case of uncertainty of the cause of hip pain, evaluation of lumbar radiographs may help to identify those hip pain patients who might have pain arising from the lumbar spine.

Comorbidity in incident osteoarthritis cases and matched controls using electronic health record data.

BACKGROUND: Comorbidities are common in patients with osteoarthritis (OA). This study aimed to determine the association of a wide range of previously diagnosed comorbidities in adults with newly diagnosed OA compared with matched controls without OA. METHODS: A case-control study was conducted. The data were derived from an electronic health record database that contains the medical records of patients from general practices throughout the Netherlands. Incident OA cases were defined as patients with one or more diagnostic codes recorded in their medical records that correspond to knee, hip, or other/peripheral OA. Additionally, the first OA code had to be recorded between January 1, 2006, and December 31, 2019. The date of cases' first OA diagnosis was defined as the index date. Cases were matched (by age, sex, and general practice) to up to 4 controls without a recorded OA diagnosis. Odds ratios were derived for each 58 comorbidities separately by dividing the comorbidity prevalence of cases by that of their matched controls at the index date. RESULTS: 80,099 incident OA patients were identified of whom 79,937 (99.8%) were successfully matched with 318,206 controls. OA cases had higher odds for 42 of the 58 studied comorbidities compared with matched controls. Musculoskeletal diseases and obesity showed large associations with incident OA. CONCLUSIONS: Most of the comorbidities under study had higher odds in patients with incident OA at the index date. While previously known associations were confirmed in this study, some associations were not described earlier.

Normalisation of SARS-CoV-2 concentrations in wastewater: The use of flow, electrical conductivity and crAssphage.

Over the course of the Corona Virus Disease-19 (COVID-19) pandemic in 2020-2022, monitoring of the severe acute respiratory syndrome coronavirus 2 ribonucleic acid (SARS-CoV-2 RNA) in wastewater has rapidly evolved into a supplementary surveillance instrument for public health. Short term trends (2 weeks) are used as a basis for policy and decision making on measures for dealing with the pandemic. Normalisation is required to account for the dilution rate of the domestic wastewater that can strongly vary due to time- and location-dependent sewer inflow of runoff, industrial discharges and extraneous waters. The standard approach in sewage surveillance is normalisation using flow measurements, although flow based normalisation is not effective in case the wastewater volume sampled does not match the wastewater volume produced. In this paper, two alternative normalisation methods, using electrical conductivity and crAssphage have been studied and compared with the standard approach using flow measurements. For this, a total of 1116 24-h flow-proportional samples have been collected between September 2020 and August 2021 at nine monitoring locations. In addition, 221 stool samples have been analysed to determine the daily crAssphage load per person. Results show that, although crAssphage shedding rates per person vary greatly, on a population-level crAssphage loads per person per day were constant over time and similar for all catchments. Consequently, crAssphage can be used as a quantitative biomarker for populations above 5595 persons. Electrical conductivity is particularly suitable to determine dilution rates relative to dry weather flow concentrations. The overall conclusion is that flow normalisation is necessary to reliably determine short-term trends in virus circulation, and can be enhanced using crAssphage and/or electrical conductivity measurement as a quality check.

Capturing the SARS-CoV-2 infection pyramid within the municipality of Rotterdam using longitudinal sewage surveillance.

Despite high vaccination rates in the Netherlands, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continues to circulate. Longitudinal sewage surveillance was implemented along with the notification of cases as two parts of the surveillance pyramid to validate the use of sewage for surveillance, as an early warning tool, and to measure the effect of interventions. Sewage samples were collected from nine neighborhoods between September 2020 and November 2021. Comparative analysis and modeling were performed to understand the correlation between wastewater and case trends. Using high resolution sampling, normalization of wastewater SARS-CoV-2 concentrations, and 'normalization' of reported positive tests for testing delay and intensity, the incidence of reported positive tests could be modeled based on sewage data, and trends in both surveillance systems coincided. The high collinearity implied that high levels of viral shedding around the onset of disease largely determined SARS-CoV-2 levels in wastewater, and that the observed relationship was independent of variants of concern and vaccination levels. Sewage surveillance alongside a large-scale testing effort where 58 % of a municipality was tested, indicated a five-fold difference in the number of SARS-CoV-2-positive individuals and reported cases through standard testing. Where trends in reported positive cases were biased due to testing delay and testing behavior, wastewater surveillance can objectively display SARS-CoV-2 dynamics for both small and large locations and is sensitive enough to measure small variations in the number of infected individuals within or between neighborhoods. With the transition to a post-acute phase of the pandemic, sewage surveillance can help to keep track of re-emergence, but continued validation studies are needed to assess the predictive value of sewage surveillance with new variants. Our findings and model aid in interpreting SARS-CoV-2 surveillance data for public health decision-making and show its potential as one of the pillars of future surveillance of (re)emerging viruses.

Rise and fall of SARS-CoV-2 variants in Rotterdam: Comparison of wastewater and clinical surveillance.

Monitoring of SARS-CoV-2 in wastewater (WW) is a promising tool for epidemiological surveillance, correlating not only viral RNA levels with the infection dynamics within the population, but also to viral diversity. However, the complex mixture of viral lineages in WW samples makes tracking of specific variants or lineages circulating in the population a challenging task. We sequenced sewage samples of 9 WW-catchment areas within the city of Rotterdam, used specific signature mutations from individual SARS-CoV-2 lineages to estimate their relative abundances in WW and compared them against those observed in clinical genomic surveillance of infected individuals between September 2020 and December 2021. We showed that especially for dominant lineages, the median of the frequencies of signature mutations coincides with the occurrence of those lineages in Rotterdam's clinical genomic surveillance. This, along with digital droplet RT-PCR targeting signature mutations of specific variants of concern (VOCs), showed that several VOCs emerged, became dominant and were replaced by the next VOC in Rotterdam at different time points during the study. In addition, single nucleotide variant (SNV) analysis provided evidence that spatio-temporal clusters can also be discerned from WW samples. We were able to detect specific SNVs in sewage, including one resulting in the Q183H amino acid change in the Spike gene, that was not captured by clinical genomic surveillance. Our results highlight the potential use of WW samples for genomic surveillance, increasing the set of epidemiological tools to monitor SARS-CoV-2 diversity.

GPs' and practice nurses' views on their management of paediatric anxiety problems: an interview study.

BACKGROUND: Anxiety problems are common in both children and adolescents, and many affected children do not receive appropriate treatment. Understaffing of mental healthcare services and long waiting lists form major barriers. In the Netherlands, practice nurses have been introduced into general practice to support general practitioners (GPs) in the management of psychosocial problems. In this study we investigated the views of GPs and practice nurses on their management of paediatric anxiety problems. METHODS: We performed an exploratory study using semi-structured interviews with 13 GPs and 13 practice nurses in the greater Rotterdam area in 2021. Interviews were transcribed and coded into topics, which were categorized per research question. RESULTS: In their management of paediatric anxiety problems, both GPs and practice nurses try to explore the case and the needs of affected children and their parents. GPs rarely follow up affected children themselves. They often refer the child, preferably to their practice nurse. Practice nurses regularly initiate follow-up consultations with affected children themselves. Practice nurses reported using a variety of therapeutic techniques, including elements of cognitive behavioural therapy. In more severe cases, practice nurses refer the child to external mental healthcare services. GPs reported being satisfied with their collaboration with practice nurses. Both GPs and practice nurses experience significant barriers in the management of paediatric anxiety problems. Most importantly, long waiting lists for external mental health care were reported to be a major difficulty. Improving cooperation with external mental healthcare providers was reported to be an important facilitator. CONCLUSIONS: In their management of paediatric anxiety problems, GPs and practice nurses experience major challenges in the cooperation with external mental healthcare providers and in the long waiting lists for these services. GPs and practice nurses believe that thanks to their shared approach more children with anxiety problems can remain treated in general practice. Future research is needed to evaluate the treatment outcomes of the shared efforts of GPs and practice nurses in their management of paediatric anxiety problems.

Changes in the Diagnosis of Stroke and Cardiovascular Conditions in Primary Care During the First 2 COVID-19 Waves in the Netherlands.

BACKGROUND AND OBJECTIVES: Although there is evidence of disruption in acute cerebrovascular and cardiovascular care during the coronavirus disease 2019 (COVID-19) pandemic, its downstream effect in primary care is less clear. We investigated how the pandemic affected utilization of cerebrovascular and cardiovascular care in general practices (GPs) and determined changes in GP-recorded diagnoses of selected cerebrovascular and cardiovascular outcomes. METHODS: From electronic health records of 166,929 primary care patients aged 30 or over within the Rotterdam region, the Netherlands, we extracted the number of consultations related to cerebrovascular and cardiovascular care, and first diagnoses of selected cerebrovascular and cardiovascular risk factors (hypertension, diabetes, lipid disorders), conditions, and events (angina, atrial fibrillation, TIA, myocardial infarction, stroke). We quantified changes in those outcomes during the first COVID-19 wave (March-May 2020) and thereafter (June-December 2020) by comparing them to the same period in 2016-2019. We also estimated the number of potentially missed diagnoses for each outcome. RESULTS: The number of GP consultations related to cerebrovascular and cardiovascular care declined by 38% (0.62, 95% confidence interval 0.56-0.68) during the first wave, as compared to expected counts based on prepandemic levels. Substantial declines in the number of new diagnoses were observed for cerebrovascular events: 37% for TIA (0.63, 0.41-0.96) and 29% for stroke (0.71, 0.59-0.84), while no significant changes were observed for cardiovascular events (myocardial infarction [0.91, 0.74-1.14], angina [0.77, 0.48-1.25]). The counts across individual diagnoses recovered following June 2020, but the number of GP consultations related to cerebrovascular and cardiovascular care remained lower than expected throughout the June to December period (0.93, 0.88-0.98). DISCUSSION: While new diagnoses of acute cardiovascular events remained stable during the COVID-19 pandemic, diagnoses of cerebrovascular events declined substantially compared to prepandemic levels, possibly due to incorrect perception of risk by patients. These findings emphasize the need to improve symptom recognition of cerebrovascular events among the general public and to encourage urgent presentation despite any physical distancing measures.