Women who smoke during pregnancy are more likely to be referred to an obstetrician during pregnancy and birth: results from a cohort study.

BACKGROUND: Women who smoke during pregnancy make less use of prenatal care; the relation of smoking behavior with the use of other forms of maternal healthcare is unknown. The objective of this study is to investigate the association between women's smoking behavior and their use of healthcare during pregnancy, birth and six weeks postpartum. METHODS: We analyzed data from the Dutch Midwifery Case Registration System (VeCaS), period 2012-2019. We included women with a known smoking status, singleton pregnancies, and who had their first appointment before 24 weeks of gestation with the primary care midwife. We compared three groups: non-smokers, early stoppers (stopped smoking in the first trimester), and late- or non-stoppers (stopped smoking after the first trimester or continued smoking). Descriptive statistics were used to report maternal healthcare utilization (during pregnancy, birth and six weeks postpartum), statistical differences between the groups were calculated with Kruskal-Wallis tests. Multivariable logistic regression was conducted to assess the association between smoking behavior and referrals to primary, secondary or tertiary care. RESULTS: We included 41 088 pregnant women. The groups differed significantly on maternal healthcare utilization. The late- or non-stoppers initiated prenatal care later and had less face-to-face consultations with primary care midwives during pregnancy. Compared to the non-smokers, the early- and late- or non-stoppers were statistically signficiantly more likely to be referred to the obstetrician during pregnancy and birth. Postpartum, the early- and late- or non-stoppers were statistically signficantly less likely to be referred to the obstetrician compared to the non-smokers. CONCLUSIONS: Although the early- and late- or non-stoppers initiated prenatal care later than the non-smokers, they did receive adequate prenatal care (according to the recommendations). The results suggest that not smoking during pregnancy may decrease the likelihood of referral to secondary or tertiary care. The large population of smokers being referred during pregnancy underlines the important role of the collaboration between healthcare professionals in primary and secondary or tertiary care. They need to be more aware of the importance of smoking as a medical and as a non-medical risk factor.

The levonorgestrel intrauterine system versus endometrial ablation for heavy menstrual bleeding: a cost-effectiveness analysis.

OBJECTIVE: To evaluate the costs and non-inferiority of a strategy starting with the levonorgestrel intrauterine system (LNG-IUS) compared with endometrial ablation (EA) in the treatment of heavy menstrual bleeding (HMB). DESIGN: Cost-effectiveness analysis from a societal perspective alongside a multicentre randomised non-inferiority trial. SETTING: General practices and gynaecology departments in the Netherlands. POPULATION: In all, 270 women with HMB, aged ≥34 years old, without intracavitary pathology or wish for a future child. METHODS: Randomisation to a strategy starting with the LNG-IUS (n = 132) or EA (n = 138). The incremental cost-effectiveness ratio was estimated. MAIN OUTCOME MEASURES: Direct medical costs and (in)direct non-medical costs were calculated. The primary outcome was menstrual blood loss after 24 months, measured with the mean Pictorial Blood Assessment Chart (PBAC)-score (non-inferiority margin 25 points). A secondary outcome was successful blood loss reduction (PBAC-score ≤75 points). RESULTS: Total costs per patient were €2,285 in the LNG-IUS strategy and €3,465 in the EA strategy (difference: €1,180). At 24 months, mean PBAC-scores were 64.8 in the LNG-IUS group (n = 115) and 14.2 in the EA group (n = 132); difference 50.5 points (95% CI 4.3-96.7). In the LNG-IUS group, 87% of women had a PBAC-score ≤75 points versus 94% in the EA group (relative risk [RR] 0.93, 95% CI 0.85-1.01). The ICER was €23 (95% CI €5-111) per PBAC-point. CONCLUSIONS: A strategy starting with the LNG-IUS was cheaper than starting with EA, but non-inferiority could not be demonstrated. The LNG-IUS is reversible and less invasive and can be a cost-effective treatment option, depending on the success rate women are willing to accept. TWEETABLE ABSTRACT: Treatment of heavy menstrual bleeding starting with LNG-IUS is cheaper but slightly less effective than endometrial ablation.

The effect of physical activity on fatigue among survivors of colorectal cancer: a systematic review and meta-analysis.

PURPOSE: Favorable health outcomes among cancer survivors are increasingly being attributed to lifestyle factors like physical activity, which is now promoted in clinical guidelines. However, the available evidence indicates that physical activity may also reduce fatigue in this patient group. In this systematic review, we aimed to examine whether physical activity could reduce fatigue among survivors of colorectal cancer. METHODS: The databases of Medline, CINAHL, and PsycINFO were systematically searched, using combinations of MeSH and free-text terms for colorectal cancer, physical activity, and fatigue. Randomized controlled trials and cohort studies with longitudinal data collection were included. We performed a random-effect meta-analysis. RESULTS: Seven studies were included, five were randomized controlled trials, and two were cohort studies. A meta-analysis of the randomized controlled trials, which comprised 630 survivors in total, failed to show that physical activity had a significant effect on fatigue (standardized mean difference = 0.21 (- 0.07 to 0.49)); however, reduced levels of fatigue were observed in all studies. The results for the cohort studies were inconclusive: one showed that increasing levels of physical activity were significantly associated with decreasing levels of fatigue; the other showed that decreasing levels of fatigue were not associated with increasing levels of physical activity. CONCLUSIONS: Based on the data reviewed, we cannot draw definitive conclusions about the effects of physical activity on fatigue. None of the included studies were performed among fatigued survivors of colorectal cancer. More research is needed in this population, ensuring that the trials are appropriately powered to find differences in fatigue.

Two-year effects and cost-effectiveness of pelvic floor muscle training in mild pelvic organ prolapse: a randomised controlled trial in primary care.

OBJECTIVE: To compare effects and cost-effectiveness of pelvic floor muscle training (PFMT) and watchful waiting in women with pelvic organ prolapse. DESIGN: Randomised controlled trial. SETTING: Dutch general practice. POPULATION: Women (≥55 years) with symptomatic mild prolapse, identified by screening. METHODS: Linear multilevel analysis. MAIN OUTCOME MEASURES: Primary outcome was change of pelvic floor symptoms (Pelvic-Floor-Distress-Inventory-20 [PFDI-20]) during 24 months. Secondary outcomes were condition-specific and general quality of life, costs, sexual functioning, prolapse stage, pelvic floor muscle function and women's perceived improvement of symptoms. RESULTS: PFMT (n = 145) resulted in a 12.2-point (95% CI 7.2-17.2, P < 0.001) greater improvement in PFDI-20 score during 24 months compared with watchful waiting (n = 142). Participants randomised to PFMT more often reported improved symptoms (43% versus 14% for watchful waiting). Direct medical costs per person were €330 for PFMT and €91 for watchful waiting but costs for absorbent pads were lower in the PFMT group (€40 versus €77). Other secondary outcomes did not differ between groups. Post-hoc subgroup analysis demonstrated that PFMT was more effective in women experiencing higher pelvic floor symptom distress at baseline. CONCLUSION: PFMT resulted in greater pelvic floor symptom improvement compared with watchful waiting. The difference was statistically significant, but below the presumed level of clinical relevance (15 points). PFMT more often led to women's perceived improvement of symptoms, lower absorbent pads costs, and was more effective in women experiencing higher pelvic floor symptom distress. Therefore, PFMT could be advised in women with bothersome symptoms of mild prolapse. TWEETABLE ABSTRACT: Pelvic floor muscle training can be effective in women with bothersome symptoms of mild prolapse.

Primary healthcare use during follow-up after curative treatment for colorectal cancer.

The rising number of colorectal cancer (CRC) survivors is likely to impose a burden on healthcare systems. Effective resource allocation between primary and hospital care to ensure ongoing high-quality care is under discussion. Therefore, it is important to understand the current role of GPs during follow-up care of CRC. This study explores the primary healthcare use of patients 2-6 years after CRC treatment. Annual rates of face-to-face contacts, prescribed medication and referrals were compared between CRC patients and age, gender and GP matched controls in a historical prospective study. Reasons for contacts and prescribed medication were compared based on International Classification of Primary Care and Anatomical Therapeutic Chemical (ATC) Classification System codes, respectively. Negative binomial regression models and non-parametric test were used. Patients showed significantly more face-to-face contacts in the 2nd (63%), 3rd (32%) and 6th (23%) year, more drug prescriptions in the 2nd, 3rd and 6th year, and more referrals in the 2nd and 5th year after diagnosis. Differences in contacts and medication were related to the alimentary tract, blood and blood-forming organs, and psychological problems. This study suggests that GPs already play a substantial role during CRC follow-up and that there may be scope for formal services to be incorporated into the current model of GP care.

A systematic review of the psychological impact of false-positive colorectal cancer screening: What is the role of the general practitioner?

Screening for colorectal cancer (CRC) has both advantages (e.g. reduction in morbidity and mortality) and disadvantages (e.g. false positives and distress). A systematic review was therefore performed to improve our understanding of how false-positive CRC screening results affect patients psychologically (and to make recommendations for primary care). The PubMed, Embase, PsychINFO, CINAHL and Cochrane databases were searched in October 2014 and supplemented in December 2016 to identify studies on the psychological impact of false-positive CRC screening. Original studies were eligible when they assessed psychological impact in a screening setting, provided they also included false-positive CRC screening results. Two authors independently assessed 2,367 available manuscripts and included seven. Heterogeneity in their outcome measures meant that data could not be pooled. Two studies showed that a false-positive CRC screening result caused some moderate psychological distress shortly before and after colonoscopy. The remaining five studies illustrated that the psychological distress of patients with true-positive and false-positive CRC screening results was comparable. We conclude that a false-positive CRC screening result may cause some moderate psychological distress, especially just before or after colonoscopy. We recommend that general practitioners mention this when discussing CRC screening with patients and monitor those with a false-positive outcome for psychological distress.

Cost-effectiveness of a pro-active approach of urinary incontinence in women.

OBJECTIVE: To estimate the cost-effectiveness and cost-utility of actively encouraging older community-dwelling women with urinary incontinence to be diagnosed and treated. DESIGN: The study was designed as cost-effectiveness and cost-utility analyses alongside a cluster randomised controlled trial. Analyses were performed from a societal perspective. Direct medical and nonmedical costs were taken into account and valued according to the standard Dutch guidelines for economic evaluations. SETTING: Primary care. POPULATION: Study participants were 350 community-dwelling women 55 years or older with urinary incontinence. METHODS: Women in the intervention group were invited for diagnostic testing and treatment. The control group received usual care according to the Dutch guideline on urinary incontinence. Follow-up period was 12 months. MAIN OUTCOME MEASURES: Incontinence Impact Adjusted Life Years (IIALY), Quality Adjusted Life Years (QALY) and incremental costs calculated per IIALY and per QALY gained. RESULTS: Costs per extra life year without impact on daily life from urinary incontinence amounted to €5179 (95% CI -17 323 to 36 260). Costs per QALY amounted to €23 907 (95% CI -124 849 to 121 849). Assuming a ceiling ratio of €20 000, the probability that the intervention was cost-effective based on IIALYs was 91% and 46% based on QALYs. CONCLUSIONS: Improvements in severity of incontinence in older community-dwelling women can be achieved against reasonable costs, with an improvement of symptom-specific QALYs. Findings support an active role of primary care physicians towards women who hesitate to ask for help for urinary incontinence. TWEETABLE ABSTRACT: Encouraging women with urinary incontinence to be treated, improves symptoms and QOL against reasonable costs.

Anxiety and depression during pregnancy in Central America: a cross-sectional study among pregnant women in the developing country Nicaragua.

BACKGROUND: Around the world, maternal psychopathology during pregnancy is associated with a range of negative consequences for mother and child. Nevertheless, in Central America the magnitude of this public health problem is still unknown. The objective of this first explorative study was to investigate the prevalence and severity of anxiety and depression during pregnancy in the Central American developing country Nicaragua, as well as the availability of mental health care and to compare with a developed country. METHODS: A population-based cohort of pregnant women in Nicaragua (N = 98) was compared with a parallel cohort in the Netherlands (N = 4725) on symptoms of anxiety (Spielberger State Trait Anxiety Inventory) and depression (Edinburgh Postnatal Depression Scale). Associations with the women's knowledge how to reach professional psychological support were assessed using multivariable linear regression analyses. RESULTS: Of the Nicaraguan women, 41 % had symptoms of anxiety and 57 % symptoms of depression, versus 15 % and 6 % of the Dutch women. Symptom scores of both anxiety and depression were significantly higher in Nicaragua (p < 0.001). However, only 9.6 % of the women indicated that professional psychological help was available for the Nicaraguan pregnant women, which was associated with an increased anxiety score. CONCLUSIONS: In Nicaragua, both prevalence and severity of symptoms of antenatal anxiety and depression are substantially higher than in developed countries. However, availability of psychological help is very limited for pregnant Nicaraguan women. These findings indicate that there is need for further research and support for these women, to prevent negative consequences for both mother and child.

Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN.

BACKGROUND: Constipation is a pediatric problem commonly encountered by many health care workers in primary, secondary, and tertiary care. To assist medical care providers in the evaluation and management of children with functional constipation, the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition were charged with the task of developing a uniform document of evidence-based guidelines. METHODS: Nine clinical questions addressing diagnostic, therapeutic, and prognostic topics were formulated. A systematic literature search was performed from inception to October 2011 using Embase, MEDLINE, the Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Clinical Trials, and PsychInfo databases. The approach of the Grading of Recommendations Assessment, Development and Evaluation was applied to evaluate outcomes. For therapeutic questions, quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation system. Grading the quality of evidence for the other questions was performed according to the classification system of the Oxford Centre for Evidence-Based Medicine. During 3 consensus meetings, all recommendations were discussed and finalized. The group members voted on each recommendation, using the nominal voting technique. Expert opinion was used where no randomized controlled trials were available to support the recommendation. RESULTS: This evidence-based guideline provides recommendations for the evaluation and treatment of children with functional constipation to standardize and improve their quality of care. In addition, 2 algorithms were developed, one for the infants <6 months of age and the other for older infants and children. CONCLUSIONS: This document is intended to be used in daily practice and as a basis for further clinical research. Large well-designed clinical trials are necessary with regard to diagnostic evaluation and treatment.

Long-term follow-up for cardiovascular disease after chemotherapy and/or radiotherapy for breast cancer in an unselected population.

PURPOSE: Whereas earlier research focused on specific patient groups, this study assessed the risk of cardiovascular disease (CVD) in an unselected population curatively treated for breast cancer (BC), compared with an age-matched random sample of controls. METHODS: Risks were determined in BC survivors and controls. CVD was divided into three categories: congestive heart failure, vascular cardiac diseases, and "other" cardiac diseases. Hazard ratios (HRs) and 95% confidence intervals (95% CI) adjusted for age, CVD, and CVD risk factors at baseline were determined by Cox regression analyses. RESULTS: All 561 survivors of BC experienced surgery of whom 229 received (neo)adjuvant radiotherapy, 145 received chemotherapy (with or without radiotherapy), and 187 received no adjuvant therapy. During follow-up (median 9; range 5-57 years), CVD occurred in 176/561 (31%) survivors and in 398/1,635 (24%) controls. After radiotherapy, no increased risks of congestive heart failure (HR 0.5; 95% CI 0.2-1.8), vascular cardiac diseases (HR 1.1; 95% CI 0.7-1.7), or other cardiac diseases (HR 1.3; 95% CI 0.8-2.3) were found compared with controls. Similar results were found after chemotherapy for congestive heart failure (HR 1.8; 95% CI 0.6-5.8), vascular cardiac diseases (HR 1.1; 95% CI 0.5-2.3), and other cardiac diseases (HR 1.2; 95% CI 0.3-5.5). CONCLUSIONS: In an unselected population of BC survivors, no significant increased risk of CVD after radiotherapy and/or chemotherapy was found compared with controls. However, the HRs after chemotherapy were in-line with previous studies. Future studies should include more detailed information on treatment and more specific outcome measures.

Second cancers after childhood cancer--GPs beware!

BACKGROUND: One of the long-term effects in childhood cancer survivors (CCS) is the development of second cancers. In a cohort of CCS, this study describes how second cancers were presented, the way they were diagnosed, and the knowledge CCS had about their increased risk to develop a second cancer. PATIENTS AND METHODS: Selected participants were all adult five-year CCS (n = 1275) who were treated at the University Medical Center Groningen since 1965. Of these, 84 (6.6%) had developed a second cancer, of which 27 had died. The 57 survivors were asked to participate in a telephone interview. RESULTS: Of the 57 CCS, 35 (61%) participated. Together they had developed 45 second cancers. Most participants (97%) were seen at the long-term follow-up clinic. Of all second cancers, 89% caused symptoms. Of all second cancers, the majority (56%) were first presented at the general practitioner's (GP's) office and 20% at follow-up testing. Of these CCS, only 28% were aware of their increased risk of developing a second cancer. CONCLUSIONS: It is important to inform CCS continuously regarding their increased risk, as a relatively small percentage are aware of this. Since most of these patients first reported their symptoms to the GP, all GPs should be aware of this increased risk, in particular because this concerns cancer at a younger age than normally expected. A survivor care plan might be an effective way of communication with both CCS and GPs.

The needs of women and their partners regarding professional smoking cessation support during pregnancy: A qualitative study.

BACKGROUND: Despite the health risks of smoking, some women continue during pregnancy. Professional smoking cessation support has shown to be effective in increasing the proportion of pregnant women who quit smoking. However, few women actually make use of professional support. AIM: To investigate the needs of women and their partners for professional smoking cessation support during pregnancy. METHODS: Semi-structured interviews were held with pregnant women and women who recently gave birth who smoked or quit smoking during pregnancy, and their partners, living in the north of the Netherlands. Recruitment was done via Facebook, LinkedIn, food banks, baby stores and healthcare professionals. The interviews were recorded, transcribed and thematically analysed. RESULTS: 28 interviews were conducted, 23 with pregnant women and women who recently gave birth, and five with partners of the women. The following themes were identified: 1) understanding women's needs, 2) responsibility without criticism, and 3) women and their social network. These themes reflect that women need support from an involved and understanding healthcare professional, who holds women responsible for smoking cessation but refrains from criticism. Women also prefer involvement of their social network in the professional support. CONCLUSION: For tailored support, the Dutch guideline for professional smoking cessation support may need some adaptations. The adaptations and recommendations, e.g. to involve women and their partners in the development of guidelines, might also be valuable for other countries. Women prefer healthcare professionals to address smoking cessation in a neutral way and to respect their autonomy in the decision to stop smoking.

Rotavirus and illness severity in children presenting with acute gastroenteritis at the primary care out-of-hours service.

BACKGROUND: Rotavirus is a common cause of acute gastroenteritis in young children in the Netherlands, where rotavirus vaccination has not yet been implemented. OBJECTIVES: To evaluate a difference in illness severity course depending on the presence of rotavirus infection and assess the prevalence of viruses and the referral rate in children with acute gastroenteritis. METHODS: A prospective cohort of children aged 6 months to 6 years presenting with acute gastroenteritis to a primary care out-of-hours service from October 2016 to March 2018. Faeces were sampled and sent to a laboratory where viral pathogens were identified and quantified by real-time polymerase chain reaction. Severe course of acute gastroenteritis was defined as a Modified Vesikari Score of ≥11. In addition, we assessed referral rates. Chi-square tests were used to evaluate differences between groups. RESULTS: We included 75 children (34 boys) with a median age of 1.5 years (interquartile range, 0.9-2.0 years). The prevalence of rotavirus was 65.3% (95% confidence interval, 53.5-76.0) with a median cycle threshold of 16.0. Severe course of acute gastroenteritis was present in 31 of 71 children (4 were lost to follow-up). Those with rotavirus (20/47) did not have a severe course more often than those without (11/24): odds ratio, 0.88 (95% confidence interval, 0.33-2.36). Referral rates were comparable for rotavirus (15.2%) and non-rotavirus (14.3%). CONCLUSION: In out-of-hours primary care, rotavirus is common but not associated with increased severity and higher referral rates in children with acute gastroenteritis.

Functional constipation in children: a systematic review on prognosis and predictive factors.

BACKGROUND AND AIM: Knowledge regarding prognosis and factors influencing the clinical course of functional constipation in children is important to enable general practitioners and paediatricians to give accurate patient information, to compare treatment strategies, and identify children with high risk for unfavourable outcome. The objective of the study was to investigate and summarize the quantity and quality of evidence on prognosis of childhood constipation with and without treatment and its predictive factors. METHODS: An extensive literature search in MEDLINE and Embase was performed to identify prospective follow-up studies evaluating the prognosis or prognostic determinants of functional constipation. Methodological quality was assessed using a standardised list. Results on prognosis of constipation were statistically pooled, and the influence of prognostic factors was summarised in a best evidence synthesis. RESULTS: The search strategy resulted in a total of 2882 abstracts. Only 14 publications met our inclusion criteria, of which 21% scored high methodological quality. Included studies showed large heterogeneity in study populations and outcome measures. Without regard to these differences, 49.3% +/- 11.8% of all of the children followed for 6 to 12 months were found to recover and taken off laxatives. The percentage of children who were free from complaints, regardless of laxative use, after 6 to 12 months was 60.6% +/- 19.2%. There is substantial evidence that defecation frequency and a positive family history are not associated with recovery from constipation. CONCLUSIONS: The few studies published on prognosis of childhood functional constipation and predictive factors showed large heterogeneity and poor methodological quality. Overall, 60.6% of children are found to be free from symptoms after 6 to 12 months. Recovery rate showed no relation with defecation frequency or positive family history. Based on the present literature, we are unable to identify a group of children with high risk for poor prognosis.

The prognostic value of the clinical ACR classification criteria of knee osteoarthritis for persisting knee complaints and increase of disability in general practice.

OBJECTIVE: To assess the prognostic value of the clinical American College of Rheumatism (ACR) classification criteria of knee osteoarthritis (OA) on persisting knee complaints and increase of disability in adult patients with knee pain in general practice after 1-year follow-up. METHODS: Patients (aged >35 years) consulting for non-traumatic knee complaints in general practice were enrolled in the study. At baseline and 1-year follow-up knee complaints and function were assessed by questionnaires and a physical examination was performed. The prognostic value of fulfilling the clinical ACR criteria of knee OA at baseline on the outcomes persisting knee complaints and increase of disability was determined. RESULTS: 549 patients were included in the study of which 480 (87.4%) were available for follow-up. The studied population consisted of 236 (49.2%) women with mean age 53.6 [standard deviation (sd) 11.3], mean body mass index (BMI) 27.1 (sd 4.2), 288 (60.0%) patients had payed employment, and 292 (60.8%) patients fulfilled the clinical ACR criteria of knee OA. After 1-year follow-up, 236 (49.2%) patients reported persisting knee complaints, and 84 (17.5%) reported an increase of disability. There was no association of fulfilling the clinical ACR criteria of knee OA at baseline with persisting knee complaints [odds ratio (OR) 1.15; 95% Confidence Interval (CI) 0.80; 1.67] or increase of disability (OR 1.05; 95% CI 0.43; 2.58) at follow-up. CONCLUSION: The clinical ACR classification criteria of knee OA have no prognostic value for predicting persisting knee complaints or an increase of disability at 1-year of follow-up in adult patients with non-traumatic knee complaints in GP.

Sublingual immunotherapy in youngsters: adherence in a randomized clinical trial.

BACKGROUND: Adherence is essential for effective treatment. Although several trials on the efficacy of sublingual immunotherapy (SLIT) in youngsters have been published, few contain data on medication intake. OBJECTIVE: We aimed to quantify adherence both to study protocol and medication intake as well as to identify factors that may influence adherence to SLIT in youngsters with rhinoconjunctivitis. METHODS: Two hundred and four youngsters (6-18 years) with hayfever participated in a randomized controlled trial and used grass pollen extract or placebo for 2 years. The primary outcome of the trial was the mean daily total rhinoconjunctivitis symptom score in the second grass pollen season. Participants having completed the follow-up were considered adherent to the study protocol. Adherence to medication intake was assessed by weighing the study medication. Participants who completed the follow-up and used > or = 80% of the prescribed medication were considered adherent to medication intake. Patient-, disease- and treatment-related factors were analysed. RESULTS: One hundred and fifty-four youngsters completed the study. The main reason for discontinuation was the inability to take medication according to schedule. Drop-outs were older, had more difficulty following the medication instructions and their overall evaluation of the treatment effect was lower. The number and reasons for drop-out did not differ between treatment groups. In total, 77% of the participants was adherent to medication intake. Self-reported adherence was 99%. Non-adherent participants experienced more severe symptoms before the trial. Symptom scores did not differ between adherent and non-adherent participants. In adherent as well as non-adherent participants, no difference was found between verum and placebo group with respect to symptom scores. CONCLUSION: Adherence to both study protocol and medication intake was good. Drop-out was affected by age, evaluation of the treatment effect and medication instructions. Non-adherence to medication intake was influenced by the severity of the disease before the trial. The ineffectiveness of SLIT could not be explained by non-adherence.

Lysholm scale and WOMAC index were responsive in prospective cohort of young general practice patients.

OBJECTIVE: To determine the construct validity and responsiveness of the Lysholm knee scoring scale and the WOMAC osteoarthritis index in adolescents and young adults with knee complaints in general practice. STUDY DESIGN AND SETTING: In the framework of a prospective cohort study with 1-year follow-up, we included 314 patients aged 12-35 years consulting the general practitioner for incident knee complaints. Subgroup analyses of traumatic and nontraumatic knee complaints and of adolescents and adults were performed. RESULTS: Construct validity was adequate for both questionnaires both in traumatic and nontraumatic patients (aged 12-35) and in adolescents (12-17) and young adults (18-35). Effect size (ES) and standardized response mean (SRM) for both Lysholm and WOMAC global scores were moderate in nontraumatic patients and high in traumatic patients. Guyatt's responsiveness statistic was high in both subpopulations. Adolescents showed high responsiveness with all measures on the Lysholm scale, and moderate (Guyatt's statistic) to high responsiveness (ES and SRM) on the WOMAC index. Young adults showed high responsiveness with all measures on both instruments. CONCLUSION: Although neither of the scales was developed for use in adolescents and young adults in general practice, both scales show adequate responsiveness, content, and construct validity in this population.

[Summary of the practice guideline 'Children with fever' (Second Revision) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Kinderen met koorts' (tweede herziening) van het Nederlands Huisartsen Genootschap.

In the second revision of the practice guideline 'Children with fever' from the Dutch College of General Practitioners, due to its greater reliability rectal measurement of the body temperature above measurement with an ear thermometer is recommended in the case of children younger than 3 months, where the classical signs of infectious diseases are often less apparent. The practice guideline distinguishes between alarm signs which can be recognised by the parents and alarm symptoms which can be diagnosed by the physician during a physical examination. In children younger than 2 years who are feverish with no apparent cause, the urine should be examined at the first consultation. An X-ray of the thorax of a child with fever is only necessary if pneumonia is suspected. As it is not possible at an early stage to identify serious cases among children who are feverish without an apparent cause, these children should be re-examined within 24-48 hours. Children with fever who are younger than 3 months should be referred to a paediatrician. A typical febrile seizure is harmless, nevertheless an underlying meningitis should be excluded.

[Summary of the practice guideline 'allergic and non-allergic rhinitis' (first revision) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Allergische en niet-allergische rhinitis' (eerste herziening) van het Nederlands Huisartsen Genootschap.

The practice guideline 'Allergic and non-allergic rhinitis' of the Dutch College ofGeneral Practitioners has been revised based on developments that have occurred in recent years. The most important modifications are: Impermeable covers for beddings are advised only for patients with serious complaints despite the use of medication and other mite-avoidance measures, and patients with allergic rhinitis with asthma. The indication for the use ofa corticosteroid nasal spray is broadened. There is more evidence for the efficacy ofa nasal spray with antihistamines. The indication for cromoglycate has been restricted. Two major unsolved points of discussion concerned the effectiveness of sublingual immunotherapy and the link between asthma and allergic rhinitis.