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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.

Diagnostic reasoning is an important topic in General Practitioners' (GPs) vocational training. Interestingly, research has paid little attention to the content of the cases used in clinical reasoning education. Malpractice claims of diagnostic errors represent cases that impact patients and that reflect potential knowledge gaps and contextual factors. With this study, we aimed to identify and prioritize educational content from a malpractice claims database in order to improve clinical reasoning education in GP training. With input from various experts in clinical reasoning and diagnostic error, we defined five priority criteria that reflect educational relevance. Fifty unique medical conditions from a malpractice claims database were scored on those priority criteria by stakeholders in clinical reasoning education in 2021. Subsequently, we calculated the mean total priority score for each condition. Mean total priority score (min 5-max 25) for all fifty diagnoses was 17,11 with a range from 13,89 to 19,61. We identified and described the fifteen highest scoring diseases (with priority scores ranging from 18,17 to 19,61). The prioritized conditions involved complex common (e.g., cardiovascular diseases, renal insufficiency and cancer), complex rare (e.g., endocarditis, ectopic pregnancy, testicular torsion) and more straightforward common conditions (e.g., tendon rupture/injury, eye infection). The claim cases often demonstrated atypical presentations or complex contextual factors. Including those malpractice cases in GP vocational training could enrich the illness scripts of diseases that are at high risk of errors, which may reduce diagnostic error and related patient harm.

Background: Although a large number of adults with intellectual disabilities have depressive symptoms, non-pharmacological treatments are scarce. The present authors investigated whether bright light therapy (BLT) is effective in decreasing depressive symptoms compared to care as usual. Methods: This multicentre randomized controlled trial consisted of three study groups (10,000 lux BLT, dim light BLT and a no-BLT group). Participants received BLT for 30 min in the morning (14 consecutive days), additional to their regular care. Primary outcome was as follows: depressive symptoms measured with the ADAMS Depressive Mood subscale 1 week after the end of BLT (same time period in the noBLT group). Results: Forty-one participants were included in our trial. In both BLT groups, a significant decrease in depressive symptoms was seen. No significant differences were found between 10,000 lux BLT and no-BLT (p = .199) and no significant differences between dim light BLT and no-BLT (p = .451). A minimum amount of side effects and no adverse events were reported. Conclusions: In both BLT interventions, a decrease in depressive symptoms was seen. With 10,000 lux BLT, depressive symptoms decreased even below the clinical cut-off point, which makes BLT a promising intervention for clinical practice.

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.

Musculoskeletal (MSK) pain is frequently reported among adolescents and children and is a common reason for consultation in primary care. Our aim is to examine its prevalence in 6-year-old children in a general population and to assess associations with physical and psychosocial factors. Data from the Generation R Study, a population-based cohort, was used. Prevalence and characteristics of MSK pain were assessed with parent-reported questionnaires at 6 years of age (N = 6200). Demographics and data on physical activity, sedentary behaviors, previous reported MSK pain, and behavioral problems were extracted from questionnaires. The body mass index SD score was calculated from objectively measured weight and height. A 3-month prevalence of 10.0% was found for MSK pain in children, of which one-third was chronic, and 44.6% experienced together with pain at other sites. Univariate analyses showed that boys and children with lower socioeconomic status reported MSK pain more frequently compared to other pain and no pain. Although no associations were found between MSK pain and children's body mass index and physical activity level, children with MSK pain were more likely to watch television ≥2 hours/day. Multivariable analysis showed significant associations for MSK pain at 3 years of age (odds ratio 5.10, 95% confidence interval 3.25-7.98) and behavioral problems (odds ratio 2.10, 95% confidence interval 1.19-3.72) with the presence of MSK pain. So, MSK pain is already common in young children and is often chronic or recurrent. Previous reported MSK pain and behavioral problems are independently associated with MSK pain in the studied population.

Background The aim of this study was to investigate the differences in objectively measured physical activity and in self-reported physical activity between overweight and normal-weight children. Methods Data from a prospective cohort study including children, presenting at the participating general practices in the south-west of the Netherlands, were used. Children (aged 4–15 years) were categorized as normal-weight or overweight using age- and sex specific cut-off points. They wore an ActiGraph accelerometer for one week to register physical activity, and filled out a diary for one week about physical activity. Results A total of 57 children were included in this study. Overweight children spent significantly less percentage time per day in sedentary behavior (β − 1.68 (95%CI -3.129, − 0.07)). There were no significant differences in percentage time per day spent in moderate to vigorous physical activity (β 0.33 (− 0.11, 0.78)). No significant differences were found between children of normal-weight and overweight in self-reported measures of physical activity. Conclusions Overweight children are not less physically active than normal-weight children, which may be associated with the risen awareness towards overweight/obesity and with implemented interventions for children with overweight/obesity.

BackgroundPlantar heel pain (PHP) is a common cause of foot complaints in general practice. However, information on the occurrence and practical management is scarce.AimThe aim of this study was to determine the incidence and prevalence of PHP in Dutch primary care and to gain insight into the types of treatments provided to patients with PHP in primary care.Design and settingA cohort study was conducted using a healthcare database containing the electronic general practice medical records of approximately 1.9 million patients throughout the Netherlands.MethodA search algorithm was defined and used to identify cases of PHP from January 2013 to December 2016. Descriptive statistics were used to obtain the incidence and prevalence. Data on the management of PHP were manually validated in a random sample of 1000 patients.ResultsThe overall incidence of PHP was 3.83 cases (95% confidence interval [CI] = 3.77 to 3.89) per 1000 patient-years, the incidence in females was 4.64 (95% CI = 4.55 to 4.72), and 2.98 (95% CI = 2.91 to 3.05) in males. The overall prevalence of PHP was 0.4374% (95% CI = 0.4369 to 0.4378%). Incidence of PHP peaked in September and October of each calendar year. The most commonly applied strategies were a wait-and-see policy (18.0%, n = 168), use of non-steroidal anti-inflammatory drugs (NSAIDs) (19.9%, n = 186), referral to a paramedical podiatric specialist (19.7%, n = 184), and advice to wear insoles (16.4%, n = 153). Treatment strategies varied greatly among GPs.ConclusionThere was large variation in treatment strategies of GPs for patients with PHP. GPs should be aware of conflicting evidence for interventions, such as insoles, and focus more on exercises for which there is evidence for effectiveness.

Objectives To examine clinical and radiological characteristics of participants with an ankle sprain in general practice, classified into subgroups of a previously described chronic ankle instability (CAI) model. Design Cross-sectional study. Methods 206 participants, who visited their general practitioner with a lateral ankle sprain 6–12 months before inclusion, completed a questionnaire, physical examination, radiography and magnetic resonance imaging. They were classified into three subgroups of the previously described CAI-model: mechanical instability (MI), perceived instability (PI) and recurrent sprains (RS). Regression analyses were applied to evaluate differences in subgroup characteristics. Results A total of 192 participants were eligible to be classified into the model. Of these participants, 153 participants were classified into the subgroups and 39 could not be classified. With overlap between the subgroups and patients falling into more than one subgroup, 59 were classified having MI, 145 having PI and 30 having RS. Participants with RS and PI were more often sports participants (OR 6.83;95%CI 1.35–34.56 and OR 4.44;95%CI1.06–18.63 respectively) than participants without RS and PI. Participants with MI more often had a tenderness on palpation of the anterior talofibular ligament (OR 4.09;95%CI 1.91–8.72) and a KL-score ≥ 1 in the talonavicular joint on X-ray (OR 2.24;95%CI 1.09–4.58), compared to participants without MI. Conclusions Sports participation, tenderness on palpation of the anterior talofibular ligament and early signs of osteoarthritis were variables that discriminated between subgroups of CAI. However, further research is mandatory in order to examine the usefulness of the CAI model in relation to prognosis and suitable intervention.

OBJECTIVE: The aim of this study was to examine which analgesics are used by patients with osteoarthritis (OA)-related pain and how the analgesics are used in the preceding month. In addition, their beliefs about (pain) medication and the rationale of those declining to use analgesics were explored. METHODS: An online cross-sectional survey was sent to 1521 patients participating in the panel of the Dutch Arthritis Foundation. Descriptive analyses and logistic regression were used to analyze data. RESULTS: Of the 842 participants (56%) with OA that responded, 70% had generalized OA, 26% had concomitant fibromyalgia, and 34% had another musculoskeletal morbidity. Of all participants, 71% used analgesics, and 34% used more than 1 type. Analgesics were used for more than 14 days in the preceding month by most participants, with paracetamol being used most frequently (51%). Doses used were predominantly lower than the daily defined dose: 58.2% for paracetamol, 31.2% for nonsteroidal anti-inflammatory drugs/cyclooxygenase-2 inhibitors, and 75.7% for weak opioids. Compared with participants with concomitant fibromyalgia or other musculoskeletal morbidities, participants with OA alone significantly more frequently declined to use analgesics (p < 0.01) and significantly less frequently used 2 or 3 types of analgesics (p < 0.05). CONCLUSIONS: In this population with generalized OA and musculoskeletal comorbidities, medication use was high, and more than 1 type of analgesic was frequently used. Patients with concomitant fibromyalgia or other musculoskeletal morbidities more frequently used 2 or 3 types of analgesics; however, this use was often intermittent and in low doses. Medication use on a daily basis and at higher doses may lead to improved analgesic effect.

Inleiding Huisartsen krijgen vaak patienten op het spreekuur die knieklachten hebben na een doorgemaakt trauma. Huisartsen kunnen voor deze patienten direct een MRI-scan aanvragen. Methode De onderzoekers voerden een kosteneffectiviteitsanalyse uit, parallel aan een prospectief multicentre gerandomiseerd en gecontroleerd onderzoek in de Nederlandse huisartsenzorg. In totaal includeerden zij via 150 huisartsen 356 patienten van 18 tot 45 jaar met traumatische knieklachten. Zij hebben de patienten in twee gelijke groepen gerandomiseerd, waarin de ene helft binnen twee weken na inclusie een MRI-scan kreeg en de andere helft zorg kreeg conform de NHG-Standaard Traumatische knieproblemen. De primaire uitkomstmaten waren quality-adjusted life years (QALY’s), met kosten vanuit een gezondheidszorg- en maatschappelijk perspectief. Resultaten De gemiddelde QALY in de MRI-groep was 0,888 versus 0,899 in de standaardzorggroep (p = 0,255). De gezondheidszorgkosten waren hoger in de MRI-groep (€ 1109) dan in de standaardzorggroep (€ 837) (p = 0,05), voornamelijk door hogere kosten voor de MRI-scan, terwijl het aantal verwijzingen naar de orthopeed niet afnam. Conclusie Een MRI-scan aangevraagd door huisartsen was niet kosteneffectief bij 18- tot 45-jarige patienten met traumatische knieklachten. De MRI-scan leidde tot hogere zorgkosten, zonder verbetering van de kwaliteit van leven.

Objectives To examine the five-year prognosis and potential prognostic factors of patients with an acute lateral ankle sprain in primary care setting. Design Observational study. Methods 206 patients who participated in a cross-sectional study and visited their general practitioner with an acute lateral ankle sprain 6–12 months prior to inclusion were approached for a 5-year follow-up measurement consisting of an online questionnaire. At baseline patients completed standardized questionnaires, underwent a standardized physical examination and radiological examination (radiography and Magnetic Resonance Imaging) and scored their perceived recovery. Logistic regression analysis was used to examine potential predictive factors at baseline for the presence of persistent complaints after 5 years. Results 132 (64.1%) patients completed the 5-year follow-up. 18.2% reported persistent complaints and 30.3% had a re-sprain during follow-up. Baseline persistent complaints 6–12 months after an acute lateral ankle sprain (OR 6.38; CI 95% 1.54–26.44), dominant leg injury (OR 4.89; CI 95% 1.16–20.62) and a recurrent ankle sprain (OR 9.81; CI 95% 2.17–44.47) were significant predictors for persistent complaints 5 years after an acute ankle sprain. Physical examination and radiological findings did not add to the predictive value of the prognostic model. Conclusions Almost 20% of patients with an acute lateral ankle sprain experience persistent complaints after 5 years follow-up. Predictive factors for persistent complaints can be identified.

Background To evaluate intermediate care for knee and hip osteoarthritis (KHOA) in the general practice that incorporate specialist services into general practice to prevent unnecessary referrals to hospitals. Methods We used a mixed methods approach including semi-structured interviews, patient experience questionnaires and data from medical records from three intermediate care projects. Semi-structured interviews were conducted with patients, general practitioners (GPs), orthopaedists and a healthcare manager in intermediate care. Satisfaction of patients who received intermediate care (n = 100) was collected using questionnaires. Referral data and healthcare consumption from medical records were collected retrospectively from KHOA patients before (n = 96) and after (n = 208) the implementation of intermediate care. Results GPs and orthopaedists in intermediate care experienced more intensive collaboration compared to regular care. This led to a perceived increase in GPs’ knowledge enabling better selection of referrals to orthopaedics and less healthcare consumption. Orthopaedists felt a higher workload and limited access to diagnostic facilities. Patients were satisfied and experienced better access to specialists’ knowledge in a trusted environment compared to regular care. Referrals to physiotherapy increased significantly after the implementation of intermediate care (absolute difference = 15%; 95% CI = 7.19 to 22.8), but not significantly to orthopaedics (absolute difference = 5.9%; 95% CI = -6.18 to 17.9). Conclusions Orthopaedists and GPs perceived the benefits of an intensified collaboration in intermediate care. Intermediate care may contribute to high quality of care through more physiotherapy referrals. Further research with longer follow-up is needed to confirm these findings and give more insight in referrals and healthcare consumption.

© 2016 American Pain Society Worldwide, approximately 1 to 2% of the adult population suffers from chronic headache due to overuse of pain medication. Guidelines recommend acute withdrawal of medication, but the optimal treatment remains unknown. We aimed to evaluate the benefit of treatments for patients with medication overuse headache (MOH). We performed an extensive literature search until November 2015, selecting randomized controlled trials that evaluated interventions for adults with MOH. Two authors assessed the eligible trials and extracted data. We calculated effect estimates and used the random effects model for the pooled analysis. Our primary outcome measures were ‘headache days’ and ‘days with medication.’ Outcome data were categorized as short-term (up to 12 weeks) or long-term (≥12 weeks) outcomes. This review consists of 16 trials including 1,105 patients. Four trials evaluated the use of prednisone with placebo or celecoxib after medication withdrawal; 7 trials evaluated various methods of withdrawal versus other methods of withdrawal, and 5 trials evaluated prophylactic medication compared with placebo or ibuprofen. We found no significant differences in headache days between prednisone versus placebo or between outpatient versus inpatient treatment, but we found a significant difference in days with medication. Overall, we found no benefit of prophylactic medication versus placebo. We found low to very low quality of evidence of no benefit of prednisone, prophylaxis, and various withdrawal interventions. Because the burden of MOH for patients is enormous, larger and high-quality intervention trials are needed. Perspective This article presents a critical look at studies of patients with MOHs. It appears that the withdrawal strategy remains the best treatment option, although there is scant evidence on the efficacy of any treatment options.

Context Although a large percentage of children with advanced-stage cancer die at home, remarkably little information is available regarding the experience of general practitioners (GPs) with respect to providing home-based palliative care to children with incurable cancer. Objectives The objective of this study was to explore the perspectives of GPs who care for children with advanced-stage cancer in a home-based setting. Methods In this cross-sectional study, 144 GPs who provided home-based palliative care to 150 children with incurable cancer from 2001 through 2010 were invited to complete a questionnaire addressing their perspectives regarding: 1) symptom management, 2) collaboration with other health care professionals, 3) the child's death and care after death, and 4) impact of having provided palliative care, scored on distress thermometer (range 0–10). Results A total of 112 GPs (78%) responded, and 91 GPs completed the questionnaire for 93 patients. The median interval between the child's death and completing the questionnaire was seven years. The most prevalent symptoms reported in the patients were fatigue (67%) and pain (61%). Difficulties with communicating with (14%), coordinating with (11%), collaborating with (11%), and contacting (2%) fellow members of the multidisciplinary treatment team were rare. Hectic (7%) and shocking (5%) situations and panic (2%) around the child's death were rare. GPs reported feelings of sadness (61%) and/or powerlessness (43%) around the time of the patient's death, and they rated their own distress level as relatively high during the terminal phase (median score 6, range 0–9.5). The majority of GPs (94%) reported that they ultimately came to terms with the child's death. Conclusion In general, GPs appear to be satisfied with the quality of home-based palliative care that they provide pediatric patients with incurable cancer. Communication among health care professionals is generally positive and is considered important. Finally, although the death of a pediatric patient has a profound impact on the GP, the majority of GPs eventually come to terms with the child's death.

Huisartsen hebben geregeld vragen waarop ze in online databases een antwoord proberen te vinden. Hoe vind je dan de meest relevante literatuur? Zoekfilters kunnen uitkomst bieden. Om het vinden van relevante publicaties in Pubmed, Ovid (Medline/Embase), Embase.com en Cochrane te vergemakkelijken hebben wij twee zoekfilters ontworpen en gevalideerd. We hebben zowel een sensitief filter (complete opbrengst, maar meer kans op ‘ruis’), als een specifiek filter (minder complete opbrengst, maar minder kans op ‘ruis’) gemaakt.

IntroductionShoulder pain is common and the prognosis is often unfavourable. Dutch guidelines on the treatment of shoulder pain in primary care recommend a corticosteroid injection or a referral to exercise therapy, if initial pain management fails and pain persists. However, evidence of the effectiveness of a corticosteroid injection compared with exercise therapy, especially in the long term, is limited. This trial will assess the clinical effectiveness and cost effectiveness of a corticosteroid injection compared with physiotherapist-led exercise therapy over 12 months follow-up in patients with shoulder pain in primary care.Methods and analysisThe SIX Study is a multicentre, pragmatic randomised clinical trial in primary care. A total of 213 patients with shoulder pain, aged ≥18 years presenting in general practice will be included. Patients will be randomised (1:1) into two groups: a corticosteroid injection or 12 sessions of physiotherapist-led exercise therapy. The effect of the allocated treatment will be assessed through questionnaires at 6 weeks and after 3, 6, 9 and 12 months. The primary outcome is patient’s reported shoulder pain-intensity and function, measured with the Shoulder Pain and Disability Index, over 12 months follow-up. Secondary outcomes include cost effectiveness, pain-intensity, function, health-related quality of life, sleep quality, patient’s global perceived effect, work absence, healthcare utilisation and adverse events. Between group differences will be evaluated using a repeated measurements analysis with linear effects models. A cost-utility analysis will be performed to assess the cost effectiveness using quality-adjusted life years from a medical and societal perspective.Ethics and disseminationThis study was approved by the Medical Ethics Committee of Erasmus MC University Medical Center Rotterdam (MEC 2020-0300). All participants will give written informed consent prior to data collection. The results from this study will be disseminated in international journals and implemented in the primary care guidelines on shoulder pain.Trial registration numberDutch Trial Registry (NL8854).

BackgroundThe added value of magnetic resonance imaging (MRI) in primary care is still being debated. A high diagnostic yield can be expected in young and active patients with post-traumatic knee complaints.AimTo determine the frequency of MRI abnormalities in young and active patients (aged 18–45 years) and the associations with patient, trauma, and clinical characteristics.Design and settingA subgroup analysis of 174 patients, aged 18–45 years with knee trauma of MethodAssociations were expressed using mean differences, odds ratio (OR) and predictive values.ResultsSixty-seven out of 174 patients (39%) had a positive MRI finding, predominantly anterior cruciate ligament (ACL) ruptures (22%) and/or traumatic meniscal tears (15%). Patients with a pre-existing musculoskeletal comorbidity had a two-fold lower prevalence of positive MRI findings (21%), OR 3.0 (95% confidence interval [CI] = 1.3 to 7.0). A ‘sports related trauma’ showed the highest OR of 4.6 (95% CI = 2.2 to 9.3) for a positive MRI finding. Clinical scores were statistically, significantly worse in patients with positive MRI findings, with mean differences ranging from 10 to 20%. Furthermore, increasing duration of complaints was correlated with decreasing prevalence rates of positive MRI findings. Overall, a popping sound and direct swelling showed the highest positive predictive value of 65% for the presence of positive MRI findings.ConclusionThe results from this study enable a preselection of patients to increase the diagnostic yield of MRI in primary care.

Background About 12% of children are affected by allergic rhinoconjunctivitis (AR). Although the main symptomatic treatments are intranasal corticosteroids (INCS) (daily or on demand) and oral antihistamines, it remains unclear which treatment provides the best relief of symptoms. Therefore, this study examines whether daily use of INCS is superior to on demand use, or to oral antihistamines on demand. Methods A single-blinded randomized controlled trial in children (aged 6-18 years) with pollen-related AR. Patients received either INCS daily (fluticasone propionate), INCS on demand (fluticasone propionate), or oral antihistamine on demand (levocetrizine) for three months during the grass pollen season. A daily online symptom diary on both nose and eye symptoms was completed. The primary outcome was the percentage of symptom-free days. Results A total of 150 children were randomized. The percentage symptom-free days was in favour of INCS on demand (30%) compared with INCS daily (22%), i.e. 8% difference (95% CI -5 to +21%; not significant). The antihistamine on demand group had 15% symptom-free days; i.e. 7% difference compared to INCS daily (95% CI -6 to +19%;, not significant). Patients in the INCS on demand group used on average 61% less fluticasone than patients in the INCS daily group during the study period (p

Structural abnormalities on MRI are frequent after an ankle sprain. To determine the association between patient history, physical examination and early osteoarthritis (OA) in patients after a previous ankle sprain, 98 patients with persistent complaints were selected from a cross-sectional study. Patient history taking and physical examination were applied and MRI was taken. Univariate and multivariable analyses were used to test possible associations. Signs of OA (cartilage loss, osteophytes and bone marrow edema) were seen in the talocrural joint (TCJ) in 40% and the talonavicular joint (TNJ) in 49%. Multivariable analysis showed a significant positive association between swelling (OR 3.58, 95%CI 1.13;11.4), a difference in ROM of passive plantar flexion (OR 1.09, 95%CI 1.01;1.18) and bone edema in the TCJ. A difference in ROM of passive plantar flexion (OR 1.07, 95%CI 1.00;1.15) and pain at the end range of dorsiflexion/plantar flexion (OR 5.23, 95%CI 1.88;14.58) were associated with osteophytes in the TNJ. Pain at the end of dorsiflexion/plantar flexion, a difference in ROM of passive plantar flexion and swelling seem to be associated with features of OA (bone marrow edema, osteophytes) in the TCJ and TNJ. Our findings may guide physicians to predict structural joint abnormalities as signs of osteoarthritis.Level of evidence: 1b

BackgroundMany patients with osteoarthritis (OA) of the knee and/or hip undergo total joint replacement (TJR) because of severely progressed symptoms.AimTo determine patient and disease characteristics associated with undergoing TJR in participants with recent-onset knee and/or hip OA.Design and settingParticipants with hip or knee pain from the nationwide prospective Cohort Hip and Cohort Knee (CHECK) study were included.MethodThe outcome measure was total hip arthroplasty (THA) or total knee arthroplasty (TKA) during 6 years of follow-up. Joint-dependent characteristics were compared using generalised estimating equations (GEE). Multivariable models were built for both subgroups. Differences in symptomatic and radiographic progression were determined between baseline and 2-year follow-up (T2).ResultsThe knee subgroup included 751 participants (1502 knees), and there were 538 participants in the hip subgroup (1076 hips). Nineteen participants (22 knees) underwent TKA and 53 participants (62 hips) THA. Participants who underwent TKA had higher baseline body mass index, painful knee flexion, and higher Kellgren and Lawrence scores. Participants who underwent THA had painful internal hip rotation and showed more severe radiographic OA features. Participants who underwent TKA or THA showed more rapid symptomatic and radiographic OA progression at T2.ConclusionIn patients with recent-onset knee or hip pain, radiographic OA features already exist and a substantial number of patients fulfil existing criteria for knee and hip OA. A trend was observed in rapid progression of radiographic and symptomatic OA severity among patients with TKA and THA. Early detection of OA by the GP is important in managing knee and hip OA.

Objective: To examine whether significant differences exist between the self-reported prevalence of atopic disorders in the open population compared with physician diagnosed prevalence of atopic disorders in general practice. Methods: Medline (OvidSP), PubMed Publisher, EMBASE, Google Scholar and the Cochrane Controlled Clinical Trials Register databases were systematically reviewed for articles providing data on the prevalence of asthma, allergic rhinitis and eczema in a GP setting. Studies were only included when they had a cross-sectional or cohort design and included more than 100 children (aged 0-18 years) in a general practice setting. All ISAAC studies (i.e. the open population) that geographically matched a study selected from the first search, were also included. A quality assessment was conducted. The primary outcome measures were prevalence of eczema, asthma and allergic rhinitis in children aged 0-18 years. Results: The overall quality of the included studies was good. The annual and lifetime prevalences of the atopic disorders varied greatly in both general practice and the open population. On average, the prevalence of atopic disorders was higher in the open population. Conclusion: There are significant differences between the self-reported prevalence of atopic disorders in the open population compared with physician diagnosed prevalence of atopic disorders in general practice. Data obtained in the open population cannot simply be extrapolated to the general practice setting. This should be taken into account when considering a research topic or requirements for policy development. GPs should be aware of the possible misclassification of allergic disorders in their practice. Key Points Epidemiological data on atopic disorders in children can be obtained from various sources, each having its own advantages and limitations. On average, the prevalence of atopic disorders is higher in the open population. GPs should take into account the possible misclassification of atopic disorders in their practice population. Policymakers should be aware that data obtained in the open population cannot simply be extrapolated to the general practice setting.

Summary Background The high prevalence of actinic keratosis (AK) requires the optimal use of healthcare resources. Objectives To gain insight in to the healthcare utilization of people with AK in a population‐based cohort, and the management of AK in a primary and secondary care setting. Methods A retrospective cohort study using three complementary data sources was conducted to describe the use of care, diagnosis, treatment and follow‐up of patients with AK in the Netherlands. Data sources consisted of a population‐based cohort study (Rotterdam Study), routine general practitioner (GP) records (Integrated Primary Care Information) and nationwide claims data (DRG Information System). Results In the population‐based cohort (Rotterdam Study), 69% (918 of 1322) of participants diagnosed with AK during a skin‐screening visit had no previous AK‐related visit in their GP record. This proportion was 50% for participants with extensive AK (i.e. ≥ 10 AKs; n = 270). Cryotherapy was the most used AK treatment by both GPs (78%) and dermatologists (41–56%). Topical agents were the second most used treatment by dermatologists (13–21%) but were rarely applied in primary care (2%). During the first AK‐related GP visit, 31% (171 of 554) were referred to a dermatologist, and the likelihood of being referred was comparable between low‐ and high‐risk patients, which is inconsistent with the Dutch general practitioner guidelines for ‘suspicious skin lesions’ from 2017. Annually, 40 000 new claims representing 13% of all dermatology claims were labelled as cutaneous premalignancy. Extensive follow‐up rates (56%) in secondary care were registered, while only 18% received a claim for a subsequent cutaneous malignancy in 5 years. Conclusions AK management seems to diverge from guidelines in both primary and secondary care. Underutilization of field treatments, inappropriate treatments and high referral rates without proper risk stratification in primary care, combined with extensive follow‐up in secondary care result in the inefficient use of healthcare resources and overburdening in secondary care. Efforts directed to better risk differentiation and guideline adherence may prove useful in increasing the efficiency in AK management. What's already known about this topic? The prevalence of actinic keratosis (AK) is high and, in particular, multiple AKs are a strong skin cancer predictor.The high prevalence of AK requires optimal use of healthcare resources.Nevertheless, (population based) AK healthcare utilization and management data are very rare. What does this study add? Although AK‐related care already consumes substantial resources, about 70% of the AK population has never received care.Primary care AK management demonstrated underutilization of topical therapies and high referral rates without proper risk stratification, while in secondary care the extensive follow‐up schedules were applied.This inefficient use of healthcare resources highlights the need for better harmonization and risk stratification to increase the efficiency of AK care., Linked Comment: https://doi.org/10.1111/bjd.17862. https://doi.org/10.1111/bjd.18269 available online https://www.bjdonline.com/article/

Background High incidence rates of keratinocyte carcinoma (KC) in Western countries put pressure on healthcare systems. The aim of this study was to describe clinical practice in order to identify areas for improvement. Methods A random selection of patients from the Integrated Primary Care Information database who consulted their general practitioner (GP) for suspicious or confirmed KC (n = 1597) was made in the analysis. For secondary care, 1569 patients with histologically confirmed KC were randomly selected from the Netherlands Cancer Registry. All patients were diagnosed between 2009 and 2013 and followed up until 2016. Details on diagnosis, treatment and care during follow-up were described. Results Among 942 patients who consulted their GP, KC was included in the working or differential diagnosis, but two-thirds (629) were not KC. If the GP suspected KC, the GP directly referred to a medical specialist in most cases (548 of 942). In half (470 of 967) of all confirmed KCs, a skin malignancy was not described in the initial working or differential diagnosis of the GP. The medical specialist treated the first primary KC in 86% (1369 of 1596) by excision, 4% (69 of 1596) by Mohs surgery and 10% (158 of 1596) by another treatment. Although follow-up is not recommended for low-risk basal cell carcinoma, 83% (29 of 35) received follow-up care. In contrast, 82% (60 of 73) patients with squamous cell carcinoma received less follow-up than recommended. Conclusions Strengthening the diagnostic pathway for KC in primary care and reduction of low-value follow-up visits in secondary care seem potential areas for improving the efficiency of KC care.

IntroductionTopical corticosteroids (TCS) of different potencies are the main treatment to control atopic dermatitis (AD). The Dutch guideline on AD for general practitioners (GPs) recommends a stepwise approach in which treatment steps are tailored to the severity of the disease, starting with the lowest possible potency of TCS. However, it remains unclear whether the recommended stepwise approach is most efficient. This randomised open-label controlled trial aims to determine whether a potent TCS is more effective than a low-potency TCS in the initial treatment of children with a moderate flare-up of AD in primary care. In the observational cohort, the overall aim is to determine the frequency, burden and determinants of flare-ups of AD during follow-up.Methods and analysisThe study is an observational cohort study with an embedded pragmatic randomised controlled, open-label trial. Eligible are patients diagnosed with AD (aged 12 weeks to 18 years) who visited the GP for AD or received repeated prescriptions for AD in the previous 12 months; follow-up of the cohort is 1 year. Children are enrolled in the trial if they have a flare-up of AD during follow-up in the cohort. Eligible children are randomised to the intervention group (with a potent TCS once daily) or to the GP guideline group (with a low potency TCS once daily). Primary outcome is the difference in average subjective disease severity over 24 weeks follow-up in the trial, measured with the patient-oriented eczema measure. As secondary outcome, the Eczema Area and Severity Index is measured.Ethics and disseminationThis study tests the hypothesis that immediate treatment with a potent TCS during a flare-up of AD leads to faster and more efficacious results as compared with starting with a TCS with low potency with less overall use of TCS. The study protocol is approved by the Medical Ethics Committee (MEC) of the Erasmus Medical Center Rotterdam, the Netherlands (MEC-2017–328). The results of the study will be published in international peer-reviewed journals and presented at national and international conferences.Trial registration numberNTR: 6679; Pre-results.

This prospective cohort study investigates whether the suggested association between weight status and respiratory complaints in open populations is also reflected in the frequency of consultations for respiratory complaints at the general practice. Children aged 2–18 years presenting at one of the participating general practices in the Netherlands could be included. Electronic medical files were used to extract data on consultations. Logistic regression analyses and negative binomial regression analyses were used to assess the associations between weight status and the presence, and frequency of respiratory consultations, respectively, during 2-year follow-up. Subgroup analyses were performed in children aged 2–6, 6–12, and 12–18 years old. Of the 617 children, 115 (18.6%) were underweight, 391 (63.4%) were normal-weight, and 111 (18%) were overweight. Respiratory consultations were not more prevalent in underweight children compared to normal-weight children (odds ratio (OR) 0.87, 95% confidence inteval (CI) 0.64–1.10), and in overweight children compared to normal-weight children (OR 1.33, 95% CI 0.99–1.77). Overweight children aged 12–18 years had more respiratory consultations (OR 2.14, 95% CI 1.14–4.01), more asthma-like consultations (OR 3.94, 95%CI 1.20–12.88), and more respiratory allergy-related consultations (OR 3.14, 95% CI 1.25–7.86) than normal-weight children. General practitioners should pay attention to weight loss as part of the treatment of respiratory complaints in overweight and obese children.

ObjectiveThere has been an increase in testing of vitamins in patients in general practice, often based on irrational indications or for non-specific symptoms, causing increasing healthcare expenditures and medicalisation of patients. So far, there is little evidence of effective strategies to reduce this overtesting in general practice. Therefore, the aim of this qualitative study was to explore the barriers and facilitators for reducing the number of (unnecessary) vitamin D and B12laboratory tests ordered.Design and settingThis qualitative study, based on a grounded theory design, used semistructured interviews among general practitioners (GPs) and patients from two primary care networks (147 GPs, 195 000 patients). These networks participated in the Reducing Vitamin Testing in Primary Care Practice (REVERT) study, a clustered randomized trial comparing two de-implementation strategies to reduce test ordering in primary care in the Netherlands.ParticipantsTwenty-one GPs, with a maximum of 1 GP per practice who took part in the REVERT study, and 22 patients (who were invited by their GP during vitamin-related consultations) were recruited, from which 20 GPs and 19 patients agreed to participate in this study.ResultsThe most important factor hampering vitamin-test reduction programmes is the mismatch between patients and medical professionals regarding the presumed appropriate indications for testing for vitamin D and B12. In contrast, the most important facilitator for vitamin-test reduction may be updating GPs’ knowledge about test indications and their awareness of their own testing behaviour.ConclusionTo achieve a sustainable reduction in vitamin testing, guidelines with clear and uniform recommendations on evidence-based indications for vitamin testing, combined with regular (individual) feedback on test-ordering behaviour, are needed. Moreover, the general public needs access to clear and reliable information on vitamin testing. Further research is required to measure the effect of these strategies on the number of vitamin test requests.Trial registration numberWAG/mb/16/039555.

Background: There is a need for prediction of knee osteoarthritis (KOA) in general practice to motivate subjects for preventive therapies and optimize preventive trials. Aim: To develop a prediction model, with questionnaire and physical examination variables, for incident frequent knee pain (FKP) and symptomatic KOA after 2.5 and/or 6.5 years among overweight and obese middle-aged women. Design and Setting: Models were developed in the Prevention of Knee Osteoarthritis in Overweight Females study (age 50 to 60 years, body mass index [BMI] ≥ 27 kg/m2) (ISRCTN 42823086). FKP was defined as knee pain during most days in the past month. Symptomatic KOA was defined according to the combined (clinical and radiographic) American College of Rheumatology criteria. Method: Multivariable analysis by backward stepwise deletion was performed for questionnaire and physical examination variables. The prediction model was externally validated in Rotterdam Study (RS)–III. Area under the curves (AUCs) of receiver operating characteristic were calculated. Results: 32% of 237 women (mean age 55.7 ± 3.2 years; mean BMI, 31.9 ± 3.8 kg/m2) developed FKP and 30% developed symptomatic KOA. AUC of age and BMI was 0.63 (0.55 to 0.71) for incident FKP. The final model included age, BMI, mild knee symptoms, knee problems climbing stairs, morning stiffness, postmenopausal status, and heavy work. AUC was 0.71 (0.63 to 0.78). Results were similar for incident KOA. Applying external validation, similar results were observed in the RS-III. Conclusion: In this study, easy-obtainable variables modestly improved the prediction of FKP and symptomatic KOA above age and BMI. To improve the identification of high-risk individuals, development of valid tests for other known risk factors, like meniscal damage, that are applicable in primary care, are urgently needed.

IntroductionGout is the most common inflammatory arthritis in the Dutch general practice population and is often managed with long-term uric acid lowering treatment. The clinical relevance of this treatment in preventing gout attacks is unclear.Primary research questionWhat is the frequency of self-reported gout attacks and what is the effect of allopurinol use in patients diagnosed with gout in general practice?Methods and analysisAdult patients with a diagnostic consultation code for gout in the year 2013, 2014 or 2015 will be invited to participate in this prospective observational cohort study. Patients with a limited life expectancy will be excluded. Baseline measurements will include blood pressure, body mass index and a blood sample (estimated glomerular filtration rate, serum uric acid, cholesterol (low-density lipoprotein (LDL) and high-density lipoprotein), glucose (fasting)). At the 2-year follow-up, patients will receive questionnaires every 3 months. The questionnaires at baseline, 12 months and 24 months assess the frequency of gout attacks, the presence of tophi, comorbidity, medication use, quality of life, diet and lifestyle. The questionnaires in between only assess the frequency of gout attacks and medication use for gout. Descriptive statistics will be used to calculate the mean frequency of self-reported gout attacks during the 2-year follow-up. The propensity score for each patient being offered allopurinol is estimated and used to match patients with and without allopurinol treatment. We will compare the frequency of gout attacks in these groups using multilevel Poisson regression analyses. With this type of analysis, we can calculate the corrected estimated effect of allopurinol on gout attack frequency.Ethics and disseminationThe research protocol was approved by the Medical Ethical Committee of the Erasmus Medical Centre in Rotterdam. The knowledge generated by this study will be transferred to the Dutch College of General Practitioners, conferences and to (inter)national peer-reviewed journals.Trial registration numberNTR6329; Pre-results.

Aim: The aim of this study is to investigate the differences between reported and measured weight and height for underweight, normal-weight, and overweight children, particularly in a general practitioner setting. Background: Screening, signaling, and treatment of childhood obesity by the general practitioner depends on accurate weight and height measurements.Methods: Data on reported and measured weight and height from a cohort including 715 normal-weight and overweight children aged 2–17 were used. Means of reported and measured weight and height were compared using the paired T-test. Findings: Of the 715 included children, 17.5% were defined as being underweight, 63.2% normal-weight, and 19.3% overweight according to direct measured height and weight. In the age group 2–8 years, parents of underweight children reported a significantly higher weight than measured weight [mean differences (MD) 0.32 kg (0.02, 0.62)], whereas parents of overweight young children reported a significantly lower weight [MD −1.08 kg (−1.77, −0.39)]. In the age group 9–17 years, normal-weight [MD −0.51 kg (−0.79, −0.23)] and overweight children [MD −1.28 kg (−2.08, −0.47)] reported a significantly lower weight than measured weight. Conclusions: General practitioners cannot rely on reported weight and height measures from parents and children. In case of suspected under- or overweight in children, it should be advised to measure weight and height in general practice.

Low back pain is associated with a large burden-of-illness. It is responsible for the most years lived with disability as compared with any other medical condition. A comprehensive overview of the evidence on pharmacological treatment options for chronic low back pain is lacking. This review evaluates the evidence for the benefits and risks of currently available pharmacological treatments for chronic low back pain.The authors focus on the recent (Cochrane) systematic reviews and meta-analyses of randomized clinical trials covering paracetamol (acetaminophen), NSAIDs, muscle relaxants, antidepressants, anticonvulsants, opioids, and other (new) drugs.The overall impression of the efficacy of pharmacological treatments for patients with chronic low back pain is rather sobering. The effects on pain reduction and improvement of function are commonly small to moderate and short lasting when compared to placebo. At the same time, the various types of drugs are not without side-effects. This holds especially true for serious side-effects associated with (prolonged) use of strong opioids. Future studies on patients with chronic back pain should aim to identify subgroups of patients with good response to specific pharmacological treatment to facilitate personalized care.

Objective. To determine how often patients with musculoskeletal (MSK) complaints prescribed a non-steroidal anti-inflammatory drug (NSAID) subsequently consult their general practitioner (GP) with a non-serious adverse drug reaction (ADR). Design. Cohort study. Setting. A healthcare database containing the electronic GP medical records of over 1.5 million patients throughout the Netherlands. Patients. A total of 16 626 adult patients with MSK complaints prescribed an NSAID. Main outcome measures. The patients' medical records were manually assessed for the duration of NSAID use for a maximum of two months, and consultations for complaints predefined as potential ADRs were identified. Subsequently, the likelihood of an association with the NSAID use was assessed and these potential ADRs were categorized as likely, possible, or unlikely ADRs. Results. In total, 961 patients (6%) consulted their GP with 1227 non-serious potential ADRs. In 174 patients (1%) at least one of these was categorized as a likely ADR, and in a further 408 patients (2.5%) at least one was categorized as a possible ADR. Dyspepsia was the most frequent likely ADR, followed by diarrhoea and dyspnoea (respectively 34%, 8%, and 8% of all likely ADRs). Conclusion. Of the patients with MSK complaints prescribed an NSAID, almost one in 30 patients re-consulted their GP with a complaint likely or possibly associated with the use of this drug. The burden of such consultations for non-serious ADRs should be taken into account by GPs when deciding whether treatment with an NSAID is appropriate.

Background We investigated the percentage of patients diagnosed with the correct underlying cause of anaemia by general practitioners when using an extensive versus a routine laboratory work-up. Methods An online survey was distributed among 836 general practitioners. The survey consisted of six cases, selected from an existing cohort of anaemia patients ( n = 3325). In three cases, general practitioners were asked to select the laboratory tests for further diagnostic examination from a list of 14 parameters (i.e. routine work-up). In the other three cases, general practitioners were presented with all 14 laboratory test results available (i.e. extensive work-up). General practitioners were asked to determine the underlying cause of anaemia in all six cases based on the test results, and these answers were compared with the answers of an expert panel. Results A total of 139 general practitioners (partly) responded to the survey (17%). The general practitioners were able to determine the underlying cause of anaemia in 53% of cases based on the routine work-up, whereas 62% of cases could be diagnosed using an extensive work-up ( P = 0.007). In addition, the probability of a correct diagnosis decreased with the patient’s age and was also affected by the underlying cause itself, with anaemia of chronic disease being hardest to diagnose ( P = 0.003). Conclusion The use of an extensive laboratory work-up in patients with newly diagnosed anaemia is expected to increase the percentage of correct underlying causes established by general practitioners. Since the underlying cause can still not be established in 31.3% of anaemia patients, further research is necessary.

Van der Mark LB, Van Wonderen KE, Mohrs J, Van Aalderen WM, Ter Riet G, Bindels PJ. Astma voorspellen bij peuters en kleuters. Huisarts Wet 2014;57(12):622-5. Er is in de huisartsenpraktijk behoefte aan een voorspellend model voor astma voor kleuters met piepende ademhaling en/of kortademigheid, aangezien de bestaande modellen voornamelijk gebaseerd zijn op de algemene bevolking. Wij stelden ons ten doel een zo informatief mogelijke en toch praktisch bruikbare set risicofactoren te vinden waarmee de huisarts de kans op astma kan bepalen bij kleuters die met klachten op het spreekuur komen. In dit prospectieve onderzoek volgden wij 438 Nederlandse kleuters met een hoog risico op astma tot zij 6 jaar oud waren. Met behulp van gevalideerde vragenlijsten verzamelden wij gegevens over de astmasymptomen en de leefomstandigheden, en we maten de concentratie specifiek IgE. Als een kind 6 jaar was, beoordeelden wij aan de hand van symptomen, medicatie en bronchiale hyperreactiviteit of het astma had. Op basis van deze gegevens ontwikkelden wij met behulp van gebootstrapte multivariabele regressie een klinische astmavoorspellende score, de CAPS. We volgden 438 kinderen (56,8%) tot zij 6 jaar waren, 187 (42,7%) hadden op dat moment astma. Vijf klinische kenmerken bleken astma optimaal te voorspellen: leeftijd waarop de klachten begonnen, astma of allergie in de familie, door piepende ademhaling geinduceerde slaapstoornissen, piepende ademhaling in afwezigheid van griep of verkoudheid en specifiek IgE, vormen de grondslag voor de CAPS. Een CAPS < 3 (op een schaal van 0 tot 11) heeft een negatief voorspellende waarde van 78,4%, een CAPS-score ≥ 7 heeft een positief voorspellende waarde van 74,3%. De CAPS is een binnen de eerstelijnsgezondheidszorg makkelijk toepasbare methode om op basis van klinische kenmerken te voorspellen of peuters en kleuters die symptomen van astma hebben, ook daadwerkelijk astma zullen ontwikkelen. De CAPS kan helpen bij de besluitvorming over medische of niet-medische interventies op maat.

Objective To compare the burden of disease and its development over time in patients referred to an early arthritis cohort who were diagnosed either as having arthralgias without synovitis or as having rheumatoid arthritis (RA). Methods Patients diagnosed as having arthralgias without synovitis or RA were selected from the Rotterdam Early Arthritis Cohort. Data on clinical and psychological characteristics, demographics, pain scores (Rheumatoid Arthritis Disease Activity Index), functional ability (Health Assessment Questionnaire), health-related quality of life (HRQOL; Short Form 36), fatigue (visual analog scale and Fatigue Assessment Scale), and health care utilization (HCU) were collected at baseline and at 6 and 12 months of followup. The burden of disease measures (pain, functional ability, fatigue, and HRQOL) and HCU levels were plotted over time for both groups. A Poisson regression model for repeated data was used to identify determinants of HCU for both groups. Results At baseline, 330 patients with arthralgias without synovitis (nonsynovitis [NS] group) and 244 RA patients (RA group) were included. Overall, the burden of disease measures and HCU levels were very similar between groups. Both groups showed improvement over time with respect to pain scores, functional ability, HRQOL, and HCU levels. Independent predictors of high HCU were identified as more pain, worse physical health, and external locus of control in the NS group and as shorter duration of symptoms, low chance locus of control, and worse physical functioning in the RA group. Conclusion Despite the absence of an inflammatory diagnosis, patients with arthralgias without synovitis experienced a similar burden of disease compared with RA patients.

Background: A setting-specific asthma prediction score for preschool children with wheezing and/or dyspnoea presenting in primary healthcare is needed since existing indices are mainly based on general populations. Aims: To find an optimally informative yet practical set of predictors for the prediction of asthma in preschool children at high risk who present in primary healthcare. Methods: A total of 771 Dutch preschool children at high risk of asthma were followed prospectively until the age of six years. Data on asthma symptoms and environmental conditions were obtained using validated questionnaires and specific IgE was measured. At the age of six years the presence of asthma was assessed based on asthma symptoms, medication, and bronchial hyper-responsiveness. A clinical asthma prediction score (CAPS) was developed using bootstrapped multivariable regression methods. Results: In all, 438 children (56.8%) completed the study; the asthma prevalence at six years was 42.7%. Five parameters optimally predicted asthma: age, family history of asthma or allergy, wheezing-induced sleep disturbances, wheezing in the absence of common colds, and specific IgE. CAPS scores range from 0 to 11 points; scores = 7 signified a positive predictive value of 74.3%. Conclusions: We have developed an easy-to-use CAPS for preschool children with symptoms suggesting asthma who present in primary healthcare. After suitable validation, the CAPS may assist in guiding shared decision-making to tailor the need for medical or non-medical interventions. External validation of the CAPS is needed. (C) 2014 Primary Care Respiratory Society UK. All rights reserved.

BackgroundPlantar heel pain (PHP) is a common cause of foot complaints, but information on the occurrence in primary care is scarce.AimThe objective of this study was to determine the incidence and prevalence of PHP and to gain insight in types of treatments provided to patients with PHP in primary care.MethodA cohort study was conducted in a healthcare database containing the electronic general practice medical records of approximately 1.9 million patients throughout the Netherlands. A search algorithm was defined and used to identify cases of PHP in the years 2013–2016. Descriptive statistics were used to obtain the incidence and prevalence of PHP. Data on the management of PHP was extracted in a random sample of 1000 patients.ResultsThe overall incidence of PHP was 3.81 (95% confidence [CI] = 3.75 to 3.87) per 1000 patient years and the overall prevalence of PHP was 0.4374% (95% CI = 0.4369 to 0.4378). Incidence of PHP peaked in the last quarter of every calendar year. The GP applied a wait-and-see policy at the first consultation for PHP in 18.0% of patients. The most commonly applied interventions included prescription for NSAID (19.9%), referral to a paramedical podiatric specialist (19.7%), and advice to wear insoles (16.4%): 34.0% of patients received multiple interventions (range 2–11) and 30.9% had multiple consultations for PHP (range 2–8).ConclusionPHP appears to be common in primary care. Despite a lack of evidence for most treatments, multiple interventions are applied. This urges the need for future research on effectiveness of treatments.

markdownabstractBackground Rising healthcare expenditures places the potential for substitution of hospital care towards primary care high on the political agenda. As low-risk basal cell carcinoma (BCC) care is one of the potential targets for substitution of hospital care towards primary care the objective of this study is to gain insight in the views of healthcare professionals regarding substitution of skin cancer care, and to identify perceived barriers and potential strategies to facilitate substitution. Methods A qualitative study was conducted consisting of 40 interviews with dermatologists and GPs and three focus groups with 18 selected GPs with noted willingness regarding substitution of skin cancer care. The interviews and focus groups focused on general views, perceived barriers and potential strategies to facilitate substitution of skin cancer care, using predefined topic lists. All sessions were audio-taped, transcribed verbatim and analyzed using the program AtlasTi. Results GPs were generally positive regarding substitution of skin care whereas dermatologists expressed more concerns. Lack of trust in GPs to adequately perform skin cancer care and a preference of patients for dermatologists are reported as barriers by dermatologists. The main barriers reported by GPs were a lack of confidence in own skills to perform skin cancer care, a lack of trust from both patients and dermatologists and limited time and financial compensation. Facilitating strategies suggested by both groups mainly focused on improving GPs’ education and improving the collaboration between primary and secondary care. GPs additionally suggested efforts from dermatologists to increase their own and patients’ trust in GPs, and time and financial compensation. The selected group of GPs suggested practical solutions to facilitate substitution focusing on changes in organizational structure including horizontal referring, outreach models and practice size reduction. Conclusions GPs and, to lesser extent, dermatologists are positive regarding substitution of low-risk BCC care, though report substantial barriers that need to be addressed before substitution can be further implemented. Aside from essential strategies such as improving GPs’ skin cancer education and time and financial compensation, rearranging the organizational structure in primary care and between primary and secondary care may facilitate effective and safe substitution of low-risk BCC care.

Background The use of non-steroidal anti-inflammatory drugs (NSAIDs) is associated with serious adverse drug events (ADEs). Aim To determine the prevalence of over-the-counter (OTC) NSAID use in the general population and in patients with a high risk of developing a serious NSAID-related ADE. Design and setting Cross-sectional study in four general practices in the Netherlands. Method Two patient samples were selected: a random sample of adults (general population sample); and adult patients with a high risk of developing a serious ADE in case of NSAID use (high-risk sample). All included patients were sent a questionnaire regarding their use of OTC NSAIDs in the 4 weeks prior to participation. Results In the general population sample, 118 of 456 (26%) invited patients completed the questionnaire. Of these, 35 (30%) had used an OTC NSAID. In the high-risk sample, 264 of 713 (37%) invited patients completed the questionnaire, and of these high-risk patients 33 (13%) had used an OTC NSAID. Over 20% of OTC NSAID users in the general population sample and over 30% in the high-risk sample had used the OTC NSAID for >7 days. OTC NSAIDs were used in a dosage exceeding the recommended daily maximum by 9% and 3% of OTC NSAID users in the general population and the high-risk sample respectively. Conclusion OTC NSAIDs are used by almost one-third of the general population. In the high-risk patients selected, one in eight patients used an OTC NSAID. Continued efforts by health authorities and healthcare professionals to inform patients of the risks of these drugs are warranted.

Background Persistent complaints are very common after a lateral ankle sprain. Aim To investigate possible associations between structural abnormalities on radiography and MRI, and persistent complaints after a lateral ankle sprain. Design and setting Observational case control study on primary care patients in general practice. Method Patients were selected who had visited their GP with an ankle sprain 6-12 months before the study; all received a standardised questionnaire, underwent a physical examination, and radiography and MRI of the ankle. Patients with and without persistent complaints were compared regarding structural abnormalities found on radiography and MRI; analyses were adjusted for age, sex, and body mass index. Results Of the 206 included patients, 98 had persistent complaints and 108 did not. No significant differences were found in structural abnormalities between patients with and without persistent complaints. In both groups, however, many structural abnormalities were found on radiography in the talocrural joint (47.2% osteophytes and 45.1% osteoarthritis) and the talonavicular joint (36.5% sclerosis). On MRI, a high prevalence was found of bone oedema (33.8%) and osteophytes (39.5) in the talocrural joint; osteophytes (54.4%), sclerosis (47.2%), and osteoarthritis (55.4%, Kellgren and Lawrence grade > 1) in the talonavicular joint, as well as ligament damage (16.4%) in the anterior talofibular ligament. Conclusion The prevalence of structural abnormalities is high on radiography and MRI in patients presenting in general practice with a previous ankle sprain. There is no difference in structural abnormalities, however, between patients with and without persistent complaints. Using imaging only will not lead to diagnosis of the explicit reason for the persistent complaint.

__Background__ The role of amitriptyline in musculoskeletal pain is not as clearly defined as in classical neuropathic pain conditions. Objective. To assess the efficacy and effectiveness of amitriptyline in the treatment of pain in musculoskeletal complaints. __Methods__ An extensive search (including Medline, Embase and Web of Science) was made up to April 2016 for randomised controlled trials on amitriptyline in musculoskeletal complaints compared to placebo, usual care, or other analgesic use. Included studies were assessed for risk of bias. Outcomes of interest were pain reduction and function improvement. __Results__ Of the 2066 articles identified, seven were finally included. These studies were performed in patients with low back pain (4), rheumatoid arthritis (2), and patients with arm pain from repetitive use (1). No meta-analysis was performed due to clinical heterogeneity of the studies. Two studies with low risk of bias found positive results. One study found that 50 mg/day of amitriptyline [Visual Analogue Scale (VAS) -3.9 points] resulted in a significantly greater reduction in pain than treatment with pregabalin 600 mg/day (VAS -2.9 points) and improved function (improvement on the Oswestry Disability Index > 20%: 65% versus 49.5%). Amitriptyline improved function in arm pain compared to placebo (Upper Extremity Function Scale: -3.9 versus 0.8). A similar amount of side-effects occurred in the amitriptyline and the comparison groups. __Conclusion__ Few studies have evaluated the use of amitriptyline in musculoskeletal complaints. Although amitriptyline may be effective in musculoskeletal complaints, more studies are required to establish for whom amitriptyline works better than other analgesics.

Purpose A comprehensive and representative nationwide general practice database was explored to study associations between atopic disorders and prescribed medication in children. Method All children aged 0-18 years listed in the NIVEL Primary Care Database in 2014 were selected. Atopic children with atopic eczema, asthma and allergic rhinitis (AR) were matched with controls (not diagnosed with any of these disorders) within the same general practice on age and gender. Logistic regression analyses were performed to study the differences in prescribed medication between both groups by calculating odds ratios (OR); 93 different medication groups were studied. Results A total of 45,964 children with at least one atopic disorder were identified and matched with controls. Disorder-specific prescriptions seem to reflect evidence-based medicine guidelines for atopic eczema, asthma and AR. However, these disorder-specific prescriptions were also prescribed for children who were not registered as having that specific disorder. For eczema-related medication, about 3.7-8.4% of the children with non-eczematous atopic morbidity received these prescriptions, compared to 1.4-3.5% of the non-atopic children. The same pattern was observed for anti-asthmatics (having non-asthmatic atopic morbidity: 0.8-6.2% vs. controls: 0.3-2.1%) and AR-related medication (having non-AR atopic morbidity: 4.7-12.5% vs. controls: 2.8-3.1%). Also, non-atopic related medication, such as laxatives and antibiotics were more frequently prescribed for atopic children. Conclusions The present study shows that atopic children received more prescriptions, compared to non-atopic children. Non-atopic controls frequently received specific prescriptions for atopic disorders. This indicates that children with atopic disorders need better monitoring by their GP. (aut. ref.)

Background: Allergic rhinitis (AR) and asthma are both inflammatory diseases and are often associated. Relationships between fractional exhaled nitric oxide (FeNO) and asthma, atopy, and quality of life have been shown.Aims: This study aimed to determine whether FeNO in children with AR (n=158) or combined AR and asthma (n=93) was associated with clinical symptoms, house dust mite (HDM)-specific IgE, and rhinitis-specific quality of life, both cross-sectionally and longitudinally.Methods: Children with AR aged 6-18 years (n=251) in primary care were assessed for FeNO, nasal symptom scores, asthma symptom scores, quality of life, and HDM-specific IgE at baseline and 2 years later.Results: We found similarly elevated FeNO in children with only AR and in those with combined AR and asthma. No correlations were found between FeNO and nasal or asthma symptoms and rhinitis-related quality of life. Longitudinal correlations were strongest for HDM-specific IgE (r=0.91, pConclusions: FeNO was similar in a selected group of children with AR with and without asthma in primary care and was unrelated to symptoms or quality of life in both groups. FeNO is unlikely to be a useful biomarker of the clinical severity of upper or lower airway disease in primary care. (C) 2013 Primary Care Respiratory Society UK. All rights reserved. CMA de Bot etal. Prim Care Respir J 2013; 22(1): 44-50 http://dx.doi.org/10.4104/pcrj.2013.00009

An increasing number of children worldwide are overweight, and the first step in treating obesity is to identify overweight. However, do parents recognise overweight in their child and which factors influence parental perception? The aim of the present review is to systematically study differences between parental perception and the actual weight status of children. Medline, EMbase, CINAHL and PsychINFO were searched. After screening 2497 abstracts and 106 full texts, two reviewers independently scored the methodological quality of 51 articles (covering 35 103 children), which fulfilled the inclusion criteria. The primary outcome parameters were sensitivity and specificity of parental perception for actual weight status of their child. The methodological quality of the studies ranged from poor to excellent. Pooled results showed that according to objective criteria 11 530 children were overweight; of these, 7191 (62.4%) were incorrectly perceived as having normal weight by their parents. The misperception of overweight children is higher in parents with children aged 2–6 years compared with parents of older children. Sensitivity (correct perception of overweight) of the studies ranged from 0.04 to 0.89, while specificity (correct perception of normal weight) ranged from 0.86 to 1.00. There were no significant differences in sensitivity or specificity for different cut-off points for overweight, or between newer and older studies. Therefore we can conclude that parents are likely to misperceive the weight status of their overweight child, especially in children aged 2–6 years. Because appropriate treatment starts with the correct perception of overweight, health care professionals should be aware of the frequent parental misperception of the overweight status of their children.

Objective This study examined whether vascular alterations are associated with the presence and progression of osteoarthritis of the knee, the hip and the different hand joints in a large prospective cohort study. Methods In this population-based study involving participants aged 55 years and older (Rotterdam Study I), men (n = 2372) and women (n = 3278) were analysed separately. x-Rays of the knee, hip and hand were scored using the Kellgren and Lawrence score for osteoarthritis at baseline, after 6.6 years and 10 years. Measures of atherosclerosis (carotid intima media thickness (IMT) and carotid plaque) and data on covariates (age, body mass index, hypertension, cholesterol ratio, diabetes mellitus and smoking) were collected at baseline. Multivariate logistic regression models with generalised estimated equations were used to calculate OR and corresponding 95% CI. Secondary multiple comparison adjustment resulted in a significance level of p < 0.0021. Results In women, IMT showed an independent association with the prevalence of knee osteoarthritis (adjusted OR (aOR) 1.7, 1.1 to 2.7), and carotid plaque with distal interphalangeal (DIP) osteoarthritis (aOR 1.4, 1.2 to 1.7) and with metacarpophalangeal osteoarthritis (aOR 1.5, 1.1 to 2.2). An independent association for IMT with progression of metacarpophalangeal osteoarthritis was found in women (aOR 2.9, 1.18 to 6.93). Additional adjustment for multiple testing yielded a signifi cant association between carotid plaque and DIP osteoarthritis in women (p < 0.001). Conclusions This study showed independent associations of atherosclerosis with osteoarthritis of the knee and hand joints in women. The evidence was most solid for a relation with DIP osteoarthritis. More research is needed to confirm the associations and examine the differential association with various joints.

Contains fulltext : 154978.pdf (Publisher’s version ) (Closed access) Physicians and researchers in the field of family medicine often need to find relevant articles in online medical databases for a variety of reasons. Because a search filter may help improve the efficiency and quality of such searches, we aimed to develop and validate search filters to identify research studies of relevance to family medicine. Using a new and objective method for search filter development, we developed and validated 2 search filters for family medicine. The sensitive filter had a sensitivity of 96.8% and a specificity of 74.9%. The specific filter had a specificity of 97.4% and a sensitivity of 90.3%. Our new filters should aid literature searches in the family medicine field. The sensitive filter may help researchers conducting systematic reviews, whereas the specific filter may help family physicians find answers to clinical questions at the point of care when time is limited.

Background: Sublingual immunotherapy (SLIT) as a therapy for the treatment of allergic rhinitis in children might be acceptable as an alternative for subcutaneous immunotherapy. However, the efficacy of SLIT with house dust mite extract is not well established. Objective: To investigate whether SLIT in house dust mite–allergic children recruited in primary care is effective and safe. Methods: Children aged 6–18 years (n = 251) recruited in primary care with a house dust mite–induced allergic rhinitis received either SLIT or placebo for 2 years. Symptoms and medication use were assessed throughout the study. Primary outcome parameter was the mean total nose symptom score (scales 0–12) during the autumn of the second treatment year. Safety was assessed by recording any adverse event. Results: Overall, the mean nose symptom score ± s.d. after 2 years of treatment showed no significant effect of SLIT (symptom score intervention group 2.26 ± 1.84 vs. placebo group, 2.02 ± 1.67; p = 0.08). There were no significant differences in secondary outcomes, nor in subgroup analyses. The number of patients reporting adverse events was comparable between both groups. Conclusions: Sublingual immunotherapy with house dust mite allergen was not better than placebo in reducing rhinitis symptoms in house dust mite–allergic children in primary care. SLIT as administered in this study can be considered safe.

Enlarged lymph glands are a common finding in general practice and can be caused by sexually transmitted diseases (STDs). The worldwide distribution of the different STDs is changing, and lymphogranuloma venereum (LGV), a 'tropical' sexually transmissible infection caused by Chlamydia trachomatis, has been detected in the Netherlands in recent years. The management of this infectious disease is described on the basis of a case report.