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Inleiding Point-of-care-tests (POCT’s) kunnen huisartsen ondersteunen bij het diagnosticeren en behandelen van patienten met acute cardiopulmonale symptomen. Momenteel is echter nog niet bekend of het gebruik van POCT’s ook echt effect heeft op klinische uitkomsten bij deze patienten. De auteurs gingen na of het gebruik van POCT’s door de huisarts bij patienten met acute cardiopulmonale symptomen leidt tot nauwkeuriger diagnoses en of dit het klinisch handelen beinvloedt. Methoden De auteurs voerden een systematisch literatuuronderzoek uit in vier bibliografische gegevensbestanden. Twee reviewers screenden artikelen die voor februari 2016 zijn gepubliceerd. Zij includeerden alleen onderzoeken die gaan over het effect van POCT-gebruik door de huisarts op de klinisch diagnostische waarde en op de behandeling en verwijzing van patienten met cardiopulmonale symptomen. Resultaten De auteurs vonden negen geschikte artikelen die gegevens beschrijven van zeven onderzoeken naar de klinisch diagnostische waarde van POCT-gebruik bij 2277 eerstelijnspatienten met acute cardiopulmonale symptomen. Vier artikelen bevatten gegevens over het gebruik van D-dimeer-POCT door huisartsen bij longembolie (gegevens van twee onderzoeken); twee onderzoeken over troponine T en een over heart-type fatty acid-binding protein (H-FABP) bij acuut coronair syndroom; een over B-type natriuretic peptide (BNP) bij hartfalen; een over een 3-in-1-POCT (troponine T, BNP, D-dimeer) bij acuut coronair syndroom, hartfalen en/of longembolie. Slechts een onderzoek was gericht op het effect van POCT-gebruik door huisartsen op de tijdsduur tot de behandeling en een had betrekking op de verwijspercentages. Conclusie Er is momenteel beperkt bewijs dat gebruik van POCT’s door huisartsen bij patienten met acute cardiopulmonale symptomen leidt tot nauwkeuriger diagnoses en het klinisch handelen beinvloedt. Enkele onderzoeken hebben veelbelovende resultaten opgeleverd, voornamelijk wanneer artsen een POCT (D-dimeren) combineren met een klinische beslisregel.

PURPOSE Our primary objective was to evaluate the Marburg Heart Score (MHS), a clinical decision rule, or to develop an adapted clinical decision rule for family physicians (FPs) to safely rule out acute coronary syndrome (ACS) in patients referred to secondary care for suspected ACS. The secondary objective was to evaluate the feasibility of using the flash-mob method, an innovative study design, for large-scale research in family medicine. METHODS In this 2-week, nationwide, prospective, observational, flash-mob study, FPs collected data on possible ACS predictors and assessed ACS probability (on a scale of 1-10) in patients referred to secondary care for suspected ACS. RESULTS We collected data for 258 patients in 2 weeks by mobilizing approximately 1 in 5 FPs throughout the country via ambassadors. A final diagnosis was obtained for 243 patients (94.2%), of whom 45 (18.5%) received a diagnosis of ACS. Sex, sex-adjusted age, and ischemic changes on electrocardiography were significantly associated with ACS. The sensitivity of the MHS (cut-off ≤2) was 75.0%, specificity was 44.0%, positive predictive value was 24.3%, and negative predictive value was 88.0%. For the FP assessment (cut-off ≤5), these test characteristics were 86.7%, 41.4%, 25.2%, and 93.2%, respectively. CONCLUSIONS For patients referred to emergency care, ACS could not be safely ruled out using the MHS or FP clinical assessment. The flash-mob study design may be a feasible alternative research method to investigate relatively simple, clinically relevant research questions in family medicine on a large scale and over a relatively short time frame.

Background: In general practice, excluding serious conditions is one of the cornerstones of the consultation. Diagnostic tests are widely used to assist the decision-making process in these cases. Little is known about general practitioners' (GPs) access to diagnostic tests at GP out-of-hours services. Objectives: To determine GPs' access to diagnostic tests-imaging, function tests, laboratory tests, and point-of-care tests (POCT)-during GP out-of-hours care and to assess whether access to diagnostic facilities differs between services located adjacent to or separate from an accident and emergency (A&E) department. Methods: Cross-sectional survey of all 117 GP out-of-hours services in the Netherlands in 2014. Results: One-hundred-seventeen GP out-of-hours services participated in the survey; response rate 100%. Access to diagnostic tests during GP out-of-hours care varied across services, although generally there was limited access. Electrocardiography was available in 26% (30/117) of all services, conventional radiography in 19% (22/117), laboratory tests between 37% (43/117) and 65% (76/117). All services had glucose POCT and urine dipstick tests available while none utilized troponin POCT. We observed no relevant differences in access to diagnostic tests between services adjacent to or separate from an A&E department. Conclusion: GPs in the Netherlands had limited and varying access to diagnostic tests during GP out-of-hours care in 2014. Out-of-hours services adjacent to A&E departments do not offer wider access to diagnostic tests. Further research on the accessibility of diagnostic tests in other European countries with similar and different GP out-of-hours care systems could shed further light on the effects of accessibility to diagnostic tests.

General practitioners would like to use more rapid tests, particularly to help them make decisions about patients with acute heart and lung problems. Unfortunately, there is limited and unconvincing evidence at the moment to suggest that the use of rapid tests by general practitioners would lead to more accurate diagnoses and improved policies for patients with acute heart and lung problems. The Marburg Heart Score, a simple clinical tool, cannot exclude acute heart damage in a referenced population suspected of acute coronary syndrome (oxygen deficiency in the heart). We argue that further research on diagnosing patients with acute heart and lung problems should focus on a strategy that combines a clinical tool with a rapid test.

Continu of intermitterend gebruik van zowel anti-epileptica, antipyretica, alsook zink wordt afgeraden bij kinderen met koortsconvulsies. Dat is de conclusie van een Cochrane-review naar de effectiviteit en veiligheid van preventief gebruik van deze middelen om een recidief koortsconvulsie bij kinderen te voorkomen.

In slechts één week met zoveel mogelijk huisartsen in Nederland gegevens verzamelen bij patiënten met klachten van een mogelijk acuut coronair syndroom (ACS). Weer eens wat anders dan jarenlang durende onderzoeken. Universiteit Maastricht organiseert dit flashmobonderzoek tijdens de Huisarts HART Week van 20 tot en met 26 november 2017.

Background Point-of-care tests (POCT) can assist general practitioners (GPs) in diagnosing and treating patients with acute cardiopulmonary symptoms, but it is currently unknown if POCT impact relevant clinical outcomes in these patients. Objective To assess whether using POCT in primary care patients with acute cardiopulmonary symptoms leads to more accurate diagnosis and impacts clinical management. Methods We performed a systematic review in four bibliographic databases. Articles published before February 2016 were screened by two reviewers. Studies evaluating the effect of GP use of POCT on clinical diagnostic accuracy and/or effect on treatment and referral rate in patients with cardiopulmonary symptoms were included. Results Our search yielded nine papers describing data from seven studies, on the clinical diagnostic accuracy of POCT in a total of 2277 primary care patients with acute cardiopulmonary symptoms. Four papers showed data on GP use of D-dimer POCT in pulmonary embolism (two studies); two studies on Troponin T in acute coronary syndrome; one on heart-type fatty acid-binding protein (H-FABP) in acute coronary syndrome; one on B-type natriuretic peptide (BNP) in heart failure; one on 3-in-1 POCT (Troponin T, BNP, D-dimer) in acute coronary syndrome, heart failure and/or pulmonary embolism. Only one study assessed the effect of GP use of POCT on treatment initiation and one on actual referral rates. Conclusion There is currently limited and inconclusive evidence that actual GP use of POCT in primary care patients with acute cardiopulmonary symptoms leads to more accurate diagnosis and affects clinical management. However, some studies show promising results, especially when a POCT is combined with a clinical decision rule.

In this time where fast, efficient, and personalised care has become increasingly important, it is not surprising that point-of-care tests (POCTs) are becoming ever more popular. A wide range and growing number of POCTs are now available to GPs. The term POCT is frequently used and many different descriptions of a POCT exist, which sometimes leads to misconceptions and confusion. With a multidisciplinary international panel of POCT experts consisting of family practitioners, laboratory specialists, policymakers, researchers, and manufacturers, we recently performed a modified e-Delphi procedure to reach consensus on a widely supported and recognised international definition of a POCT in family practice: a point-of-care test in family practice is a test to support clinical decision making, which is performed by a qualified member of the practice staff nearby the patient and on any part of the patient’s body or its derivatives, during or very close to the time of consultation, to help the patient and physician to decide upon the best-suited approach, and of which the results should be known at the time of the clinical decision making.1 POCTs have many potential benefits, for example, saving patients’ and physicians’ time, optimising management, reducing referrals to secondary care and healthcare costs, improving patient satisfaction, and better adherence to treatment. An international survey among 2770 GPs in the UK, Australia, Belgium, the Netherlands, and the US has shown that GPs would like to use more laboratory POCTs. They specifically want POCTs to help them diagnose acute conditions, such as infections (C-reactive protein [CRP], chlamydia, gonorrhoea), acute cardiac disease (troponin, B-type natriuretic peptide), pulmonary embolism and deep-vein thrombosis (D-dimer), and some chronic conditions (for example, HbA1c, haemoglobin).2,3 However, GPs also …

ObjectivesTo investigate how many general practitioner (GP)-referred venous thromboembolic events (VTEs) are diagnosed during 1 year in one geographical region and to investigate the (urgent) referral pathway of VTE diagnoses, including the role of laboratory D-dimer testing.DesignHistorical cohort study.SettingGP patients of 47 general practices in a demarcated geographical region of 161 503 inhabitants in the Netherlands.ParticipantsWe analysed all 895 primary care patients in whom either the GP determined a D-dimer value or who had a diagnostic work-up for suspected VTE in a non-academic hospital during 2015.Primary and secondary outcome measuresThe primary outcomes of this study were the total number of VTEs per year and the diagnostic pathways—including the role of GP determined D-dimer testing—of patients urgently referred to secondary care for suspected VTE. Additionally, we explored the use of an age-adjusted D-dimer cut-off.ResultsThe annual VTE incidence was 0.9 per 1000 inhabitants. GPs annually ordered 5.1 D-dimer tests per 1000 inhabitants. Of 470 urgently GP-referred patients, 31.3% had a VTE. Of those urgently referred based on clinical assessment only (without D-dimer testing), 73.8% (96/130) had a VTE; based on clinical assessment and laboratory D-dimer testing yielded 15.0% (51/340) VTE. Applying age-adjusted D-dimer cut-offs to all patients aged 50 years or older resulted in a reduction of positive D-dimer results from 97.9% to 79.4%, without missing any VTE.ConclusionsAlthough D-dimer testing contributes to the diagnostic work-up of VTE, GPs have a high detection rate for VTE in patients who they urgently refer to secondary care based on clinical assessment only.

Objectives To explore general practitioners’ (GPs’) experiences with and views on the diagnosis and management of patients with cardiorespiratory symptoms during GP out-of-hours care. We also aimed to identify ways of (diagnostic) support during these consultations. Design Qualitative study; face-to-face semistructured interviews. Setting GP out-of-hours care in the Netherlands. Participants 15 GPs in the province of Limburg, the Netherlands. Results Overall, GPs find cardiorespiratory consultations challenging and difficult. Tension and uncertainty as well as defensive behaviour were the key themes that characterised GPs’ experiences. We identified several subthemes underlying the key themes: setting, potentially severe consequences, absence of a pre-existing relationship and little knowledge of the patient9s background, difficulties differentiating between possible causes of symptoms, changed public opinion and patient population, and previous experiences. GPs approach cardiorespiratory consultations differently and their threshold for referring patients and performing diagnostic tests is lower. We identified differing views on the use of additional diagnostic tests at GP out-of-hours services. Conclusions This study sheds further light on how GPs experience cardiorespiratory consultations during out-of-hours care and how this leads to a high number of cardiorespiratory referrals. GPs relate cardiorespiratory consultation during out-of-hours care with tension and uncertainty leading to defensive behaviour, which can be translated into a different approach towards cardiorespiratory consultations and a lower threshold for referring patients and performing diagnostic tests. Opinions on the possible added value of additional diagnostics in reducing the number of referrals should be further investigated, as we identified differing views on the use of additional diagnostic tests at GP out-of-hours services.

To determine GPs' access to diagnostic tests (medical imaging, laboratory tests, and point-of-care tests) during GP out-of-hours care in the Netherlands and to assess whether access differs between services located adjacent to or separate from an Accident and Emergency (AE) department.Cross-sectional survey.In 2014 we invited all GP out-of-hours services in the Netherlands to participate in a survey on GPs' access to diagnostic tests in Dutch GP out-of-hours services.117 GP out-of-hours services participated in the survey; response rate 100%. Although access to diagnostic tests during GP out-of-hours care varied across services, overall there was limited access. Electrocardiography was available in 26% (30/117) of all services, and conventional radiography in 19% (22/117). Access to various types of laboratory tests ranged between 37% (43/117) and 65% (76/117). All services had glucose point-of-care tests and urine dipstick tests available. We observed no relevant differences in access to in-house diagnostic tests between services adjacent to or separate from an AE department. More than half (56%) of out-of-hours services expressed plans to expand their diagnostic facilities.GPs in the Netherlands have limited and varying access to diagnostic tests in GP out-of-hours services. GPs working in out-of-hours services adjacent to AE departments do not have wider access to diagnostic tests than GPs working at a separate location. With current developments towards joint organisation structures of GP out-of-hours services and AE departments in the Netherlands, the organisation of diagnostic facilities within out-of-hours care may be subject of debate.

To provide insight into the current use, future needs, and attitudes towards point-of-care testing among Dutch family practitioners.Cross-sectional online survey.We performed a survey among 2129 Dutch family practitioners. We asked respondents to report on the current and desired use of point-of-care tests, frequency of use, their opinions on aspects of point-of-care tests and consequences of point-of-care tests on their practice, acceptable waiting times for test results to come in, the desire for point-of-care tests at out-of-hours services, and conditions for which a point-of-care test could assist in diagnosis.639 family practitioners completed the survey (response rate: 30%). The most common point-of-care tests currently used by family physicians were: blood glucose (96%), urine leucocytes or nitrite (96%), urine pregnancy (94%), haemoglobin (58%), and CRP (48%). The most commonly desired point-of-care tests were: D-dimer (70%), troponin (65%), BNP (62%), chlamydia (60%), and INR (54%). Family practitioners expected point-of-care tests to have a positive effect on patient satisfaction (93%), diagnostic certainty (89%), antibiotics use (84%), and substitution to primary care (78%). They considered the proven effect on clinical management (46%) and the tests' reliability (35%) to be important aspects of point-of-care tests. Respondents wanted point-of-care tests to help them diagnose acute conditions, such as acute thromboembolic disorders (D-dimers), cardiac disorders (troponin, BNP), and infections (CRP, chlamydia).The current use of point-of-care testing in family practice is restricted to a limited number of tests. In the future, Dutch family practitioners wish to use more point-of-care tests, especially in acute conditions in which a diagnostic decision needs to be made immediately.

Objective: To provide insight into the current use, future needs, and attitudes towards point-of-care testing among Dutch family practitioners. Design: Cross-sectional online survey. Method: We performed a survey among 2129 Dutch family practitioners. We asked respondents to report on the current and desired use of point-of-care tests, frequency of use, their opinions on aspects of point-of-care tests and consequences of point-of-care tests on their practice, acceptable waiting times for test results to come in, the desire for point-of-care tests at out-of-hours services, and conditions for which a point-of-care test could assist in diagnosis. Results: 639 family practitioners completed the survey (response rate: 30%). The most common point-of-care tests currently used by family physicians were: blood glucose (96%), urine leucocytes or nitrite (96%), urine pregnancy (94%), haemoglobin (58%), and CRP (48%). The most commonly desired point-of-care tests were: D-dimer (70%), troponin (65%), BNP (62%), chlamydia (60%), and INR (54%). Family practitioners expected point-of-care tests to have a positive effect on patient satisfaction (93%), diagnostic certainty (89%), antibiotics use (84%), and substitution to primary care (78%). They considered the proven effect on clinical management (46%) and the tests' reliability (35%) to be important aspects of point-of-care tests. Respondents wanted point-of-care tests to help them diagnose acute conditions, such as acute thromboembolic disorders (D-dimers), cardiac disorders (troponin, BNP), and infections (CRP, chlamydia). Conclusion: The current use of point-of-care testing in family practice is restricted to a limited number of tests. In the future, Dutch family practitioners wish to use more point-of-care tests, especially in acute conditions in which a diagnostic decision needs to be made immediately.

Background and Purpose— The aim of this study was to estimate the annual adult incidence and risk of intracerebral hemorrhage (ICH) and oral anticoagulant–associated ICH (OAC-ICH) in the Netherlands. Methods— We retrospectively selected all consecutive adult patients with a nontraumatic ICH seen in 1 of 3 hospitals in the region South-Limburg, the Netherlands, from 2007 to 2009. Crude incidences were age-adjusted to Dutch and European population. Results— We identified 652 ICH cases, of which 168 (25.8%) were OAC associated. The adult Dutch age-adjusted annual incidence of ICH and OAC-ICH was 34.8 (95% confidence interval, 32.0–37.8) and 8.7 (95% confidence interval, 7.3–10.3) per 100 000 person-years, respectively. The absolute risk of OAC-ICH was estimated at 0.46% per patient-year of OAC treatment. Conclusions— The annual incidences of ICH and OAC-ICH are relatively high in the Netherlands when compared with international literature.

Smartphones and Mobile Clinical Decision Support Systems (MCDSS) could help to overcome information overload and support physicians in providing up-to-date medical care. However, would smartphones and MCDSS also be useful for medical students during their clinical clerkships? In this prospective pilot study eight students were asked to use a smartphone during their daily clerkship activities and specifically to evaluate a basic MCDSS. Students were asked to fill out a short survey and exit interviews were conducted. Most students found the smartphone, especially access to the internet, a useful tool during their clerkship. Some students thought that the internet was an easier accessible information source compared to many applications. Several students were not aware of any high-quality applications and most students were not willing to pay more than ten Euros for such an application. In the opinion of most students smartphones should not be used in the presence of a patient. Students expressed a desire for more basic content in the tested MCDSS. In conclusion, smartphones can be a useful tool for medical students during their clerkship. MCDSS for medical students should be designed to their needs. Further research is needed to guide MCDSS development specifically targeted at medical students.