Berger, M.Y.

Course and prognosis of older back pain patients in general practice: A prospective cohort study (Article)

2013-04-16T00:00:00Z

The aim of the current study was to determine the course of back pain in older patients and identify prognostic factors for non-recovery at 3 months' follow-up. We conducted a prospective cohort study (the BACE study) of patients aged >55 years visiting a general practitioner (GP) with a new episode of back pain in the Netherlands. The course of back pain was described in terms of self-perceived recovery, pain severity, disability, pain medication, and GP visits at 6 weeks' and 3 months' follow-up. Prognostic factors for non-recovery at 3 months' follow-up were derived from the baseline questionnaire and physical examination. Variables with a prognostic value were identified with multivariable logistic regression analysis (method backward), and an area under the receiver operating curve (AUC) was calculated for the prognostic model. A total of 675 back pain patients (mean age 66.4 (SD 7.6) years) participated in the BACE cohort study. At 6 weeks' follow-up 64% of the patients reported non-recovery from back pain. At 3 months' follow-up 61% still reported non-recovery, but only 26% of these patients had revisited the GP. Longer duration of the back pain, severity of back pain, history of back pain, absence of radiating pain in the leg below the knee, number of comorbidities, patients' expectation of non-recovery, and a longer duration of the timed 'Up and Go' test were significantly associated with non-recovery in a multiple regression model (AUC 0.79). This information can help GPs identify older back pain patients at risk for non-recovery.

The relevance of patient-reported outcomes in a grass pollen immunotherapy trial in children and adolescents with rhinoconjunctivitis (Article)

2013-02-01T00:00:00Z

Background: Patient-reported outcomes (PROs) are the only instruments available to assess the efficacy of an intervention in patients with allergic rhinoconjunctivitis. As allergic rhinoconjunctivitis is a systemic disease, it is now recommended to use not only PROs focusing at classical symptoms, but also health-related quality of life (HRQL) instruments in immunotherapy trials. Methods: A previously published immunotherapy trial in children and adolescents (6-18yr) with hay fever provided us with data to assess the relevance of two of these additional outcome measures, the disease-specific rhinoconjunctivitis quality of life questionnaire (RQLQ) and the generic COOP/WONCA-charts (CWC). A PRO was considered relevant if it was responsive to pollen exposure and at least had a moderate correlation with the classical symptoms of allergic rhinoconjunctivitis. Furthermore, we evaluated a post-season PRO, that is, a global assessment of symptoms (GAS). This assessment is used in clinical trials as a tool for selecting participants with sufficient symptoms and in daily practice to evaluate the patient's complaints during the preceding season. We assessed the correlation of this retrospective score with the actual symptoms during the previous pollen season. Results: Data from 36 children and 63 adolescents were analysed. On the basis of the total scores of the paediatric and adolescent version of the RQLQ, both questionnaires were considered relevant as they were responsive to exposure and showed a moderate to strong correlation with the rhinoconjunctivitis symptoms. However, in both children and adolescents, 40% of the RQLQ items were not relevant according to our definition. The CWC as a whole and the separate charts appear less relevant because of the weak correlations with the daily symptom score from the diary. The correlation between our post-season GAS and the in season daily symptom score was weak. Conclusion: The paediatric and adolescent RQLQ are relevant, but could be shortened as they contain a substantial number of irrelevant items. The CWC are not relevant in the monitoring of children and adolescents with allergic rhinoconjunctivitis caused by grass pollen. The retrospective GAS does not sufficiently reflect the actual symptoms during the preceding season.

Exhaled nitric oxide measures allergy not symptoms in children with allergic rhinitis in primary care: A prospective cross-sectional and longitudinal cohort study (Article)

2013-01-28T00:00:00Z

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, p<0.0001). CONCLUSIONS: 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.

Predictors of persistent complaints after a knee injury in primary care (Article)

2012-08-01T00:00:00Z

Background: Prognosis of persistent complaints after knee injury is based on secondary care populations. In a primary care setting, however, no studies have addressed this issue. Aim: To identify possible predictors of persistent complaints 1 year after a knee injury. These predictors are important for guiding the GP's therapeutic management, and giving advice to patients about work and/or sports-related activities. Design and setting: Primary care prospective cohort study with a 1- year follow-up period in five municipalities in the southwest region of the Netherlands. Method: Patients who were eligible were recruited to the study by a GP research network with around 84 000 patients and 40 participating GPs. A total of 134 patients (aged 18-65 years) who consulted their GP within 5 weeks after a knee injury entered the study. Follow-up after 1 year was conducted in 122 patients. The main outcome was persistent complaints 1 year after injury; possible predictors for these complaints were obtained with a questionnaire, a physical examination, and magnetic resonance imaging (MRI), according to a standardised protocol. Results: After 1 year, of the 122 available patients, 21 (17%) reported persistent complaints and 101 (83%) reported full recovery ormajor improvement. In this study being aged >40 years had a significant association (P<0.05) with persistent complaints (odds ratio 8.0, 95% confidence interval 2.1 to 30.5). Physical examination and MRI findings revealed no predictors that were associated with these complaints. Conclusion: Being aged >40 years was the only determinant with a significant association with persistent complaints. As physical examination and MRI had no predictive value, they are not recommended for prognosis of persistent complaints.

Sublingual immunotherapy in children with allergic rhinitis: Quality of systematic reviews (Article)

2011-09-01T00:00:00Z

Systematic reviews have gained popularity as a way to combine the increasing amount of research information. This study assessed the quality of systematic reviews and meta-analyses of sublingual immunotherapy (SLIT) for allergic rhinitis in children, published since 2000. Eligible reviews were identified by searching Medline/Pubmed, Embase, and the Cochrane Library, from 2000 through 2008. Methodological quality was assessed using the assessment of multiple systematic reviews instrument. Ten systematic reviews were included, one of which was published in the Cochrane Library. Eight reviews gave some details about the search strategy. None of the reviews included measures to avoid selection bias. In 60% of the reviews, the methodological quality of the included studies was (partly) assessed. Four reviews pooled the results of individual studies, neglecting clinical heterogeneity. Three of the 10 reviews provided information about sources of funding or grants from industry. Of the 10 reviews, the six reviews with the highest overall score scored 5-8 points, indicating moderate quality. Systematic reviews are useful to evaluate the efficacy of SLIT in children. Although more reviews have become available, the methodological quality could be improved. SLIT for children could be promising, but methodological flaws in the reviews and individual studies are too serious to draw definite conclusions.

Back Complaints in the Elders (BACE); Design of cohort studies in primary care: An international consortium (Article)

2011-08-23T00:00:00Z

Background: Although back complaints are common among older people, limited information is available in the literature about the clinical course of back pain in older people and the identification of older persons at risk for the transition from acute back complaints to chronic back pain. The aim of this study is to assess the course of back complaints and identify prognostic factors for the transition from acute back complaints to chronic back complaints in older people who visit a primary health care physician. Methods/design. The design is a prospective cohort study with one-year follow-up. There will be no interference with usual care. Patients older than 55 years who consult a primary health care physician with a new episode of back complaints will be included in this study. Data will be collected using a questionnaire, physical examination and X-ray at baseline, and follow-up questionnaires after 6 weeks and 3, 6, 9 and 12 months. The study 'Back Complaints in the Elders' (BACE) will take place in different countries: starting in the Netherlands, Brazil and Australia. The research groups collaborate in the BACE consortium. The design and basic objectives of the study will be the same across the studies. Discussion. This consortium is a collaboration between different research groups, aiming to provide insight into the course of back complaints in older people and to identify prognostic factors for the transition from acute back complaints to chronic back complaints in older persons. The BACE consortium allows to investigate differences between older people with back complaints and the health care systems in the different countries and to increase the statistical power by enabling meta-analyses using the individual patient data. Additional research groups worldwide are invited to join the BACE consortium.

Childhood nonspecifi c abdominal pain in family practice: Incidence, associated factors, and management (Article)

2011-07-01T00:00:00Z

PURPOSE Nonspecifi c abdominal pain (NSAP) is a common complaint in childhood. In specialist care, childhood NSAP is considered to be a complex and time-consuming problem, and parents are hard to reassure. Little is known about NSAP in family practice, but the impression is that family physicians consider it to be a benign syndrome needing little more than reassurance. This discrepancy calls for a better understanding of NSAP in family practice. METHODS Data were obtained from the Second Dutch National Survey of General Practice (2001). Using registration data of 91 family practices, we identifi ed children aged 4 to 17 years with NSAP. We calculated the incidence, and we studied factors associated with childhood NSAP, referrals, and prescriptions. RESULTS The incidence of NSAP was 25.0 (95% confi dence interval [CI], 23.7- 26.3) per 1,000 person years. Most children (92.7%) with newly diagnosed NSAP (N = 1,480) consulted their doctor for this condition once or twice. Factors independently associated with NSAP were female sex (odds ratio [OR] = 1.4; 95% CI, 1.3-1.5), nongastrointestinal-nonspecifi c somatic symptoms (OR = 1.3; 95% CI, 1.1-1.5), and health care use (OR = 1.04; 95% CI, 1.03-1.05). When NSAP was diagnosed at the fi rst visit, 3% of the patients were referred to specialist care, and 1% received additional testing. Family physicians prescribed medication in 21.3% of the visits for NSAP. CONCLUSIONS Childhood NSAP is a common problem in family practice. Most patients visit their doctor once or twice for this problem. Family physicians use little additional testing and make few referrals in their management of childhood NSAP. Despite the lack of evidence for effectiveness, family physicians commonly prescribe medication for NSAP.

Headache: The placebo effects in the control groups in randomized clinical trials; An analysis of systematic reviews (Article)

2011-06-01T00:00:00Z

Objective: The purpose of this study is to describe the effects in the placebo and "no treatment" arms in trials with headache patients. Method: This is a secondary analysis of randomized controlled trials from 8 systematic reviews and selected trials with a "no treatment" or placebo control group. The different types of "no treatment" and placebo interventions were assessed and classified into 6 subgroups. The analyses were carried out according to type of outcome variable. Results: In total, 119 studies were included (7119 participants). The mean recovery rate in all control groups was 35.7%. Significantly more participants recovered in control groups of pharmacological studies than in nonpharmacological studies: 38.5% vs 15.0%, respectively. Adults were more likely to recover in nonpharmacological studies and children in pharmacological studies. Conclusions: The mean recovery rate in the control groups was 36%. The recovery rate varied substantially between type of intervention and patients.

Duration of fever and serious bacterial infections in children: A systematic review (Article)

2011-05-18T00:00:00Z

Background: Parents of febrile children frequently contact primary care. Longer duration of fever has been related to increased risk for serious bacterial infections (SBI). However, the evidence for this association remains controversial. We assessed the predictive value of duration of fever for SBI. Methods. Studies from MEDLINE, Embase and Cochrane databases (from January 1991 to December 2009) were retrieved. We included studies describing children aged 2 months to 6 years in countries with high Haemophilus influenzae type b vaccination coverage. Duration of fever had to be studied as a predictor for serious bacterial infections. Results: Seven studies assessed the association between duration of fever and serious bacterial infections; three of these found a relationship. Conclusion: The predictive value of duration of fever for identifying serious bacterial infections in children remains inconclusive. None of these seven studies was performed in primary care. Studies evaluating the duration of fever and its predictive value in children in primary care are required.

Prognostic factors for persistence of chronic abdominal pain in children (Article)

2011-02-01T00:00:00Z

Objectives: The aim of the study was to identify prognostic factors for the persistence of chronic abdominal pain (CAP) in children. Materials and Methods: For this systematic review, MEDLINE, EMBASE, and PsycINFO were searched up to June 2008 for prospective follow-up studies of pediatric CAP as defined by the criteria of Apley, von Baeyer, or the Rome committee. The outcome measure of interest was persistence of CAP. Persistent CAP was considered only when the abdominal pain of children with CAP persisted during follow-up at the same level of frequency and severity. For each study the risk for bias was assessed. The evidence for prognostic factors was summarized according to a best-evidence synthesis. Results: Eight studies, which examined 17 prognostic factors, were included. Moderate evidence was found that having a parent with gastrointestinal symptoms predicts the persistence of CAP. Strong evidence was found for no association between female sex and the duration of CAP, and moderate evidence that the severity of abdominal pain does not predict persistence of CAP. There is conflicting evidence as to whether psychological factors prevent, or have no relation with, persistence of Cap. Conclusions: Because there are few prognostic follow-up studies on pediatric CAP, the evidence for prognostic factors is limited. Physicians should ask about parental gastrointestinal problems because this is a risk factor for persistence of CAP in children. The hypothesis that psychological factors of the child predict persistence of CAP is not supported by evidence from the follow-up studies.

Cryotherapy with liquid nitrogen versus topical salicylic acid application for cutaneous warts in primary care: Randomized controlled trial (Article)

2010-10-19T00:00:00Z

Background: Cryotherapy is widely used for the treatment of cutaneous warts in primary care. However, evidence favours salicylic acid application. We compared the effectiveness of these treatments as well as a wait-and-see approach. Methods: Consecutive patients with new cutaneous warts were recruited in 30 primary care practices in the Netherlands between May 1, 2006, and Jan. 26, 2007. We randomly allocated eligible patients to one of three groups: cryotherapy with liquid nitrogen every two weeks, self-application of salicylic acid daily or a wait-and-see approach. The primary outcome was the proportion of participants whose warts were all cured at 13 weeks. Analysis was on an intention-to-treat basis. Secondary outcomes included treatment adherence, side effects and treatment satisfaction. Research nurses assessed outcomes during home visits at 4, 13 and 26 weeks. Results: Of the 250 participants (age 4 to 79 years), 240 were included in the analysis at 13 weeks (loss to follow-up 4%). Cure rates were 39% (95% confidence interval [CI] 29%-51%) in the cryotherapy group, 24% (95% CI 16%-35%) in the salicylic acid group and 16% (95% CI 9.5%-25%) in the wait-andsee group. Differences in effectiveness were most pronounced among participants with common warts (n = 116): cure rates were 49% (95% CI 34%-64%) in the cryotherapy group, 15% (95% CI 7%-30%) in the salicylic acid group and 8% (95% CI 3%-21%) in the wait-and-see group. Cure rates among the participants with plantar warts (n = 124) did not differ significantly between treatment groups. Interpretation: For common warts, cryotherapy was the most effective therapy in primary care. For plantar warts, we found no clinically relevant difference in effectiveness between cryotherapy, topical application of salicylic acid or a wait-and-see approach after 13 weeks. (ClinicalTrial.gov registration no. ISRCTN42730629).

Diagnostic accuracy of history taking and physical examination for assessing anterior cruciate ligament lesions of the knee in primary care (Article)

2010-09-01T00:00:00Z

Abstract OBJECTIVE: To assess the diagnostic accuracy of history taking and physical examination for assessing anterior cruciate ligament (ACL) lesions in primary care. DESIGN: Cross-sectional diagnostic study. SETTING: Primary care. PARTICIPANTS: Patients (N=134; age, 18-65y) who consulted their general practitioner (GP) within 5 weeks after injury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Index tests were obtained with a questionnaire and physical examination. Magnetic resonance imaging (MRI) was used as the reference test. Logistic regression analysis was used to determine associations with ACL lesions. Diagnostic accuracy was determined by calculating sensitivity (Se), specificity (Sp), predictive values, and likelihood ratio (LR). RESULTS: MRI showed an ACL lesion in 28 of 134 included patients. "Effusion," "popping sensation," "giving way," and "anterior drawer test (ADT)" showed associations with an ACL lesion (P<.05). Popping sensation showed Se, Sp, positive predictive value (PPV), and positive LR (LR(+)) of .63, .73, .39, and 2.3, respectively. Combining determinants from history taking (2 of 3 positive results regarding effusion, popping sensation, and giving way) improved diagnostic accuracy (Se, .71; Sp, .71; PPV, .42; and LR(+), 2.5). The ADT added diagnostic accuracy to these combinations (Se, .63; Sp, .85; PPV, .52; and LR(+), 4.2). CONCLUSIONS: ACL lesions are seen frequently. Based on history taking (effusion, popping sensation, and/or giving way) and physical examination (ADT), GPs can screen for ACL lesions in primary care.

Childhood abdominal pain in primary care: Design and patient selection of the HONEUR abdominal pain cohort (Article)

2010-04-15T00:00:00Z

Background: Abdominal pain in children is a common complaint presented to the GP. However, the prognosis and prognostic factors of childhood abdominal pain are almost exclusively studied in referred children. This cohort study aims at describing prognosis and prognostic factors of childhood abdominal pain in primary care. In this paper we describe methods used for data-collection and determine possible selective recruitment. Methods/Design. We conducted an observational, prospective cohort study with a 1-year follow-up. From May 2004 to March 2006, 53 Dutch GPs recruited consecutive children aged 4-17 years with a new episode of abdominal pain not preceded by a consultation for this complaint in the previous 3 months. Participants filled in standardized questionnaires, and faeces and urine were sampled. To evaluate selective recruitment, the electronic medical records of participating GPs were retrospectively searched for eligible non-included children. Discussion. This study allows us to describe prognosis and prognostic factors of childhood abdominal pain in primary care. A total of 305 children were included of whom 142 (46.6%) met predefined criteria for chronic/recurrent abdominal pain at presentation; from the total group of eligible children identified from the electronic medical record, 27% were included. The included children were significantly younger than non-included children (mean age 8.49 and 9.20 years). In proportion to identified eligible children, significantly less children diagnosed with "gastroenteritis" (6.8%) and significantly more children with "generalized abdominal pain" (39%) were included compared to the 27% that was expected. This cohort represents young school-aged children consulting GPs for a new episode of abdominal pain, not diagnosed as gastroenteritis. Almost half of them fulfil the criteria for chronic abdominal pain at presentation.

Association between Helicobacter pylori and gastrointestinal symptoms in children (Article)

2010-03-01T00:00:00Z

OBJECTIVE: Recurrent abdominal pain (RAP) and other gastrointestinal (GI) symptoms are common complaints among children. The role of Helicobacter pylori in the cause of these complaints remains controversial. Nevertheless, there is an increasing pressure on primary care clinicians to screen for H pylori infection in symptomatic children. We systematically reviewed the published evidence for an association between H pylori infection and GI symptoms in children. METHODS: Medline and Embase databases up to July 2009 were searched to identify studies that evaluated the association between H pylori and GI symptoms in children aged up to 18 years. When studies reported on abdominal pain without additional definition, thus not fulfilling Apley's criteria, we grouped these outcomes as unspecified abdominal pain (UAP). Methodologic quality was scored by using a standardized list of criteria, and crude odds ratios (ORs) with 95% confidence intervals (CIs) were calculated and pooled. RESULTS: Thirty-eight studies met our inclusion criteria: 23 casecontrol studies, 14 cross-sectional studies, and 1 prospective cohort study. The overall methodologic quality was low. Pooled ORs for the association between RAP and H pylori infection in children were 1.21 (95% CI: 0.82-1.78) in 12 case-control studies and 1.00 (95% CI: 0.76-1.31) in 7 cross-sectional studies. Meta-analysis of the association between UAP and H pylori infection in 6 hospital-based studies resulted in a pooled OR of 2.87 (95% CI: 1.62-5.09) compared with 0.99 (95% CI: 0.46 -2.11) in 5 population-based studies. Two of 3 studies concerning epigastric pain reported a statistically signi.cant positive association with H pylori infection. CONCLUSIONS: We found no association between RAP and H pylori infection in children and conflicting evidence for an association between epigastric pain and H pylori infection. We found evidence for an association between UAP but could not confirm this finding in children seen in primary care.

Functional constipation in children: A systematic review on prognosis and predictive factors (Article)

2010-03-01T00:00:00Z

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

Outcome of knee injuries in general practice: 1-year follow-up (Article)

2010-02-01T00:00:00Z

Abstract BACKGROUND: Knee injuries may lead to pain and to functional limitations in the activities of daily living. Patients with knee injuries are frequently seen in general practice; however, the outcome and management in these patients is not known. AIM: To assess the outcome and management of knee injuries at 12 months' follow-up in general practice. DESIGN OF STUDY: A prospective observational cohort study with a 1-year follow-up. SETTING: Primary health care. METHOD: Adult patients consulting their GP after knee injury (n = 134) participated in the cohort. A magnetic resonance imaging scan was carried out and patients were diagnosed as either no lesion or an isolated meniscal tear, an isolated collateral or cruciate ligament lesion, or a combination. Follow-up questionnaires were filled in up to 12 months' follow-up. RESULTS: At 12 months' follow-up, 34 patients reported full recovery and 67 patients reported major improvement. At baseline, 37 patients (28%) were referred to physical therapy and 17 patients (13%) were referred to secondary care. During 1 year of follow-up, another 21 referrals to physical therapy and 11 referrals to secondary care took place. The pain severity decreased the most, and the Lysholm knee score increased in the majority of patients during the first 3 months after injury. In total, 18 arthroscopies were performed in 15 patients. One patient underwent an anterior cruciate ligament reconstruction. CONCLUSION: The vast majority of patients report clinically relevant recovery. There is no clear difference in outcomes between patients with meniscal tears or ligament lesions and patients without these diagnoses.

Lack of benefit for prophylactic drugs of tension-type headache in adults: A systematic review (Article)

2009-12-22T00:00:00Z

Objective. To assess the efficacy and tolerability of prophylactic drugs for chronic tension-type headache (TTH) in adults. Methods. We searched several databases from inception to August 2009. We selected randomized trials that reported the effects of prophylactic drugs in patients with TTH, with a pain measure (intensity, frequency, duration, improvement or index) as outcome measure. Two authors independently assessed risk of bias and extracted data from the original reports. A data synthesis was carried out according to the type of medication. Results. We included 44 trials (3399 patients), of which 15 (34.1%) were considered to be of low risk of bias. Main types of medications studied were antidepressants, muscle relaxants, benzodiazepines and vasodilator agents. Overall, antidepressants were no more effective than placebo, and there were no significant differences between different types of antidepressants. There was conflicting evidence about the effectiveness of benzodiazepines and vasodilator agents compared with placebo. Furthermore, there was limited evidence that propranolol had negative effects on depression in TTH patients, when compared with placebo or biofeedback. There was no evidence concerning the effectiveness of muscle relaxants alone or 5-HT receptor agonist compared with placebo. Conclusions. Overall, antidepressants were no more effective on headache intensity or frequency and analgesic use than placebo. Propranolol seemed to have negative effects on depression in TTH patients when compared with placebo or biofeedback. No evidence was found for the use of muscle relaxants alone or 5-HT receptor agonist.

Supervised exercise therapy versus usual care for patellofemoral pain syndrome: an open label randomised controlled trial. (Article)

2009-11-24T00:00:00Z

OBJECTIVE: To assess the effectiveness of supervised exercise therapy compared with usual care with respect to recovery, pain, and function in patients with patellofemoral pain syndrome. DESIGN: Open label randomised controlled trial. SETTING: General practice and sport physician practice. PARTICIPANTS: Patients with a new episode of patellofemoral pain syndrome recruited by their general practitioner or sport physician. INTERVENTIONS: The intervention group received a standardised exercise programme for 6 weeks tailored to individual performance and supervised by a physical therapist, and were instructed to practise the tailored exercises at home for 3 months. The control group were assigned usual care, which comprised a "wait and see" approach of rest during periods of pain and refraining from pain provoking activities. Both the intervention group and the control group received written information about patellofemoral pain syndrome and general instructions for home exercises. MAIN OUTCOME MEASURES: The primary outcomes were self reported recovery (7 point Likert scale), pain at rest and pain on activity (0-10 point numerical rating scale), and function (0-100 point Kujala patellofemoral score) at 3 months and 12 months follow-up. RESULTS: A total of 131 participants were included in the study: 65 in the intervention group and 66 in the control group. After 3 months, the intervention group showed better outcomes than the control group with regard to pain at rest (adjusted difference -1.07, 95% confidence interval -1.92 to -0.22; effect size 0.47), pain on activity (-1.00, -1.91 to -0.08; 0.45), and function (4.92, 0.14 to 9.72; 0.34). At 12 months, the intervention group continued to show better outcomes than the control group with regard to pain (adjusted difference in pain at rest -1.29, -2.16 to -0.42; effect size 0.56; pain on activity -1.19, -2.22 to -0.16; effect size 0.54), but not function (4.52, -0.73 to 9.76). A higher proportion of patients in the exercise group than in the control group reported recovery (41.9% v 35.0% at 3 months and 62.1% v 50.8% at 12 months), although the differences in self reported recovery between the two groups were not statistically significant. Predefined subgroup analyses revealed that patients recruited by sport physicians (n=30) did not benefit from the intervention, whereas those recruited by general practitioners (n=101) showed significant and clinically relevant differences in pain and function in favour of the intervention group. CONCLUSION: Supervised exercise therapy resulted in less pain and better function at short term and long term follow-up compared with usual care in patients with patellofemoral pain syndrome in general practice. Exercise therapy did not produce a significant difference in the rate of self reported recovery. TRIAL REGISTRATION: ISRCTN83938749.

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

2009-10-01T00:00:00Z

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

Behavioral treatments of chronic tension-type headache in adults: Are they beneficial? (Article)

2009-06-01T00:00:00Z

To assess the efficacy of behavioral treatments in patients with tension headache. Medline, Cinahl, EMBASE, and the Cochrane library were searched from inception to October 2007 and reference lists were checked. We selected randomized trials evaluating behavioral treatments (e.g., relaxation, electromyographic EMG biofeedback, and cognitive behavioral training) in patients with tension-type headache (TTH). We assessed the risk of bias using the Delphi list and extracted data from the original reports. A qualitative analysis was carried out. We found 44 trials (2618 patients), which were included in this review, of which only 5 studies (11.4%) were considered to have low risk of bias. Most trials lacked adequate power to show statistical significant differences, but frequently, recovery/improvement rates did not reach clinical relevance. In 8 studies, relaxation treatment was compared with waiting list conditions, and in 11 studies, biofeedback was compared with waiting list conditions, both showing inconsistent results. On the basis of the available literature, we found no indications that relaxation, EMG biofeedback, or cognitive behavioral treatment is better than no treatment, waiting list, or placebo controls.

Author's reply to 'Sublingual immunotherapy in children: More optimism today': Letter to the Editor (Article)

2009-06-01T00:00:00Z

Prognostic factors in adults with knee pain in general practice (Article)

2009-02-15T00:00:00Z

Objective. To predict the 1-year outcome of incident nontraumatic knee symptoms in adults presenting in general practice. Methods. Adults age >35 years with nontraumatic knee symptoms (n = 480) were followed for 1 year. At baseline, data on knee symptoms and demographics were collected and a physical examination performed. Knee symptoms were assessed by self-report questionnaires at 3-month intervals. After 1 year the physical examination was repeated. Multivariate prognostic regression models of patient characteristics, symptom characteristics, and physical examination were used to predict persisting knee symptoms after 1 year. Areas under receiving operating characteristic curves (AUCs) were used to determine the predictive value of the model. To assess the added predictive value of symptom characteristics and physical examination, these models were added to the model of patient characteristics. The improvement was expressed as the difference between the 2 AUCs. Results. In the multivariate prognostic model of patient characteristics, age >60 years, educational level, kinesophobia, and comorbidity of the skeletal system were associated with persistent knee symptoms after 1 year (AUC 0.67). Of the symptom characteristics, history of nontraumatic knee symptoms, bilateral symptoms, and duration of symptoms > 3 months were associated (AUC 0.73). For determinants of physical examination, crepitus of passive extension was associated (AUC 0.55). The added value of the symptom characteristics model to the patient characteristics model was 0.09 (AUC 0.76). Physical examination added no further value. Conclusion. Symptom characteristics are the strongest predictors of persisting knee symptoms at 1-year followup. Physical examination has no added value in predicting persistent knee symptoms in general practice.

Currently recommended treatments of childhood constipation are not evidence based: A systematic literature review on the effect of laxative treatment and dietary measures (Article)

2009-02-01T00:00:00Z

Introduction: Constipation is a common complaint in children and early intervention with oral laxatives may improve complete resolution of functional constipation. However, most treatment guidelines are based on reviews of the literature that do not incorporate a quality assessment of the studies. Objective: To investigate and summarise the quantity and quality of the current evidence for the effect of laxatives and dietary measures on functional childhood constipation. Methods: The Medline and Embase databases were searched to identify studies evaluating the effect of a medicamentous treatment or dietary intervention on functional constipation. Methodological quality was assessed using a validated list of criteria. Data were statistically pooled, and in case of clinical heterogeneity results were summarised according to a best evidence synthesis. Results: Of the 736 studies found, 28 met the inclusion criteria. In total 10 studies were of high quality. The included studies were clinically and statistically heterogeneous in design. Most laxatives were not compared to placebo. Compared to all other laxatives, polyethylene glycol (PEG) achieved more treatment success (pooled relative risk (RR): 1.47; 95% CI 1.23 to 1.76). Lactulose was less than or equally effective in increasing the defecation frequency compared to all other laxatives investigated. There was no difference in effect on defecation frequency between fibre and placebo (weighted standardised mean difference 0.35 bowel movements per week in favour of fibre, 95% CI -0.04 to 0.74). Conclusion: Insufficient evidence exists supporting that laxative treatment is better than placebo in children with constipation. Compared to all other laxatives, PEG achieved more treatment success, but results on defecation frequency were conflicting. Based on the results of this review, we can give no recommendations to support one laxative over the other for childhood constipation.

Diagnostic Value of History Taking and Physical Examination to Assess Effusion of the Knee in Traumatic Knee Patients in General Practice (Article)

2009-01-01T00:00:00Z

Kastelein M, Luijsterburg PA, Wagemakers HP, Bansraj SC, Berger MY, Koes BW, Bierma-Zeinstra SM. Diagnostic value of history taking and physical examination to assess effusion of the knee in traumatic knee patients in general practice. Objective: To assess the diagnostic value of history taking and physical examination for knee joint effusion in patients with a knee injury who consult their general practitioner (GP). In addition, to determine the association between effusion seen on magnetic resonance imaging (MRI) and internal derangement of the knee. Design: Prospective, observational cohort study. Setting: Primary care. Participants: Patients (N=134) aged 18 to 65 years with a traumatic knee injury who consulted their GP. Interventions: Not applicable. Main Outcome Measures: Patients filled out a questionnaire, underwent a standardized physical examination and underwent an MRI scan to assess the presence of effusion. Multivariate logistic regression analysis was used to determine the diagnostic value of history taking and physical examination (P<0.10) as assessed by sensitivity, specificity, predictive values, and likelihood ratios. The relationship between effusion and internal derangement of the knee was assessed with a chi-square test. Results: Of the 134 participating patients, 42 had knee joint effusion seen on MRI. Multivariate analysis showed an association with knee joint effusion for the symptom "self-noticed swelling" (history taking) and for the "ballottement test" (physical examination). The likelihood ratio positive (LR+) was 1.5 for self-noticed swelling and 1.6 for the ballottement test. These 2 combined improved the diagnostic value to an LR+ of 3.6. Effusion showed a positive association with internal derangement of the knee (chi-square 9.5); 31 of the 42 patients with knee joint effusion had internal derangement of the knee. Conclusions: In patients with traumatic knee injury, knee joint effusion is frequently seen on MRI. The combination of self-noticed swelling and the ballottement test was of diagnostic value. Knee joint effusion was associated with internal derangement of the knee.

Randomized double-blind placebo-controlled trial of sublingual immunotherapy in children with house dust mite allergy in primary care: Study design and recruitment (Article)

2008-11-17T00:00:00Z

Background. For respiratory allergic disorders in children, sublingual immunotherapy has been developed as an alternative to subcutaneous immunotherapy. Sublingual immunotherapy is more convenient, has a good safety profile and might be an attractive option for use in primary care. A randomized double-blind placebo-controlled study was designed to establish the efficacy of sublingual immunotherapy with house dust mite allergen compared to placebo treatment in 6 to18-year-old children with allergic rhinitis and a proven house dust mite allergy in primary care. Described here are the methodology, recruitment phases, and main characteristics of the recruited children. Methods. Recruitment took place in September to December of 2005 and 2006. General practitioners (in south-west Netherlands) selected children who had ever been diagnosed with allergic rhinitis. Children and parents could respond to a postal invitation. Children who responded positively were screened by telephone using a nasal symptom score. After this screening, an inclusion visit took place during which a blood sample was taken for the RAST test. Results. A total of 226 general practitioners invited almost 6000 children: of these, 51% was male and 40% <12 years of age. The target sample size was 256 children; 251 patients were finally included. The most frequent reasons given for not participating were: absence or mildness of symptoms, absence of house dust mite allergy, and being allergic to grass pollen or tree pollen only. Asthma symptoms were reported by 37% of the children. Of the enrolled children, 71% was sensitized to both house dust mite and grass pollen. Roughly similar proportions of children were diagnosed as being sensitized to one, two, three or four common inhalant allergens. Conclusion. Our study was designed in accordance with recent recommendations for research on establishing the efficacy of sublingual immunotherapy; 98% of the target sample size was achieved. This study is expected to provide useful information on sublingual immunotherapy with house dust mite allergen in primary care. The results on efficacy and safety are expected to be available by 2010. Trial registration. the trial is registered as ISRCTN91141483 (Dutch Trial Register).

Sublingual immunotherapy in youngsters: Adherence in a randomized clinical trial (Article)

2008-10-01T00:00:00Z

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

Prognosis of chronic or recurrent abdominal pain in children (Article)

2008-09-01T00:00:00Z

Background: Chronic abdominal pain (CAP) or recurrent abdominal pain is common in childhood and is rarely associated with organic disease. With modern diagnostic technology, new organic abnormalities are found in children with CAP. Thus far a causal relation between these abnormalities and CAP has not been established. The additional prognostic value of extensive testing of children with CAP is a subject of debate. Objectives: To investigate how often abdominal pain persists in children with CAP and to investigate whether medical tests such as laboratory tests, imaging, and endoscopy have additional prognostic value to history taking and clinical examination. Materials and Methods: A systematic search was conducted in MEDLINE, EMBASE, and PsycINFO for prospective cohort studies published from 1960 until October 2005. The most common medical key words for CAP were used in our search strategy. The methodological quality of studies was determined. Clinical heterogeneity between studies was analyzed. The percentages of children with abdominal pain after follow-up were pooled. Results: The search yielded 2620 citations, of which 18 studies met the inclusion criteria. In total, 1331 children were followed up for 5 years (median, range 1-29 years). In total, 29.1% (95% CI 28.1-30.2) of patients with CAP had abdominal pain after follow-up. The prognosis of CAP diagnosed clinically was similar to that diagnosed after additional medical testing. Conclusions: CAP persisted in 29.1% (95% CI 28.1-30.2) of children. In the absence of alarming symptoms, additional diagnostic testing did not influence the prognosis of CAP.

Lysholm scale and WOMAC index were responsive in prospective cohort of young general practice patients (Article)

2008-05-01T00:00:00Z

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

Immunotherapy in children and adolescents with allergic rhinoconjunctivitis: A systematic review (Article)

2008-05-01T00:00:00Z

Allergen-specific immunotherapy is one of the cornerstones of allergic rhinoconjunctivitis treatment. Since the development of non-invasive administration forms with better safety profiles, there is an increasing tendency to prescribe immunotherapy in youngsters. However, no overview is available on the efficacy of immunotherapy in all its different administration forms in youngsters. Therefore, we systematically reviewed randomized controlled trials (RCTs) to evaluate the effect of immunotherapy with inhalant allergens on symptoms and medication use in children and adolescents with allergic rhinoconjunctivitis. Medline, EMBASE, the Cochrane Controlled Clinical Trials Register and reference lists of recent reviews and published trials were searched. RCTs including youngsters aged 0-18 yr with allergic rhinoconjunctivitis and comparing immunotherapy with placebo, symptomatic treatment or a different administration form of immunotherapy were included. Primary outcome measures were rhinoconjunctivitis symptom and/or medication scores. Methodological quality was assessed using the validated Delphi list. A method of best evidence synthesis, a rating system with levels of evidence based on the overall quality and the outcome of the trials, was used to assess efficacy. Six subcutaneous (SCIT), four nasal (LNIT), seven oral (OIT) and 11 sublingual (SLIT) immunotherapy trials, comprising 1619 youngsters, were included. Only 39% of the trials were of high methodological quality. For the SCIT and OIT subgroups the level of evidence for efficacy was conflicting. Moderate evidence of effect was found for LNIT. Analysis of the SLIT subgroup showed no evidence of effect. The evidence for the perennial and seasonal allergen trials within the subgroups varied from moderate evidence of effect to no evidence of effect. In conclusion, there is at present insufficient evidence that immunotherapy in any administration form has a positive effect on symptoms and/or medication use in children and adolescents with allergic rhinoconjunctivitis.

Knee complaints seen in general practice: Active sport participants versus non-sport participants (Article)

2008-04-09T00:00:00Z

Background. Since knee complaints are common among athletes and are frequently presented in general practice, it is of interest to investigate the type of knee complaints represented in general practice of athletes in comparison with those of non-athletes. Therefore, the aim of this study is to investigate the differences in type of knee complaints between sport participants, in this study defined as athletes, and non-sport participants, defined as non-athletes, presenting in general practice. Further, differences in the initial policy of the GP, medical consumption, and outcome at one-year follow-up were also investigated. Methods. Patients consulting their GP for a new episode of knee complaints were invited to participate in this prospective cohort study. From the total HONEUR knee cohort population (n = 1068) we extracted patients who were athletes (n = 421) or non-athletes (n = 388). Results. The results showed that acute distortions of the knee were significantly more diagnosed in athletes than in non-athletes (p = 0.04). Further, more athletes were advised by their GP to 'go easy on the knee' than the non-athletes (p < 0.01), but no differences were found in number of referrals and medication prescribed by the GP. The medical consumption was significantly higher among athletes; however, no significant differences were found between the two groups for recovery at one-year follow-up. Conclusion. There are no major differences in the diagnosis and prognosis of knee complaints between athletes and non-athletes presented to the GP. This implies that there are no indications for different treatment strategies applied in both groups. However, athletes are more often advised to 'go easy on the knee' and to rest than non-athletes. Further, there is a trend towards increased medical consumption among athletes while functional disability and pain are lower than among the non-athletes.

Diagnostic value of history-taking and physical examination for assessing meniscal tears of the knee in general practice (Article)

2008-01-01T00:00:00Z

OBJECTIVE: To assess the diagnostic value of history-taking and physical examination of meniscal tears in general practice. DESIGN: An observational study determining diagnostic values (sensitivity, specificity, predictive value, and likelihood ratios). SETTING: General practice. PATIENTS: Consecutive patients aged 18 to 65 years with a traumatic knee injury who consulted their general practitioner within 5 weeks after trauma. ASSESSMENT: Participating patients filled out a questionnaire (history-taking) followed by a standardized physical examination. MAIN OUTCOME: Assessment of meniscal tears was determined by means of magnetic resonance imaging (MRI) and was performed blinded for the results of physical examination and history-taking. RESULTS: Of the 134 patients included in this study, 47 had a meniscal tear. From history-taking, the determinants "age over 40 years," "continuation of activity impossible," and "weight-bearing during trauma" indicated an association with a meniscal tear after multivariate logistic regression analysis, whereas from physical examination only "pain at passive flexion" indicated an association. These associated determinants from history-taking showed some diagnostic value; the positive likelihood ratio (LR+) reached up to 2.0 for age over 40 years, whereas the isolated test pain at passive flexion from physical examination has less diagnostic value, with an LR+ of 1.3. Combining determinants from history-taking and physical examination improved the diagnostic value with a maximum LR+ of 5.8; however, this combination only applied to a limited number of patients. CONCLUSION: History-taking has some diagnostic value, whereas physical examination did not add any diagnostic value for detecting meniscal tears in general practice.

Allergic rhinoconjunctivitis in children (Article)

2007-11-10T00:00:00Z

Sublingual immunotherapy with grass pollen is not effective in symptomatic youngsters in primary care (Article)

2007-04-01T00:00:00Z

Background: Sublingual immunotherapy (SLIT) is considered safer and more convenient than subcutaneous therapy and therefore has been proposed as especially suitable for children and in primary care. Most efficacy studies in children lack power to be conclusive, and all have been performed in referral centers. Objective: To investigate the efficacy of SLIT with grass pollen allergen in children and adolescents with rhinoconjunctivitis in a primary care setting. Methods: Youngsters aged 6-18 years with hay fever were enrolled from general practices and randomly assigned to receive placebo or grass pollen mix for 2 years. The primary outcome was the mean daily total symptom score (scale 0-15) comprising sneezing, itching nose, watery running nose, nasal blockage, and itching eyes during the months May-August of the second treatment year. Results: Out of 204 youngsters randomized, 168 entered the intention-to-treat analysis (91 verum, 77 placebo). The mean daily total symptom score did not differ between participants allocated to verum and those allocated to placebo (difference for verum minus placebo: -0.08, 95%CI, -0.66-0.50; P = .78). No differences were found for rescue medication-free days, disease-specific quality of life, and overall evaluation of the treatment effect. Local side effects were more frequent in the verum group (39% vs 17% of participants; P = .001). Conclusion: Sublingual immunotherapy with grass pollen in a primary care setting is not effective in children and adolescents. Clinical implications: Currently, SLIT cannot be recommended for general practitioners as a therapeutic modality in youngsters with grass pollen allergy.

Prognostic factors of progression of osteoarthritis of the knee: A systematic review of observational studies (Article)

2007-02-15T00:00:00Z

Objective. To provide an overview of prognostic factors of knee osteoarthritis (OA) progression. Methods. We searched Medline and Embase up to December 2003 according to a specified search strategy (keywords for disease, location, and study design). Studies that fulfilled predefined criteria were assessed for methodologic quality. Study characteristics and associations were extracted and the results were summarized according to a best evidence synthesis. Results. Of the 1,004 studies found, 37 met the inclusion criteria. Methodologic quality was assessed and only high-quality studies were included (n = 36). The best evidence synthesis yielded strong evidence that hyaluronic acid serum levels and generalized OA are predictive for progression of knee OA. Sex, knee pain, radiologic severity, knee injury, quadriceps strength, and regular sport activities were not predictive. Conflicting evidence for associations was found for several factors including body mass index and age. Limited evidence for an association with progression of knee OA was found for several factors, including the alignment (varus/valgus) of the joint. Limited evidence for no association with progression of OA was also found for several factors, including meniscectomy, several markers of bone or cartilage turnover, and the clinical diagnosis of localized OA. Conclusion. Generalized OA and level of hyaluronic acid seem to be associated with the radiologic progression of knee OA. Knee pain, radiologic severity at baseline, sex, quadriceps strength, knee injury, and regular sport activities seem not to be related. For other factors, the evidence was limited or conflicting.

Human Bocavirus in Febrile Children Consulting a GP Service in the Netherlands (Letter To Editor)

2007-01-01T00:00:00Z

Human bocavirus (HBoV) was detected in nasopharyngeal swabs of 1.6% (95% CI 0.4% to 3.9%) of 257 febrile children presented to a GP center. Symptoms of respiratory tract infection, gastrointestinal symptoms and skin rash were reported. Our results suggest HBoV as a pathogen causing mild disease in non-hospitalized febrile children.

The PEX study - Exercise therapy for patellofemoral pain syndrome: design of a randomized clinical trial in general practice and sports medicine [ISRCTN83938749]. (Article)

2006-03-17T00:00:00Z

BACKGROUND: Patellofemoral complaints are frequently seen in younger and active patients. Clinical strategy is usually based on decreasing provoking activities as sports and demanding knee activities during work and leisure and reassuring the patient on the presumed good outcome.Exercise therapy is also often prescribed although evidence on effectiveness is lacking.The objective of this article is to present the design of a randomized clinical trial that examines the outcome of exercise therapy supervised by a physical therapist versus a clinically accepted "wait and see" approach (information and advice about the complaints only).The research will address to both effectiveness and cost effectiveness of supervised exercise therapy in patients with patellofemoral pain syndrome (PFPS). METHODS/DESIGN: 136 patients (adolescents and young adults) with patellofemoral pain syndrome are recruited in general practices and sport medicine centers. They will be randomly allocated receiving either 3 months of exercise therapy (or usual care.The primary outcome measures are pain, knee function and perception of recovery after 3 months and 12 months of follow up and will be measured by self reporting.Measurements will take place at baseline, 6 weeks, and 3 monthly until 1 year after inclusion in the study.Secondary outcome measurements include an economic evaluation.A cost-utility analysis will be performed that expresses health improvements in Quality Adjusted Life Years (QALYs) and incorporates direct medical costs and productivity costs DISCUSSION: This study has been designed after reviewing the literature on exercise therapy for patellofemoral pain syndrome. It was concluded that to merit the effect of exercise therapy a trial based on correct methodological concept needed to be executed.The PEX study is a randomized clinical trial where exercise therapy is compared to usual care. This trial started in April 2005 and will finish in June 2007. The first results will be available around December 2007.

Symptomatic treatment of migraine in children: a systematic review of medication trials. (Article)

2005-12-01T00:00:00Z

OBJECTIVE: Treatment of pediatric migraine includes an individually tailored regimen of both nonpharmacologic and pharmacologic measures. The mainstay of symptomatic treatment in children with migraine is intermittent oral or suppository analgesics, but there is no coherent body of evidence on symptomatic treatment of childhood migraine available. The objective of this review is to describe and assess the evidence from randomized and clinical controlled trials concerning the efficacy and tolerability of symptomatic treatment of migraine in children. DESIGN: Systematic review according to the standards of the Cochrane Collaboration. METHODS: Databases were searched from inception to June 2004. Additional reference checking was performed. Two authors independently selected randomized and controlled trials evaluating the effects of symptomatic treatment in children (<18 years old) with migraine, using headache (HA) clinical improvement as an outcome measure. Two authors assessed trial quality independently by using the Delphi list, and data were extracted from the original reports by using standardized forms. Quantitative and qualitative analysis was conducted according to type of intervention. RESULTS: A total of 10 trials were included in this review, of which 6 studies were considered to be of high quality. The number of included participants in each trial ranged from 14 to 653, with a total of 1575 patients included in this review. Mean dropout rate was 19.8% (range: 0-39.1%), and the mean age of participants was 11.7 +/- 2.2 years (range: 4-18 years). All studies used HA diaries to assess outcomes. In most studies, a measure of clinical improvement was calculated by using these diaries. Improvement often was regarded as being clinically relevant when the patients' HA declined by > or =50%. Regarding oral analgesic treatment, the effectiveness of acetaminophen, ibuprofen, and nimesulide were evaluated. When compared with placebo, acetaminophen (relative risk [RR]: 1.5; 95% confidence interval [CI]: 1.0-2.1) and ibuprofen (pooled RR: 1.5; 95% CI: 1.2-1.9) significantly reduced HAs. We conclude that there is moderate evidence that both acetaminophen and ibuprofen are more effective in reduction of symptoms 1 and 2 hours after intake than placebo with minor adverse effects. No clear differences in effect were found between acetaminophen and ibuprofen or nimesulide. Regarding the nonanalgesic interventions, nasal-spray sumatriptan, oral sumatriptan, oral rizatriptan, oral dihydroergotamine, intravenous prochlorperazine, and ketorolac were evaluated. When compared with placebo, nasal-spray sumatriptan (pooled RR: 1.4; 95% CI: 1.2-1.7) seemed to significantly reduce HAs. We conclude that there is moderate evidence that nasal-spray sumatriptan is more effective in reduction of symptoms than placebo but with significantly more adverse events. No differences in effect were found between oral triptans and placebo. All medications were well tolerated, but significantly more adverse events were reported for nasal-spray sumatriptan compared with placebo. We also conclude that there is moderate evidence that intravenous prochlorperazine is more effective than intravenous ketorolac in the reduction of symptoms 1 hour after intake. No differences in effect were found between oral dihydroergotamine and placebo. CONCLUSIONS: Acetaminophen, ibuprofen, and nasal-spray sumatriptan are all effective symptomatic pharmacologic treatments for episodes of migraine in children. The new frontier for symptomatic treatment is likely to be the development of triptan agents for use in children. Most treatments have only been evaluated in 1 or 2 studies, which limits the generalizability of the findings. We strongly recommend performing a large, high-quality randomized, controlled trial evaluating different symptomatic medications compared with each other or to placebo treatment. Favorable high-quality studies should be performed and reported according to the CONSORT statement. Clinical improvement of HA should be used as the primary outcome measure, but quality of life, days missed at school, and satisfaction of child or parents should also be used as an outcome measure in future studies.

Knee disorders in primary care: design and patient selection of the HONEUR knee cohort. (Article)

2005-08-23T00:00:00Z

BACKGROUND: Knee complaints are a frequent reason for consultation in general practice. These patients constitute a specific population compared to secondary care patients. However, information to base treatment decisions on is generally derived from specialistic settings. Our cohort study is aimed at collecting knowledge about prognosis and prognostic factors of knee complaints presented in a primary care setting. This paper describes the methods used for data collection, and discusses potential selectiveness of patient recruitment. METHODS: This is a descriptive prospective cohort study with one-year follow-up. 40 Dutch GPs recruited consecutive patients with incident knee complaints aged 12 years and above from October 2001 to October 2003. Patients were assessed with questionnaires and standardised physical examinations. Additional measurements of subgroups included MRI for recent knee traumas and device assessed function measurements for non-traumatic patients. After the inclusion period we retrospectively searched the computerized medical files of participating GPs to obtain a sample to determine possible selective recruitment. We assessed differences in proportions of gender, traumatic onset of injury and age groups between participants and non-participants using Odds Ratios (OR) and 95% confidence intervals. RESULTS: We recruited 1068 patients. In a sample of 310 patients visiting the GP, we detected some selective recruitment, indicating an underrepresentation of patients aged 12 to 35 years (OR 1.70; 1.15-2.77), especially among men (OR 2.16; 1.12-4.18). The underrepresentation of patients with traumatic onset of injury was not statistically significant. CONCLUSION: This cohort is unique in its size, setting, and its range of both age and type of knee complaints. We believe the detected selective recruitment is unlikely to introduce significant bias, as the cohort will be divided into subgroups according to age group or traumatic onset of injury for future analyses. However, the underrepresentation of men in the age group of 12 to 35 years of age warrants caution. Based on the available data, we believe our cohort is an acceptable representation of patients with new knee complaints consulting the GP, and we expect no problems with extrapolation of the results to the general Dutch population.

Diagnostic value of abdominal radiography in constipated children: a systematic review. (Article)

2005-07-01T00:00:00Z

BACKGROUND: Constipation is a common problem in children. Diagnosis is based on clinical features. In case of doubt about the presence of constipation, the existence of fecal retention can be evaluated on plain abdominal radiography. OBJECTIVES: To describe and to assess the evidence from observational, controlled studies concerning the association between abdominal radiography and symptoms and signs related to constipation in children. METHODS: MEDLINE was searched from inception to April 2004 using a specified search strategy. Studies that fulfilled predefined criteria were assessed for methodological quality. Study characteristics and associations were extracted and the results were summarized according to a best-evidence synthesis. RESULTS: Of the 392 publications identified, 6 studies met the inclusion criteria. Only 2 studies were of high methodological quality. The best-evidence synthesis yielded conflicting evidence for an association between a clinical and a radiological diagnosis of constipation. The likelihood ratio (LR) in 2 high-quality studies was close to 1 (LR, 1.2; 95% confidence interval [CI], 1.0-1.4; and LR, 1.0; 95% CI, 0.5-1.6). Conflicting evidence was found for an association between digital rectal examination and fecal impaction on radiography. Limited evidence was found for an association between a history of hard stool and a finding of rebound tenderness and radiography (LR, 1.2; 95% CI, 1.0-1.4; and LR, 1.1; 95% CI, 1.0-1.2, respectively). CONCLUSIONS: The limited amount of data available shows conflicting evidence for an association between clinical symptoms of constipation and fecal loading on abdominal radiographs in children. The recommendation to perform a plain abdominal radiograph in case of doubt of the presence of constipation in a child cannot be supported. Further research of good methodological quality is needed.

Is biliary pain exclusively related to gallbladder stones? A controlled prospective study (Article)

2004-01-01T00:00:00Z

BACKGROUND: The uncertainty around true clinical manifestations of gallbladder stone disease is in contrast with the unanimous recommendation that only symptomatic gallstones should be treated. AIM: To evaluate the relationship between biliary pain, other gastrointestinal symptoms and gallstones. DESIGN OF STUDY: A pragmatic, prospective cohort questionnaire study. SETTING: Seventy-five general practices in Rotterdam, The Netherlands. METHOD: All patients suspected by their general practitioner (GP) to have gallstone disease underwent ultrasound examination of the upper abdomen. Using a self-administered questionnaire, the presence of 11 gastrointestinal symptoms was assessed at inclusion and after 1 year. Likelihood ratios (LRs) for the presence of gallstones and symptom relief rates after 1 year were calculated. The mean difference in health status at inclusion and after follow-up was calculated for patients without gallstones, for patients with gallstones who were operated on and for patients with gallstones who were not operated on. RESULTS: In total, 61% of the patients with gallstones diagnosed by ultrasound scan reported biliary pain, as did 45% of the patients without gallstones (LR = 1.34, 95% confidence interval [CI] = 1.05 to 1.71). Patients operated on for gallstone disease did not show significant relief of biliary pain compared to patients not operated on for gallstones or patients without gallstones (87%, 63% and 83%, respectively). Health status improved in all patients. The mean improvement in health status did not differ between the three patient groups. GPs were able to discriminate between patients with high and low probability of gallbladder stones by ultrasound examination (53% versus 23%). This selection, however, did not predict the outcome of cholecystectomy. CONCLUSION: Neither biliary pain nor any other gastrointestinal symptom was consistently related to gallstone disease. Therefore, the indication for elective cholecystectomy cannot be based on the presence of biliary pain alone. Relief of biliary pain in patients operated on for gallstones should not simply be attributed to a successful cholecystectomy.

The clinical value of abdominal symptoms and sonography in gallstone disease (Doctoral Thesis)

2000-04-20T00:00:00Z

Gallstones are a very common finding in adults of Western industrialised countries. At age 60 almost 30% of women and 20% of men will have developed gallstones (Fig. 11-6). Gallstones are rare in children. The prevalence of gallstones is most probably equal between the sexes until puberty, whereafter prevalence increases faster with increasing age among women than men. Gallstones occur more among women than among men at almost every age. After the menopause, the increase seems fairly equal in the two sexes with a marked narrowing of the gender gap with advancing age.