The diagnosis of allergic rhinitis: how to combine the medical history with the results of radioallergosorbent tests and skin prick tests.

OBJECTIVE: To identify the most useful combinations of symptoms and the results of radioallergosorbent tests (RASTs) and skin prick tests (SPTs) for the diagnosis of allergic rhinitis. DESIGN: A prospective comparison was made of symptoms and the results of RASTs and SPTs with 7 different nasal allergies; the references used were the "consensus diagnoses" provided by 3 experts. SETTING: Nineteen general practices in The Netherlands. PATIENTS: 365 consecutive patients aged 12 or over who visited their general practitioner because of chronic or recurrent nasal symptoms between 1 March 1990 and 1 March 1991. MAIN OUTCOME MEASURES: The most useful combinations of items from the history, RASTs, and SPTs, for the diagnosis of 7 different nasal allergies; the predictive probabilities of these combinations. RESULTS: Diagnostic criteria could be drawn up resulting in a near-perfect discrimination between patients diagnosed as having allergic rhinitis and patients diagnosed as not having allergic rhinitis. Most of these criteria combined only a single item from the history with either RAST or SPT. For nearly all nasal allergies, both the negative predictive probabilities and the positive predictive probabilities were 97% or more. CONCLUSIONS: The common nasal allergies can be diagnosed with a very high certainty with the aid of simple diagnostic criteria. Data from a strictly limited case history combined with either RAST or SPT are sufficient.

Prevalence of depression and clues to focus diagnosis. A study among Dutch general practice patients 65+ years of age.

AIMS: To assess the prevalence of depression in elderly patients presenting in general practice, and to assess which patient characteristics and presenting symptoms are useful clues for predicting depression. DESIGN: Cross-sectional survey based on data collected at the presenting consultation and at a subsequent domiciliary interview. SUBJECTS AND SETTING: 580 of 706 consecutive patients aged 65+ years consulting 13 general practitioners in the Netherlands. METHOD: GPs entered data on presenting symptoms and their assessment of psychological state during the consultation. Formal psychiatric assessment was subsequently done at home using the Diagnostic Interview Schedule (plus additional questions to assess minor depression according to ICHPPC-2-Defined). Major depression and dysthymia were assessed with the Diagnostic Interview Schedule. RESULTS: The estimated prevalence of depression (both major and minor plus dysthymia) was 7.9%, and was very similar whether based on GP assessment or formal validated interview schedule, but the GPs did not identify the same patients as the formal psychiatric assessment. GPs identified only 26% (95% CI 4-71%) of patients with major depression. Clinical clues which could help the GP to suspect underlying depression were female gender, the presentation of vague symptoms, and gastrointestinal symptoms. CONCLUSIONS: Although presentation of symptoms does provide some clues about the likelihood of underlying depression, the sensitivity of GP diagnosis remains low and needs to be improved.

Health-related quality of life assessments in osteoarthritis during NSAID treatment.

There is some evidence that nabumetone (1000 mg once daily) in comparison with piroxicam (20 mg once daily) in patients with OA in general practice is associated with a lower incidence and less severe occurrence of stomach pain but with more withdrawals due to lack of efficacy. The aim of this analysis was to investigate whether these differences are reflected in health-related quality of life assessments. Patients (n = 198) included in this study were selected in general practice according to a protocol. The patients were randomized and treated for a period of six weeks. Clinical assessments were performed by the general practitioner (CP) during treatment. The Sickness Impact Profile (SIP), the Activities of Daily Living (ADL), and a pain questionnaire were filled out by the patients before and after treatment. As measured with the SIP, the ADL and the pain questionnaire, there were no significant differences between nabumetone and piroxicam. The correlations between (changes in) patient assessments and (changes in) clinical assessments were low. The differences between the two drugs regarding withdrawals and adverse events were not reflected by patient health-related quality of life assessments. There was a low correlation between patient health-related quality of life assessment and clinical assessments. To get a complete picture of the efficacy and safety of a drug, patient health-related quality of life assessments should be a part of a clinical trial.

Health-related quality of life in patients with osteoarthritis in a family practice setting.

OBJECTIVE: To study the impact of osteoarthritis (OA) on all areas of a patient's health-related quality of life. METHODS: The Sickness Impact Profile (SIP) was administered to a group of patients with OA selected from a family medicine setting. The results were compared to a reference population, stratified by age, and adjusted for sex. RESULTS: OA was associated with significant impairment, and had an important impact on, health-related quality of life in the areas of ambulation, body care and movement, emotional behavior, sleep and rest, home management, and work, especially in patients ages 41-60. The older patients differed less from the controls than did the younger ones. Items that contributed to the differences between OA patients and controls were mainly related to physical limitations. CONCLUSION: Most dysfunctions related to OA are physical.

Medically treated suicide attempts: a four year monitoring study of the epidemiology in The Netherlands.

OBJECTIVE: The incidence of medically treated attempted suicides was investigated in a defined area in the western part of The Netherlands, and demographic groups at risk were identified. DATA AND METHODS: Suicide attempts treated at general hospitals, psychiatric hospitals, and in general practice were monitored between 1 January 1989 and 1 January 1993. Information on demographic characteristics of the subjects who attempted suicide and characteristics of the attempts was registered through a monitoring system and there was maximum coverage. Data on the general population in the catchment area were derived from national, regional, and municipal bureaux of statistics. RESULTS: The mean annual incidences of medically treated suicide attempts (events) were 95/100,000 for males and 155/100,000 for females. At risk groups for attempted suicide were the young (< 40 years); females; people who were divorced, unemployed, or disabled; or those who had low levels of education. CONCLUSIONS: Apart from general hospitals and psychiatric hospitals, 28% of all reported suicide attempts were reported exclusively by general practitioners, which supports the conclusion that they are an important source of information. There were indications that the number of medically treated suicide attempts in this area is stabilising.

Evaluation of the feasibility, reliability and diagnostic value of shortened versions of the geriatric depression scale.

BACKGROUND: Many scales have been developed to assess depression, but they are often too lengthy to be of practical use in general practice consultations. AIM: A study was undertaken to investigate the feasibility, reliability and diagnostic value of the geriatric depression scale and its shorter versions for screening in general practice. METHOD: A total of 586 consecutive consulting patients aged 65 years and over were studied in nine general practices in the west of the Netherlands (13 doctors). The 30-item version of the geriatric depression value was compared with the diagnostic interview schedule as a reference test. RESULTS: The reference test indicated a major depression in six patients while 27 patients had a dysthymic disorder (that is, a chronic mild depression). Five per cent of patients required help for 50% of the questions on the geriatric depression scale. The diagnostic value of the 30-item, 15-item, 10-item and four-item versions did not differ significantly, but the one-item version performed no better than chance. Two items discriminated best between patients who were and who were not depressed (P < 0.05), only one of which was included in a previously proposed four-item version of the scale. The reliability of the proposed four-item version was 0.64, the reliability of the other versions ranging from 0.70 to 0.87. CONCLUSION: The results for the different versions of the geriatric depression scale suggest the use of a 10-item or a four-item version. For practical purposes, the smallest subset would be the most desirable: the four-item version. These scales may be better suited for exclusion rather than inclusion purposes. The feasibility of screening for depression in elderly people in a general practice setting is discussed in the light of the results of the study.

Management of depression in elderly general practice patients.

OBJECTIVE: To describe general practitioners' (GP) management (i.e., recognition and treatment) of depression in elderly patients. DESIGN: Two separate studies were performed: (a) to study recognition of depression, a postal survey was sent to GPs; (b) to evaluate the consistency of treatment, patients considered depressed by GPs were described. SETTING: general practices in the West of The Netherlands. SUBJECTS: 65 GPs, and 44 patients of 7 GPs. MAIN OUTCOME MEASURES: (a) degree of recognition of depression as described in major depression case-vignettes (b) consistency of treatment. RESULTS: (a) On average 65% of the GPs recognized every depressive symptom in case-vignette one, while 52% of GPs recognized each symptom in case two. Most (39) doctors used a time criterion of less than 5 weeks for depressive disorder. (b) Depressed patients with at least three depressive symptoms all received treatment. Chronically depressed patients appeared to be treated somewhat inadequately. CONCLUSION: The results suggest some inadequate knowledge of criteria for major depression and some inconsistency in treatment. The management of depression in elderly GP patients appears to need improvement.

Effects of doxycycline in patients with acute cough and purulent sputum: a double blind placebo controlled trial.

BACKGROUND: Acute cough with purulent sputum is a common complaint presented to general practitioners. AIM: A randomized, double blind, placebo controlled clinical trial was undertaken to determine the efficacy of doxycycline in persons aged 18 years and over presenting to 22 general practices in the Netherlands with acute cough and purulent sputum. METHOD: Patients were excluded if they were pregnant, had an allergy or intolerance to tetracyclines, had severe dyspnoea and fine crackles on auscultation, purulent rhinitis together with maxillary tenderness, chronic airways disease, or had taken antibiotics in the previous two weeks. Patients entered in to the study were given oral doxycycline for 10 days, 200 mg on the first day, followed by 100 mg on the next nine days, or placebo. RESULTS: Duration of frequent daytime cough after entry was a mean of 1.5 days shorter in the group of 71 patients receiving doxycycline than in the group of 69 patients on placebo (4.7 days versus 6.2 days, respectively). In patients aged 55 years and over the mean duration of frequent day-time cough after entry was 4.1 days shorter in the group taking doxycycline than in the placebo group. Patients with a very frequent cough and who also felt ill at entry regained their normal daily activities 2.1 days earlier when using doxycycline than the control group. CONCLUSION: Doxycycline has small beneficial effects in patients with acute cough and purulent sputum. These beneficial effects are more prominent, and probably clinically relevant, in patients aged 55 years and over and in patients who cough very frequently and who also feel ill.

[Body weight of elderly patients on admission to a nursing home]. / Het lichaamsgewicht van ouderen bij opname in het verpleeghuis.

Body weight of elderly patients on admission to a 'verpleeghuis' (Nursing-home in the Netherlands) was 5 to 8 kg lower than that of healthy persons of the same age living at home. No difference in body weight was found between 'verpleeghuis' patients on admission and after long stay. Psychogeriatric men weighed more than somatic; the body weight of psychogeriatric and somatic women did not differ. Terminal patients weighed less than chronic patients and patients, who could be discharged from the 'verpleeghuis'. A relationship was found between body weight and age: the older the patient is, the lower he weighs. Body weight of women was also lower in the case of 'unmarried status' and 'admission residential homes'.

Prevalence of depressive symptoms and depressive disorder in primary care patients over 65 years of age.

The aim of this study was to estimate the prevalence of depressive symptoms and depressive disorder (ICHPPC-2-defined) in patients over 65 years of age. A cross-sectional, partly two-phased, study was performed in general practices in The Netherlands. A total of 384 consecutive patients aged 65 and above, 116 men and 268 women were included, both during practice visits and home visits. Depressive symptoms were recorded with the Zung Self-rating Depression Scale, the Geriatric Depression Scale, and with physician ratings. Assessments of depressive disorder were based on an adaptation of interview ratings with the Montgomery Asberg Depression Rating Scale. The proportion of patients considered to have depressive symptoms ranged from 11 to 29% of patients, depending on the self-report instrument and the cut-off point. According to interviews a depressive disorder was estimated to be present in 17%. The high prevalence of depressive symptoms and depressive disorder suggest a higher index of suspicion of depression in elderly general practice patients.

Acute maxillary sinusitis in general practice: a decision problem.

OBJECTIVE: This paper describes a qualitative analysis of a decision problem of acute maxillary sinusitis in general practice. The criteria and expected outcomes on which general practitioners (GPs) base their choice of a management strategy are presented. DESIGN: Structured open-ended interviews, all done by the first author, were transcribed, and summarized for each management strategy. These summaries were sent back to the experts for verification. PARTICIPANTS: Eight expert GPs from The Netherlands participated; all had been practising for at least three years, and had conducted postgraduate research into upper respiratory tract infections. RESULTS: There was a high degree of consensus among the eight GPs. While most practitioners generally considered the prevention of complications of therapy more important than the prevention of complications of disease, patients at risk (e.g., the elderly, children, patients with other chronic diseases, and patients in weakened condition) of complications of acute sinusitis (e.g., chronic sinusitis) were considered an exception to this rule, possibly because the complications of sinusitis are more serious than those of its therapy. Major differences between the GPs concerned the timing of decisions (e.g. prescribing antibiotics after 5 or 21 days of complaints while local therapy was used). CONCLUSION: Although this study gives no answer as to which management strategy is optimal, the results served as a basis in the development of the Dutch "Sinusitis in general practice standard". In order further to develop the optimal strategy, in future research, the probabilities and weights attached to the criteria and expected outcomes have to be quantified.

Osteoarthritis pain assessment in family practice.

PURPOSE: The objective is to study the assessment of pain severity, following the conventional family physician routines, in patients with peripheral osteoarthritis. METHODS: The patient's perception of pain and the physician's assessment of the pain were measured by means of questionnaires and were compared in a study population of 198 patients with osteoarthritis. RESULTS: A rather low association was found between a patient's perception of pain and the physician's assessment of pain. CONCLUSIONS: It is an accepted fact that too much treatment can have undesirable effects, and that inadequate management of symptoms seems to be associated with a reduced quality of life in osteoarthritic patients. In the absence of a high correlation between patient's perception and physician's assessment of pain severity, it is concluded that a patients' pain questionnaire could be a very useful instrument for improving the care given to patients with osteoarthritis in family practice.

The Phadiatop test compared with RAST, with the CAP system; proposal for a third Phadiatop outcome: "inconclusive".

In 19 general practices, blood samples were obtained from 361 patients aged 12 years or older with chronic nasal symptoms. The Phadiatop test and a panel of RASTs to common inhalant allergens were performed on all sera with the recently introduced Pharmacia CAP system. The RAST panel was accepted as the standard. The sensitivity of the Phadiatop was 94% (95% confidence interval (CI): 89-97%), the specificity 98% (95% CI: 95-99%), the positive predictive value 97% (95% CI: 94-99%), and the negative predictive value 95% (95% CI: 91-98%). It is noteworthy that these values are very similar to those found in hospital outpatient departments. It was possible to reduce further the small percentage of false outcomes by replacing the cutoff point of the Phadiatop ratio of 1.00 by the two cutoff points 0.75 and 1.15. This resulted in three possible outcomes: a highly predictive positive outcome, a highly predictive negative outcome, and an "inconclusive" outcome. Alternatively, the cutoff point of 1.00 may be maintained while attaching the annotation "borderline" to all positive or negative Phadiatop outcomes where the Phadiatop ratio is between 0.75 and 1.15. By this simple method, physicians are alerted to the possibility of a false outcome; on the basis of the case history and other clinical findings, they can then decide whether further testing should be done.

Fosfomycin trometamol in a single dose versus seven days nitrofurantoin in the treatment of acute uncomplicated urinary tract infections in women.

In general practice acute uncomplicated urinary tract infections in women are treated with different courses of antibiotics. In this study the efficacy and tolerability of a single dose of 3 g fosfomycin trometamol and the conventional treatment with nitrofurantoin 50 mg four times daily for seven days were compared. In a randomized, double-blind, double-dummy trial in 31 general practices in the Netherlands 231 patients with symptoms of acute dysuria, stranguria and/or urinary frequency received treatment. Evaluation was based on resolution of symptoms, dipslide results and side-effects at 4, 9 and 42 days after starting the treatment. The clinical cure rates and bacteriological cure rates were not significantly different between the treatment groups. Side-effects were reported at day 4 by 43% of the women receiving single-dose treatment, compared with 25% of the women in the seven-day treatment group, a significant difference. At day 9 the groups did not significantly differ in the number of patients with side-effects. Almost all side-effects were mild and gastro-intestinal complaints were reported most. Taking into account the convenience of taking a single dose we conclude that fosfomycin trometamol is a reasonable alternative to 7 days nitrofurantoin 50 mg four times a day in the treatment of women with symptoms of acute uncomplicated urinary tract infections in general practice.

Compliance with pulmonary medication in general practice.

We wanted to assess compliance with regular pulmonary medication, in 156 patients in a general practice setting. Patients completed a questionnaire on their reported daily intake, the perceived prescription, and their self-assessed perceived compliance with pulmonary medication. Compliance was defined as a reported daily intake > or = 50% of the prescribed amount. Using this definition, 30% of patients were considered to be compliant. Compliant patients had daily symptoms more often, were more often prescribed two or more different medications, and a greater proportion of them had at some time consulted a chest physician. When patients correctly perceived the prescription to refer to medication which had to be taken on a regular basis, they were more likely to be compliant. We conclude that, since less than one third of patients was compliant with medication, more efforts are needed to improve compliance in general practice. Non-compliance with medication may well provide an alternative explanation for the discrepancy between prescribed medication and medical outcome, which has been labelled in the literature as "undertreatment".

Randomized double-blind study of nabumetone and piroxicam in the treatment of osteoarthritis in Dutch general practice: efficacy and tolerability.

To study nabumetone (1,000 mg once daily) by comparison with piroxicam (20 mg once daily) in patients with osteoarthritis, a randomized, double-blind trial was set up in 40 general practices. Evaluation was based on clinical outcome in 198 patients. There was some evidence that nabumetone is associated with a lower and less severe occurrence of gastric pain, and with more withdrawals due to lack of efficacy. Although the differences between nabumetone and piroxicam were small in this study, these were clinically relevant. The general practitioner should balance the respective benefits of greater safety and tolerance against greater efficacy in meeting the requirements of an individual patient with osteoarthritis.

Dutch general practitioners' management of patients with distal osteoarthritic symptoms.

Little is known about general practitioners' (GPs') policy with respect to patients with distal osteoarthritic symptoms. Therefore, the medical records of 196 patients with distal osteoarthritis were studied with respect to the GPs' management. In addition, 14 Dutch GPs' were interviewed on their management of patients with distal osteoarthritic symptoms. We found varying approaches with no consensus among GPs' and no relationship between their policies and GP, patient, or illness characteristics. We believe there is a need to develop a consensus on GPs' policy with respect to osteoarthritic patients, and to develop standards, based on research in general practice.

[The family physician and depression in the elderly. A pilot study of prevalence of depressive symptoms and depression in the elderly in 2 family practices]. / De huisarts en depressiviteit van ouderen. Een pilot-onderzoek naar de prevalentie van depressieve symptomen en depressiviteit bij ouderen in twee huisartspraktijken.

A pilot-study on the prevalence of depressive symptoms and GPs' assessment of depressed mood in elderly attenders of two general practices. The aim of this pilot was to gather information on both depressive symptoms and GP's' assessments of depressive mood in persons over 65 coming for a consultation in two general practices. To assess the prevalence of depressive symptomatology, 87 patients were asked to complete the Zung Self-Rating Depression Scale (ZSDS) and the Geriatric Depression Scale (GDS). Six patients were identified as having depressive symptoms on the ZSDS and seven on the GDS. Information on GP's' assessments of depressive mood was gathered by asking GP's to what extent they thought patients had been depressed recently. With regard to patients identified by the GP's as being mildly or severely depressed, the GP's answered additional questions on diagnostic and therapeutic approaches. The GP's identified eleven out of 87 patients as being mildly depressed, nobody was classified as being severely depressed. Five out of six patients with a ZSDS score of 50 and higher were not identified by the GP's as being mildly depressed. The prevalence of depressive symptoms based on ZSDS-scores was somewhat lower than expected (7.5%).

Concerns and choices in general practice.

Osteoarthritis is a common problem in general practice and a major indication for NSAIDs. Many patients with osteoarthritis are elderly and therefore particularly at risk from adverse reactions. Co-morbidity and co-prescription may lead to drug interactions. For these reasons, safe NSAIDs are the first choice for this disease.