Overweight and obese children do not consult their general practitioner more often than normal weight children for musculoskeletal complaints during a 2-year follow-up.

BACKGROUND: Childhood obesity is associated with self-reported musculoskeletal complaints, injuries and fractures. In the current study, we investigated the association between weight status of children and the frequency and type of musculoskeletal consultations at the general practitioner (GP) during a 2-year follow-up. METHODS: Data from a prospective longitudinal cohort study including children aged 2-18 years presenting in general practices in the Netherlands were used. Height and weight were measured at baseline, at 6-month, 1-year and 2-year follow-ups. Electronic medical files were used to collect information on the frequency and type of consultations at the GP during the 2-year follow-up period. Associations between weight status and frequency and type of GP consultations were calculated. RESULTS: Of the 617 included children, 111 (18%) were overweight or obese and 506 (82%) were non-overweight. Overweight children were significantly older (mean age in years (SD): 9.8 (3.6)vs7.8 (4.0), p=0.004). Overweight children consulted the GP in general significantly more frequent during the 2-year follow-up than non-overweight children (mean (SD): 7.3 (5.7)vs6.7 (5.4), OR 1.09, 95% CI 1.01 to 1.18). No significant difference was seen in the number of overweight and non-overweight children consulting their GP for musculoskeletal complaints (OR 1.20 (0.86 to 1.68)). Additionally, no significant difference between overweight and non-overweight children was seen for the number of consultations for further specified musculoskeletal disorders. CONCLUSION: No association was seen between childhood weight status and the frequency and type of musculoskeletal consultations at the GP during a 2-year follow-up.

Defining trajectories in older adults with back pain presenting in general practice.

BACKGROUND: although back pain is a frequently recurring disorder, the course of back pain remains uncertain. Therefore, this study aimed to identify different trajectories in older adults with back pain who presented in general practice and to determine which baseline characteristics are associated with these trajectories. METHODS: the BACE study is a prospective cohort study including 675 patients (aged >55 years) with back pain who consulted a general practitioner; patients were followed for 3 years. Latent class growth analysis was used to identify different trajectories in back pain severity measured at eight different time points. A multinomial regression analysis was used to assess variables associated with membership of an identified trajectory. RESULTS: using the different indices of fit and the usefulness of the different trajectories in clinical practice, a 3-class cubic model was determined to be the best model. The three trajectories were defined as 'low pain trajectory', 'high pain trajectory' and 'intermediate pain trajectory'. Baseline variables associated with a higher chance of being in the intermediate or high trajectory were: female gender, higher body mass index, chronic back pain, more disability, lower scores on the SF-36 physical summary scale, and negative expectations of recovery. CONCLUSIONS: three different back pain trajectories were identified in older adults presenting with back pain in general practice. Various baseline characteristics were associated with a higher chance of being in the high or intermediate back pain trajectory. These characteristics might help identify patients at risk for a less favourable outcome.

Prevalence and "Red Flags" Regarding Specified Causes of Back Pain in Older Adults Presenting in General Practice.

BACKGROUND: In a small proportion of patients experiencing unspecified back pain, a specified underlying pathology is present. OBJECTIVE: The purposes of this study were: (1) to identify the prevalence of physician-specified causes of back pain and (2) to assess associations between "red flags" and vertebral fractures, as diagnosed by the patients' general practitioner (GP), in older adults with back pain. METHODS: The Back Complaints in the Elders (BACE) study is a prospective cohort study. Patients (aged >55 years) with back pain were included when consulting their GP. A questionnaire was administered and a physical examination and heel bone densitometry were performed, and the results determined back pain and patient characteristics, including red flags. Participants received a radiograph, and reports were sent to their GP. The final diagnoses established at 1 year were collected from the GP's patient registry. RESULTS: Of the 669 participants included, 6% were diagnosed with a serious underlying pathology during the 1-year follow-up. Most of these participants (n=33, 5%) were diagnosed with a vertebral fracture. Multivariable regression analysis showed that age of ≥75 years, trauma, osteoporosis, a back pain intensity score of ≥7, and thoracic pain were associated with a higher chance of getting the diagnosis of a vertebral fracture. Of these variables, trauma showed the highest positive predictive value for vertebral fracture of 0.25 (95% confidence interval=0.09, 0.41) and a positive likelihood ratio of 6.2 (95% confidence interval=2.8, 13.5). A diagnostic prediction model including the 5 red flags did not increase these values. LIMITATIONS: Low prevalence of vertebral fractures could have led to findings by chance. CONCLUSIONS: In these older adults with back pain presenting in general practice, 6% were diagnosed with serious pathology, mainly a vertebral fracture (5%). Four red flags were associated with the presence of vertebral fracture.

Analgesic use in older adults with back pain: the BACE study.

BACKGROUND: Older patients with back pain are more likely to visit their general practitioner (GP) and are more likely to be prescribed analgesics. OBJECTIVE: To assess analgesic use in older adults with back pain in general practice. METHODS: The BACE study in the Netherlands is a prospective cohort study. Patients (aged >55 years) with back complaints were recruited when consulting their GP or shortly thereafter. Measurements took place at baseline and at 3- and 6-month follow-up. For medication use, patients were asked if they had used any medication for their back pain in the previous 3 months and, if so, to specify the medication name, dosage used, frequency of usage, and whether the medication was prescribed or purchased over the counter. RESULTS: Of the 1,402 patients who were approached to enter the study, 675 were included. Of these patients, 484 (72%) reported medication use at baseline. Nonsteroidal anti-inflammatory drugs (NSAIDs) (57%) were more often used than paracetamol (49%). Paracetamol was mostly obtained over the counter (69%), and NSAIDs were mostly obtained by prescription (85%). At baseline, patients with severe pain (numerical rating scale score ≥7) used more paracetamol, opioids, and muscle relaxants. Patients with chronic pain (back pain >3 months) used more paracetamol, while patients with a shorter duration of pain used more NSAIDs. During follow-up there was an overall decline in medication use; however, at 3- and 6-month follow-up, 36% and 30% of the patients, respectively, still used analgesics. CONCLUSIONS: In these older adults consulting their GP with back pain, 72% used analgesics at baseline. Despite a decrease in medication use during follow-up, at 3 and 6 months a considerable proportion still used analgesics.

Back complaints in older adults: prevalence of neuropathic pain and its characteristics.

OBJECTIVE: Neuropathic symptoms are reported in 16-55.6% of patients with back pain. Studies were performed in various populations; however, none focused on older adults. The aim of the study was to assess prevalence of neuropathic pain in older adults with back pain. METHODS: Prevalence of neuropathic pain, measured with the Dolour Neuropathique en 4 questions (DN4), was assessed in the Back Complaints in the Elders study (Netherlands). Patients (>55 years) consulting their general practitioner with a new episode of back complaints were included. Two DN4-versions were used: one based on interview plus physical examination, the other based on interview alone. In the interview plus physical examination version, patients' and complaint characteristics were compared between groups with different scores (0, 1, 2, 3, and ≥4). The DN4 interview-version compared patients with negative and positive scores. RESULTS: Of the 261 included patients available for analysis were 250 patients (95.8%) with the DN4 interview plus physical examination, and 259 patients (99.2%) with the DN4 interview. In DN4 interview plus physical examination (N = 250), five patients (2%) scored positive (score ≥4). Higher score was associated with pain radiating below the knee (P < 0.001) and use of paracetamol (P = 0.02). In DN4 interview (N = 259), 29 (11.2%) patients scored positive (score ≥3). Positive score was associated with higher body mass index (P = 0.01), pain radiating below the knee (P = 0.001), and use of paracetamol (P = 0.002). CONCLUSIONS: In older adults with back pain presenting with a new episode in primary care, prevalence of neuropathic pain is low and seems to be associated with pain radiating below the knee, use of paracetamol, and higher body mass index.

Opinions of the Dutch public on palliative sedation: a mixed-methods approach.

BACKGROUND: Palliative sedation is defined as deliberately lowering a patient's consciousness, to relieve intolerable suffering from refractory symptoms at the end of life. Palliative sedation is considered a last resort intervention in end-of-life care that should not be confused with euthanasia. AIM: To inform healthcare professionals about attitudes of the general public regarding palliative sedation. design and setting: A cross-sectional survey among members of the Dutch general public followed by qualitative interviews. METHOD: One thousand nine hundred and sixty members of the general public completed the questionnaire, which included a vignette describing palliative sedation (response rate 78%); 16 participants were interviewed. RESULTS: In total, 22% of the responders indicated knowing the term 'palliative sedation'. Qualitative data showed a variety of interpretations of the term. Eighty-one per cent of the responders agreed with the provision of sedatives as described in a vignette of a patient with untreatable pain and a life expectancy of <1 week who received sedatives to alleviate his suffering. This percentage was somewhat lower for a patient with a life expectancy of <1 month (74%, P = 0.007) and comparable in the case where the physician gave sedatives with the aim of ending the patient's life (79%, P = 0.54). CONCLUSION: Most of the general public accept the use of palliative sedation at the end of life, regardless of a potential life-shortening effect. However, confusion exists about what palliative sedation represents. This should be taken into account by healthcare professionals when communicating with patients and their relatives on end-of-life care options.

Teachers' ideas versus experts' descriptions of 'the good teacher' in postgraduate medical education: implications for implementation. A qualitative study.

BACKGROUND: When innovations are introduced in medical education, teachers often have to adapt to a new concept of what being a good teacher includes. These new concepts do not necessarily match medical teachers' own, often strong beliefs about what it means to be a good teacher.Recently, a new competency-based description of the good teacher was developed and introduced in all the Departments of Postgraduate Medical Education for Family Physicians in the Netherlands. We compared the views reflected in the new description with the views of teachers who were required to adopt the new framework. METHODS: Qualitative study. We interviewed teachers in two Departments of Postgraduate Medical Education for Family Physicians in the Netherlands. The transcripts of the interviews were analysed independently by two researchers, who coded and categorised relevant fragments until consensus was reached on six themes. We investigated to what extent these themes matched the new description. RESULTS: Comparing the teachers' views with the concepts described in the new competency-based framework is like looking into two mirrors that reflect clearly dissimilar images. At least two of the themes we found are important in relation to the implementation of new educational methods: the teachers' identification and organisational culture. The latter plays an important role in the development of teachers' ideas about good teaching. CONCLUSIONS: The main finding of this study is the key role played by the teachers' feelings regarding their professional identity and by the local teaching culture in shaping teachers' views and expectations regarding their work. This suggests that in implementing a new teaching framework and in faculty development programmes, careful attention should be paid to teachers' existing identification model and the culture that fostered it.

What is the role of virus vaccination in patients with asthma?

It is estimated that viruses play a role in 30% to 80% of asthma exacerbations. Thus, virus vaccination in patients with asthma could play an important role in preventing asthma exacerbations and other complications. Influenza is the only agent for which a routine vaccine is currently available. This article discusses whether influenza vaccination in patients with asthma, based on the available evidence, is justified. Cost-effectiveness of (influenza) vaccination for patients with asthma is questionable. For the other major viruses involved, the present state of affairs is described. Although progress is being made, a vaccine may be available in the near future only for respiratory syncytial virus (RSV). Meanwhile, clinicians and patients should aim for an optimal treatment with the currently available asthma medication.

Incidence of influenza and associated illness in children aged 0-19 years: a systematic review.

A systematic review was conducted to estimate the incidence of influenza and concomitant morbidity and mortality in children from 0 to 19 years (0-19 years). Medline was searched for observational studies and placebo or non-treated arms of experimental studies providing occurrence rates of laboratory-proven influenza illness. From the 2758 titles identified, 356 full papers were reviewed based on the abstract or title; after searching their reference lists an additional 16 papers were found. Finally 28 studies met our inclusion criteria, reporting a varying seasonal incidence of influenza of up to 46%. However, when analysing two long-term observational studies and averaging seasonal fluctuations, the overall incidence of influenza was found to range from 5% to 9.5% per year. Serious morbidity was seldom reported and no cases of mortality were found. Our review shows influenza as an infection with a moderate average incidence and a self-limiting character that is associated with mild morbidity and rare cases of mortality in children. This systematic review may be subject to two contrasting biases. First, the limited number of children reported in the literature with proven influenza infections would tend to under-represent the incidence of uncommon but serious complications such as death. Second, the preferential reporting of influenza outbreak seasons may over-estimate the importance of influenza. Future population based studies should focus on consecutive influenza seasons and capture indirect benefits of vaccinations such as interruption of transmission in the community so that preventive strategies for children can be reconsidered with special attention to their cost effectiveness.

Is influenza vaccination in asthma helpful?

PURPOSE OF REVIEW: Influenza infections are frequently involved in asthma exacerbations. During influenza epidemics substantial excess morbidity due to respiratory tract complications is reported in all age categories as well as excess mortality among the elderly. Vaccines are available for protection against influenza. Worldwide, vaccination is advised and considered a quality point for asthma care. However, the protective effect of influenza vaccination in patients with asthma is still disputed. In order to establish the current state of affairs we reviewed the recent literature on the protective effect of influenza vaccination and its usefulness in patients with asthma. RECENT FINDINGS: Several studies were found addressing influenza and the protective aspects of vaccination. They discussed the incidence, the adverse effects of vaccination, the coverage of influenza vaccination among patients with asthma and the effectiveness of the vaccine. SUMMARY: Influenza vaccination can safely be used in patients with asthma. Allegations that vaccination could provoke asthma exacerbations are convincingly invalidated by previous and recent research. Although patients with asthma are one of the major target groups for immunization, vaccine coverage in all age categories remains low. So far, no unequivocal beneficial effect of influenza vaccination in patients with asthma was found in observational and experimental studies in the sense of reduction of asthma exacerbations and other complications. Recent studies confirm these negative findings. More long-term randomized, placebo-controlled studies, focusing on influenza- proven illness in patients with asthma, are needed to address the question of how helpful influenza vaccination is in these patients.

Does influenza vaccination exacerbate asthma in children?

BACKGROUND: The risks of influenza vaccination in asthmatic children are still being discussed. Especially, the risk that influenza vaccination may exacerbate asthma is an issue in this debate. METHODS: We conducted a randomised double-blind placebo-controlled trial in 696 children 6-18 years of age with asthma recruited in general practice during two influenza seasons, 1999-2000 and 2000-2001. Children participated for only one season. During the first week after vaccination, participants recorded local, influenza like and asthma symptoms as well as use of medication, health care use and absenteeism. RESULTS: Except for cough during the day in the first season, favouring placebo, there were no differences indicating that vaccination exacerbates asthma. CONCLUSIONS: Influenza vaccination does not seem to exacerbate asthma.

Influenza vaccination in children with asthma: randomized double-blind placebo-controlled trial.

There is little evidence that influenza vaccination reduces asthma exacerbations. We determined whether influenza vaccination is more effective than placebo in 6-18-year-old children with asthma. We performed a randomized, double-blind, placebo-controlled trial. Parenteral vaccination with inactivated influenza vaccine or placebo took place approximately November 1, and children were followed until April 1 of the next year. Airway symptoms were reported in a diary. When symptom scores reached a predefined level, a pharyngeal swab was taken. Primary outcome was the number of asthma exacerbations associated with virologically proven influenza infection. Three hundred forty-nine children were assigned placebo, and 347 were assigned vaccine. Pharyngeal swabs positive for influenza were related to 42 asthma exacerbations, 24 in the vaccine group and 18 in the placebo group, a difference of 33% favoring placebo (31% after adjustment for confounders; 95% confidence interval, -34% to 161%). Influenza-related asthma exacerbations were of similar severity in both groups; they lasted 3.1 days shorter in the vaccine group (95% confidence interval, -6.2 to 0.002 days, p = 0.06). We conclude that influenza vaccination did not result in a significant reduction of the number, severity, or duration of asthma exacerbations caused by influenza. Additional studies are warranted to justify routine influenza vaccination of children with asthma.