Patients' gut feelings seem useful in primary care professionals' decision making.

BACKGROUND: Family physicians' diagnostic gut feelings have proved to be valuable. But what about patients' gut feelings? Research has shown that patients' gut feelings may contribute to their physicians' clinical reasoning. Dutch medical tribunals consider patients' worry useful for doctors' diagnostic process. However, how general practitioners and other primary care professionals recognize gut feelings of patients and deal with them in their decision making is yet unclear. We aim to explore how primary care professionals perceive patients' gut feelings and use this information in their decision-making. METHODS: We interviewed 30 Dutch and Belgian primary care professionals, exploring how they recognize and value patients' gut feelings. We coded all interviews using a descriptive content analysis in an iterative process. Data sufficiency was achieved. RESULTS: Primary care professionals acknowledged gut feelings in their patients, and most participants found them a useful source of information. Patients' gut feelings might alert them to possible hidden problems and might provide quicker insight into patients' perceptions. Primary care professionals listed a whole series of wordings relating to trusting or distrusting the situation or to any changes in normal patterns. A patient's gut feeling was often a reason for the professionals to explore patients' worries and to reconsider their own clinical reasoning. CONCLUSIONS: Primary care professionals regularly considered patients' gut feelings useful, as they might contribute to their clinical reasoning and to a deeper understanding of the patient's problem. The next step could be to ask patients themselves about their gut feelings and explore their diagnostic value.

How do gut feelings feature in tutorial dialogues on diagnostic reasoning in GP traineeship?

Diagnostic reasoning is considered to be based on the interaction between analytical and non-analytical cognitive processes. Gut feelings, a specific form of non-analytical reasoning, play a substantial role in diagnostic reasoning by general practitioners (GPs) and may activate analytical reasoning. In GP traineeships in the Netherlands, trainees mostly see patients alone but regularly consult with their supervisors to discuss patients and problems, receive feedback, and improve their competencies. In the present study, we examined the discussions of supervisors and their trainees about diagnostic reasoning in these so-called tutorial dialogues and how gut feelings feature in these discussions. 17 tutorial dialogues focussing on diagnostic reasoning were video-recorded and transcribed and the protocols were analysed using a detailed bottom-up and iterative content analysis and coding procedure. The dialogues were segmented into quotes. Each quote received a content code and a participant code. The number of words per code was used as a unit of analysis to quantitatively compare the contributions to the dialogues made by supervisors and trainees, and the attention given to different topics. The dialogues were usually analytical reflections on a trainee's diagnostic reasoning. A hypothetico-deductive strategy was often used, by listing differential diagnoses and discussing what information guided the reasoning process and might confirm or exclude provisional hypotheses. Gut feelings were discussed in seven dialogues. They were used as a tool in diagnostic reasoning, inducing analytical reflection, sometimes on the entire diagnostic reasoning process. The emphasis in these tutorial dialogues was on analytical components of diagnostic reasoning. Discussing gut feelings in tutorial dialogues seems to be a good educational method to familiarize trainees with non-analytical reasoning. Supervisors need specialised knowledge about these aspects of diagnostic reasoning and how to deal with them in medical education.

The course of newly presented unexplained complaints in general practice patients: a prospective cohort study.

OBJECTIVE: Newly presented unexplained complaints (UCs) are common in general practice. Factors influencing the transition of newly presented into persistent UCs have been scarcely investigated. We studied the number and the nature of diagnoses made over time, as well as factors associated with UCs becoming persistent. Finally, we longitudinally studied factors associated with quality of life (QoL). METHODS: Prospective cohort study in general practice of patients presenting with a new UC. Data sources were case record forms, patient questionnaires and electronic medical registries at inclusion, 1, 6 and 12 months. Presence of complaints and diagnoses made over time were documented. Potential risk factors were assessed in mixed-effect logistic and linear regression models. RESULTS: Sixty-three GPs included 444 patients (73% women; median age 42) with unexplained fatigue (70%), abdominal complaints (14%) and musculoskeletal complaints (16%). At 12 months, 43% of the patients suffered from their initial complaints. Fifty-seven percent of the UCs remained unexplained. UCs had (non-life-threatening) somatic origins in 18% of the patients. QoL was often poor at presentation and tended to remain poor. Being a male [odds ratio (OR) 0.6; 95% confidence interval (CI) 0.4-0.8] and GPs' being more certain about the absence of serious disease (OR 0.9; 95% CI 0.8-0.9) were the strongest predictors of a diminished probability that the complaints would still be present and unexplained after 12 months. The strongest determinants of complaint persistence [regardless of (un)explicability] were duration of complaints >4 weeks before presentation (OR 2.6; 95% CI 1.6-4.3), musculoskeletal complaint at baseline (OR 2.3; 1.2-4.5), while the passage of time acted positively (OR 0.8 per month; 95% CI 0.78-0.84). Musculoskeletal complaints, compared to fatigue, decreased QoL on the physical domain (4.6 points; 2.6-6.7), while presence of psychosocial factors decreased mental QoL (5.0; 3.1-6.9). CONCLUSION: One year after initial presentation, a large proportion of newly presented UCs remained unexplained and unresolved. We identified determinants that GPs might want to consider in the early detection of patients at risk of UC persistence and/or low QoL.

Inflammation in deep vein thrombosis and the development of post-thrombotic syndrome: a prospective study.

BACKGROUND: The aim of this study was to investigate whether inflammatory markers (interleukin-6 [IL-6] and C-reactive protein [CRP]) in the acute phase of deep vein thrombosis (DVT) are associated with elevated venous outflow resistance (VOR), thrombosis score (TS), reflux and the development of clinical post-thrombotic syndrome (PTS). METHODS: In 110 patients with a first DVT, plasma concentrations of IL-6 and CRP were determined on the day of admission. VOR, TS and reflux were measured 7 days, 1 and 3 months after diagnosis. After 1 year patients were evaluated for PTS using the Clinical, Etiologic, Anatomic and Pathophysiologic (CEAP) classification and Villalta scale. RESULTS: Median levels of IL-6 and CRP were 7 pg mL(-1) and 21 mg L(-1), respectively. After 3 months, VOR was elevated in 33 patients (30%), TS in 33 (30%) and reflux in 57 (52%). Incidence of PTS was 36.7% using CEAP>or=3 and 35.4% using Villalta-scale>or=5. Elevated levels of IL-6 and CRP were related to higher outcomes of VOR after 3 months [relative risks (RR) 2.4 (95% CI 1.5-3.9) and 1.4 (1.1-3.3), respectively] and for IL-6 to TS [1.5 (1.1-2.1)]. For reflux no relation was found. After 90 days, elevated outcomes of VOR, TS and reflux were related to PTS after 1 year. The association of IL-6 and CRP with PTS was weak using the CEAP classification with a RR of 1.2 (0.7-2.2) and 1.8 (0.9-3.3) and absent according to the Villalta scale 0.6 (0.2-1.4) and 1.2 (0.6-2.5), respectively. CONCLUSION: The results of this study suggest that inflammation might play a role in incomplete thrombus clearance, venous outflow obstruction and the development of PTS after 1 year.

[Ventricular assist device implantation as a bridge to cardiac transplantation in two adolescents with end-stage cardiomyopathy and heart failure as a result of anthracycline use]. / Een steunhart als overbrugging naar een harttransplantatie bij 2 adolescenten met cardiomyopathie en hartfalen in een eindstadium als gevolg van antracyclinegebruik.

In a adolescent women aged 15 and 17 years respectively, severe heart failure developed within a few months of anthracycline chemotherapy given for osteosarcoma. In the guidelines of the European Society of Cardiology, malignancy with a remission duration of less than 5 years is an absolute contraindication to cardiac transplantation. Neither patient was eligible to receive a ventricular assist device (VAD) as a bridge to cardiac transplantation in the Netherlands, but they were accepted in Germany. One patient received a cardiac transplant 13 months later and at the last follow-up check she was in good health with a remission of 3 years. The other patient developed bone metastases 6 months after the VAD implantation. Cardiac transplantation was not a treatment option for her. Dose-dependent cardiotoxicity is a serious complication of the use of anthracyclines. In severe heart failure the prognosis is often worse than in adjuvantly treated malignancies like osteosarcoma. VAD may therefore be a valid option for patients with severe heart failure after anthracycline use for a malignancy. In cases of sustained remission VAD may be the bridge to transplantation.

[Liver abscesses as a complication of Crohn's disease]. / Leverabcessen als complicatie bij de ziekte van Crohn.

Liver abscesses were found in two women aged 23 and 34 years who suffered from Crohn's disease. The first patient was seen because of fever and thoracic pain and had been treated with infliximab. The second patient, who was pregnant, presented with abdominal pain that was thought to be due to an exacerbation of her inflammatory bowel disease. Ultrasonography and CT revealed that both patients had large liver abscesses. Both received antibiotic treatment, the first patient underwent drainage of the abscess, and the second underwent puncture twice, resulting in clinical improvements in both patients. In contrast to intra-abdominal abscesses, liver abscesses are rarely seen in patients with Crohn's disease. The clinical presentation can be mistaken for an exacerbation of Crohn's disease, but the diagnosis can be made easily using ultrasonography or CT. Treatment consists of (ultrasound-guided) percutaneous drainage and administration of antibiotics.

Designing a quality improvement intervention: a systematic approach.

Most quality improvement or change management interventions are currently designed intuitively and their results are often disappointing. While improving the effectiveness of interventions requires systematic development, no specific methodology for composing intervention strategies and programmes is available. This paper describes the methodology of systematically designing quality of care improvement interventions, including problem analysis, intervention design and pretests. Several theories on quality improvement and change management are integrated and valuable materials from health promotion are added. One method of health promotion-intervention mapping-is introduced and applied. It describes the translation of knowledge about barriers to and facilitators of change into a concrete intervention programme. Systematic development of interventions, although time consuming, appears to be worthwhile. Decisions that have to be made during the design process of a quality improvement intervention are visualised, allowing them to serve as a starting point for a systematic evaluation of the intervention.

A double-blind study of topical 1 alpha,25-dihydroxyvitamin D3 in psoriasis.

Several open studies with active forms of vitamin D3 have been reported to be effective in the treatment of psoriasis. We report a double-blind study of 1 alpha,25-dihydroxycholecalciferol in psoriasis using 0.5 microgram of active substance applied topically twice daily. In contrast to previous studies, the present investigation does not provide evidence of clinical efficacy for the drug at that dosage and with the vehicle that was used.

Active vitamin D3 does not suppress recruitment of G0 cells following injury.

The effect of topically applied active vitamin D3 on epidermal regeneration was studied in eight healthy volunteers following sellotape stripping. The mobilization of resting (Go) cells was assessed by means of DNA flow cytometry, using a narrow window in the mid-S phase to monitor the progress of the recruited cells. Although vitamin D3 was applied at a concentration exceeding the range reported to be effective in psoriasis, we were unable to find any effect of active vitamin D3 on Go mobilization in vivo.