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Objective: To review the effects of monotherapy with alpha-glucosidase inhibitors (AGIs) for patients with type 2 diabetes, with respect to mortality, morbidity, glycemic control, insulin levels, plasma lipids, body weight, and side effects.Research Design and Methods: We systematically searched the Cochrane Central register of Controlled Trials, MEDLINE, EMBASE, Current Contents, LILACS, databases of ongoing trials, and reference lists, and we contacted experts and manufacturers. Inclusion criteria were randomized controlled trials of at least 12 weeks' duration, AGI monotherapy compared with any intervention, and one of the following outcome measures: mortality, morbidity, GHb, blood glucose, lipids, insulin levels, body weight, or side effects. Two independent reviewers assessed all abstracts, extracted all data, and assessed quality. We contacted all authors for data clarification. Continuous data were expressed as weighted mean differences and analyzed with a random-effects model. Possible influences of study characteristics and quality were assessed in sensitivity and meta-regression analyses.Results: Forty-one studies were included in the review (30 acarbose, 7 miglitol, 1 voglibose, and 3 combined), and heterogeneity was limited. We found no evidence for an effect on mortality or morbidity. Compared with placebo, AGIs had a beneficial effect on GHb (acarbose -0.77%; miglitol -0.68%), fasting and postload blood glucose and postload insulin. With acarbose dosages higher than 50 mg t.i.d., the effect on GHb was the same, but the occurrence of side effects increased. Acarbose decreased the BMI by 0.17 kg/m2 (95% CI 0.08-0.26). None of the AGIs had an effect on plasma lipids. Compared with sulfonylurea, AGIs seemed inferior with respect to glycemic control, but they reduced fasting and postload insulin levels. For comparisons with other agents, little data were available.Conclusions: We found no evidence for an effect on mortality or morbidity. AGIs have clear beneficial effects on glycemic control and postload insulin levels but not on plasma lipids. There is no need for dosages higher than 50 mg acarbose t.i.d. [ABSTRACT FROM AUTHOR]

Background: Patients experience long-lasting health problems defined as post-intensive care syndrome (PICS) after Intensive Care Unit (ICU) admission. Little is known about PICS in primary care., Objectives: To investigate whether ICU survivors encounter more new International Classification of Primary Care-2 (ICPC-2) diagnoses and general practitioner (GP) contact compared to patients with similar comorbidity without ICU admission., Methods: Prospective multicentre cohort study in three Dutch general practices. Numbers of disease-episodes and GP contacts of ICU survivors ≥ 16 years admitted between 2008 and 2017 were extracted from GPs' information systems. A non-ICU reference cohort was matched 1:1 for age, sex, follow-up period and comorbidity groups from patients' medical history. Negative binominal regression analysis was used to compare both cohorts 0-3, 3-6, 6-12 months, 1-2 and 2-5 years after ICU admission and 1 year prior to admission., Results: ICU survivors ( n  = 199) encountered more new disease-episodes 1 year before (mean 3.97 (95% confidence interval [CI] 3.50-4.52]]; reference 2.36 [1.28-3.17]) to 2-5 years after ICU admission (3.65 [3.15-4.26]; reference 2.86 [2.52-3.22]). ICU survivors also had more GP contacts 1 year before (mean 19.61 [17.31-22.17]; reference 10.02 [7.81-12.38]) to 2-5 years after ICU admission (18.53 [15.58-21.85]; reference 12.03 [10.33-13.91]). Patients with prior ICU admission did not encounter patterns in specific ICPC-2 chapters compared to non-ICU patients., Conclusion: Patients admitted to the ICU encounter more new primary care disease-episodes and GP contacts. As patients present their symptoms to their GP first, it is therefore up to the GP to recognise these critical illness-related symptoms.

Background: The high demand for mental health care is increasing the pressure on Dutch basic and specialized mental health care. Consultative psychiatry in primary care may help to support primary mental health care. These consultations are increasingly used nationwide. However, little is known about how this help takes shape in practice and what the experiences of both patients and caregivers are., Method: We carried out a database and file study into the characteristics of the patients who received psychiatric consultation, in which we also examined the consultation questions of the general practitioners (GP) and the given advice. In addition, 15 semi-structured in-depth interviews were conducted with patients, general practitioners, mental healthcare nurse practitioners and psychiatrists, after which the transcripts were coded and analyzed thematically., Aim: To explore for which patients the GP requests a psychiatric consultation, what the consultation questions are and the advice given, and to identify the experiences of patients and healthcare providers with consultative psychiatry in general practice., Results: The database study showed that consultative psychiatry was mainly used for patients with a psychiatric history, multiple psychiatric diagnosis and current psychopharmaceutical use. The consultation question usually concerned medication or treatment advice. In addition to advice regarding the consultation question, the psychiatrist often gave additional advice. Consultative psychiatry was experienced positively by both health care providers and patients due to the low threshold of the general practice, the mutual trust that is involved, the short waiting times compared to the second and third line psychiatry and the expertise of the psychiatrist., Conclusion: Consultative psychiatry in general practice is widely applicable, but is mainly applied to patients with multiple psychiatric diagnoses and current psychopharmaceutical use. It is experienced as positive by both patients and healthcare providers.

Background: Relatives of intensive care unit (ICU) survivors may suffer from various symptoms after ICU admittance of their relative, known as post-intensive care syndrome-family (PICS-F). Studies regarding PICS-F have been performed but its impact in primary care is unknown., Objectives: To explore health problems of relatives of ICU survivors in primary care., Methods: This is an exploratory prospective cohort study in which we combined data from two hospitals and a primary care research network in the Netherlands. ICU survivors who had been admitted between January 2005 and July 2017 were identified and matched by sex and age with up to four chronically ill (e.g. COPD, cardiovascular disease) patients. In both groups, relatives living in the same household were identified and included in this study. Primary outcome was the number of new episodes of care (International Classification of Primary Care-2) for up to five years. Hazard ratios (HRs) for the total number of new episodes were calculated., Results: Relatives of ICU survivors ( n  = 267, mean age 38.1 years, 41.0% male) had significantly more new care episodes compared to the reference group ( n  = 705, mean age 36.3 years, 41.1% male) 1-2 years (median 0.11 vs. 0.08, HR 1.26; 95% confidence interval (CI) 1.03-1.54) and 2-5 years (median 0.18 vs. 0.13, HR 1.28; 95%CI 1.06-1.56) after ICU discharge. No differences were found in the period before ICU admission., Conclusion: Relatives of ICU survivors present more morbidity in primary care than relatives of chronically ill patients up to five years after ICU discharge.

Introduction: Over 70% of the intensive care unit (ICU) survivors suffer from long-lasting physical, mental and cognitive problems after hospital discharge. Post-ICU care is recommended by international guidelines, but evidence for cost-effectiveness lacks. The aim of this study is to evaluate the clinical effectiveness and cost-effectiveness of structured, multidisciplinary and personalised post-ICU care versus usual care on physical and psychological functioning and health-related quality of life (HRQoL) of ICU survivors, 1- and 2-year post-ICU discharge., Methods and Analysis: The MONITOR-IC post-ICU care study (MiCare study) is a multicentre stepped-wedge randomised controlled trial conducted in five hospitals. Adult patients at high risk for critical illness-associated morbidity post-ICU will be selected and receive post-ICU care, including an invitation to the post-ICU clinic 3 months after ICU discharge. A personalised long-term recovery plan tailored to patients' reported outcome measures will be made. 770 (intervention) and 1480 (control) patients will be included. Outcomes are 1- and 2-year HRQoL (EuroQol Instrument (EQ-5D-5L)), physical (fatigue and new physical problems), mental (anxiety, depression and post-traumatic stress disorder), and cognitive symptoms and cost-effectiveness. Medical data will be retrieved from patient records and cost data from health insurance companies., Ethics and Dissemination: Due to the lack of evidence, Dutch healthcare insurers do not reimburse post-ICU care. Therefore, evaluation of cost-effectiveness and integration in guidelines supports the evidence. Participation of several societies for physicians, nurses, paramedics, and patients and relatives in the project team increases the support for implementation of the intervention in clinical practice. Patients and relatives will be informed by the patient associations, hospitals and professional associations. Informing healthcare insurers about this project's results is important for the consideration for inclusion of post-ICU care in Dutch standard health insurance. The study is approved by the Radboud University Medical Centre research ethics committee (2021-13125)., Trial Registration Number: NCT05066984., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Skin cancer is the most common type of cancer worldwide. Family physicians (FPs) need to differentiate between nonmalignant and malignant skin conditions, but the diagnostic accuracy of FPs has never been studied in primary care., Aim: To assess the accuracy of skin cancer diagnoses by FPs. Our secondary aim was to analyze the number of patients with premalignant lesions and examine the diversity of skin-related questions in Dutch primary care., Method: This study is a retrospective cohort of all new skin-related health questions between January 1, 2018, and July 1, 2018, in a Dutch primary care registration network with data from 26 FPs in 6 practices, with a follow-up of at least 1 year. The initial FP diagnosis was dichotomized as malignant or nonmalignant and compared in a crosstab to the final diagnosis registered after the follow-up period (reference standard)., Results: Our study population included 2952 patients. During the research period, 35 patients received a final diagnosis of skin cancer. The sensitivity and specificity of the FP diagnosis of malignancy was 74.3% (95% confidence interval [CI], 56.7% to 87.5%) and 97.3% (95% CI, 96.7% to 97.8%), the positive predictive value and negative predictive value was 21.5% (95% CI, 17.2% to 26.5%) and 99.7% (95% CI, 99.5% to 99.8%), respectively. Seventy-two patients were diagnosed with a premalignant lesion. Included patients received 141 different diagnoses., Conclusion: The calculated diagnostic accuracy of FPs is high and shows that FPs are especially accurate in excluding malignancy. This research shows the variety of skin problems in primary care and shows that the FP can deliver safe and effective dermatologic care., Competing Interests: Conflict of interest: None., (© Copyright 2021 by the American Board of Family Medicine.)

Background: Alpha-glucosidase inhibitors (AGI) reduce blood glucose levels and may thus prevent or delay type 2 diabetes mellitus (T2DM) and its associated complications in people at risk of developing of T2DM., Objectives: To assess the effects of AGI in people with impaired glucose tolerance (IGT), impaired fasting blood glucose (IFG), moderately elevated glycosylated haemoglobin A1c (HbA1c) or any combination of these., Search Methods: We searched CENTRAL, MEDLINE, Embase, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform, and the reference lists of systematic reviews, articles and health technology assessment reports. The date of the last search of all databases was December 2017., Selection Criteria: We included randomised controlled trials (RCTs), with a duration of one year or more, comparing AGI with any pharmacological glucose-lowering intervention, behaviour-changing intervention, placebo or no intervention in people with IFG, IGT, moderately elevated HbA1c or combinations of these., Data Collection and Analysis: Two review authors read all abstracts and full-text articles or records, assessed quality and extracted outcome data independently. One review author extracted data, which were checked by a second review author. We resolved discrepancies by consensus or involvement of a third review author. For meta-analyses we used a random-effects model with assessment of risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, using 95% confidence intervals (CIs) for effect estimates. We assessed the overall quality of the evidence by using the GRADE instrument., Main Results: For this update of the Cochrane Review (first published 2006, Issue 4) we included 10 RCTs (11,814 participants), eight investigating acarbose and two investigating voglibose, that included people with IGT or people "at increased risk for diabetes". The trial duration ranged from one to six years. Most trials compared AGI with placebo (N = 4) or no intervention (N = 4).Acarbose reduced the incidence of T2DM compared to placebo: 670 out of 4014 people (16.7%) in the acarbose groups developed T2DM, compared to 812 out of 3994 people (20.3%) in the placebo groups (RR 0.82, 95% CI 0.75 to 0.89; P < 0.0001; 3 trials; 8008 participants; moderate-certainty evidence). One trial including participants with coronary heart disease and IGT contributed 64% of cases for this outcome. Acarbose reduced the risk of T2DM compared to no intervention: 7 out 75 people (9.3%) in the acarbose groups developed T2DM, compared to 18 out of 65 people (27.7%) in the no-intervention groups (RR 0.31, 95% CI 0.14 to 0.69; P = 0.004; 2 trials; 140 participants; very low-certainty evidence).Acarbose compared to placebo did not reduce or increase the risk of all-cause mortality (RR 0.98, 95% CI 0.82 to 1.18; P = 0.86; 3 trials; 8069 participants; very low-certainty evidence), cardiovascular mortality (RR 0.88; 95% CI 0.71 to 1.10; P = 0.26; 3 trials; 8069 participants; very low-certainty evidence), serious adverse events (RR 1.12, 95% CI 0.97 to 1.29; P = 0.13; 2 trials; 6625 participants; low-certainty evidence), non-fatal stroke (RR 0.50, 95% CI 0.09 to 2.74; P = 0.43; 1 trial; 1368 participants; very low-certainty evidence) or congestive heart failure (RR of 0.87; 95% CI 0.63 to 1.12; P = 0.40; 2 trials; 7890 participants; low-certainty evidence). Acarbose compared to placebo reduced non-fatal myocardial infarction: one out of 742 participants (0.1%) in the acarbose groups had a non-fatal myocardial infarction compared to 15 out of 744 participants (2%) in the placebo groups (RR 0.10, 95% CI 0.02 to 0.53; P = 0.007; 2 trials; 1486 participants; very low-certainty evidence). Acarbose treatment showed an increased risk of non-serious adverse events (mainly gastro-intestinal events), compared to placebo: 751 of 775 people (96.9%) in the acarbose groups experienced an event, compared to 723 of 775 people (93.3%) in the placebo groups (RR 1.04; 95% CI 1.01 to 1.06; P = 0.0008; 2 trials; 1550 participants). Acarbose compared to no intervention showed no advantage or disadvantage for any of these outcome measures (very low-certainty evidence).One trial each compared voglibose with placebo (1780 participants) or diet and exercise (870 participants). Voglibose compared to placebo reduced the incidence of T2DM: 50 out of 897 participants (5.6%) developed T2DM, compared to 106 out of 881 participants (12%) in the placebo group (RR 0.46, 95% CI 0.34 to 0.64; P < 0.0001; 1 trial; 1778 participants; low-certainty evidence). For all other reported outcome measures there were no clear differences between voglibose and comparator groups. One trial with 90 participants compared acarbose with diet and exercise and another trial with 98 participants reported data on acarbose versus metformin. There were no clear differences for any outcome measure between these two acarbose interventions and the associated comparator groups.None of the trials reported amputation of lower extremity, blindness or severe vision loss, end-stage renal disease, health-related quality of life, time to progression to T2DM, or socioeconomic effects., Authors' Conclusions: AGI may prevent or delay the development of T2DM in people with IGT. There is no firm evidence that AGI have a beneficial effect on cardiovascular mortality or cardiovascular events.

Objectives: To assess the incidence of head injury and predictors of complication across the care continuum., Design: Retrospective cohort study using data from a research network. We calculated the incidence of overall head injury in a longitudinal cohort covering 1-year interval (31 369 patient-years), and the incidence of complicated head injury in a longitudinal cohort covering 10 years interval (220 352 patient-ears). Incidence rates were calculated per 1000 patient-years with 95% CI using the Mid-P exact test. We calculated ORs to assess potential risk factors for a complicated head injury., Setting: A practice-based research network covering a population of >30 000 patients., Participants: All patients listed in practices within the research network during the years 2005-2014., Main Outcome Measures: Incidence of (complicated) head injury and predictors for clinical complications., Results: The incidence of overall head injury was 22.1 per 1000 person-years and the incidence of a complicated course following head injury was 0.16 per 1000 person-years. The following determinants were risk factors for a complicated course: high energy trauma, bicycle accident, traffic accident in general, use of anticoagulants, alcohol intoxication, age above 60 years and low Glasgow Coma Scale at initial presentation. A complicated course was very unlikely when the patients' first encounter with a healthcare professional was in primary care (OR 0.03, 95% CI 0.01 to 0.07)., Conclusions: Complication after head injury are rarely seen in general practice. Patients who do experience complications are often easily identifiable as requiring specialist care. A more reserved referral policy for general practice may be desirable, suggesting that current guidelines are too defensive., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Physicians and researchers in the field of family medicine often need to find relevant articles in online medical databases for a variety of reasons. Because a search filter may help improve the efficiency and quality of such searches, we aimed to develop and validate search filters to identify research studies of relevance to family medicine. Using a new and objective method for search filter development, we developed and validated 2 search filters for family medicine. The sensitive filter had a sensitivity of 96.8% and a specificity of 74.9%. The specific filter had a specificity of 97.4% and a sensitivity of 90.3%. Our new filters should aid literature searches in the family medicine field. The sensitive filter may help researchers conducting systematic reviews, whereas the specific filter may help family physicians find answers to clinical questions at the point of care when time is limited., (© 2015 Annals of Family Medicine, Inc.)

Objective: Neuralgic amyotrophy is considered a rare peripheral nervous system disorder but in practice seems grossly under recognized, which negatively affects care for these patients. In this study we prospectively counted the one-year incidence rate of classic neuralgic amyotrophy in a primary care setting., Methods: In a prospective cohort study during the year 2012 we registered all new cases of neck, shoulder or arm complaints from two large primary care centers serving a population of 14,118. Prior to study, general practitioners received a short training on how to diagnose classic neuralgic amyotrophy. Neuralgic amyotrophy was defined according to published criteria irrespective of family history. Only patients with a classic phenotype were counted as definite cases. After inclusion, patients with suspected neuralgic amyotrophy who had not yet seen a neurologist were offered neurologic evaluation for diagnostic confirmation., Results: Of the 492 patients identified with new onset neck, shoulder or arm complaints, 34 were suspected of having neuralgic amyotrophy. After neurologic evaluation the diagnosis was confirmed in 14 patients. This amounts to a one-year incidence rate for classic neuralgic amyotrophy of 1 per 1000., Conclusions: Our findings suggest that neuralgic amyotrophy is 30-50 times more common than previously thought. Unawareness of the disorder and its clinical presentation seems the most likely explanation for this difference. An incidence rate of 1 per 1000 and the long-term sequelae many patients suffer warrant more vigilance in diagnosing the disorder, to pave the way for timely treatment and prevent complications.

Background: Cardiovascular disease (CVD) is the most prevalent complication of type 2 diabetes with an estimated 65% of people with type 2 diabetes dying from a cause related to atherosclerosis. Adenosine-diphosphate (ADP) receptor antagonists like clopidogrel, ticlopidine, prasugrel and ticagrelor impair platelet aggregation and fibrinogen-mediated platelet cross-linking and may be effective in preventing CVD., Objectives: To assess the effects of adenosine-diphosphate (ADP) receptor antagonists for the prevention of cardiovascular disease in type 2 diabetes mellitus., Search Methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (issue 2, 2011), MEDLINE (until April 2011) and EMBASE (until May 2011). We also performed a manual search, checking references of original articles and pertinent reviews to identify additional studies., Selection Criteria: Randomised controlled trials comparing an ADP receptor antagonist with another antiplatelet agent or placebo for a minimum of 12 months in patients with diabetes. In particular, we looked for trials assessing clinical cardiovascular outcomes., Data Collection and Analysis: Two review authors extracted data for studies which fulfilled the inclusion criteria, using standard data extraction templates. We sought additional unpublished information and data from the principal investigators of all included studies., Main Results: Eight studies with a total of 21,379 patients with diabetes were included. Three included studies investigated ticlopidine compared to aspirin or placebo. Five included studies investigated clopidogrel compared to aspirin or a combination of aspirin and dipyridamole, or compared clopidogrel in combination with aspirin to aspirin alone. All trials included patients with previous CVD except the CHARISMA trial which included patients with multiple risk factors for coronary artery disease. Overall the risk of bias of the trials was low. The mean duration of follow-up ranged from 365 days to 913 days.Data for diabetes patients on all-cause mortality, vascular mortality and myocardial infarction were only available for one trial (355 patients). This trial compared ticlopidine to placebo and did not demonstrate any statistically significant differences for all-cause mortality, vascular mortality or myocardial infarction. Diabetes outcome data for stroke were available in three trials (31% of total diabetes participants). Overall pooling of two (statistically heterogeneous) studies showed no statistically significant reduction in the combination of fatal and non-fatal stroke (359/3194 (11.2%) versus 356/3146 (11.3%), random effects odds ratio (OR) 0.81; 95% confidence interval (CI) 0.44 to 1.49) for ADP receptor antagonists versus other antiplatelet drugs. There were no data available from any of the trials on peripheral vascular disease, health-related quality of life, adverse events specifically for patients with diabetes, or costs., Authors' Conclusions: The available evidence for ADP receptor antagonists in patients with diabetes mellitus is limited and most trials do not report outcomes for patients with diabetes separately. Therefore, recommendations for the use of ADP receptor antagonists for the prevention of CVD in patients with diabetes are based on available evidence from trials including patients with and without diabetes. Trials with diabetes patients and subgroup analyses of patients with diabetes in trials with combined populations are needed to provide a more robust evidence base to guide clinical management in patients with diabetes.

Introduction: Diabetes mellitus is a progressive disorder of glucose metabolism. It is estimated that about 285 million people between the ages of 20 and 79 years had diabetes worldwide in 2010, or 5% of the adult population. Type 2 diabetes may occur with obesity, hypertension, and dyslipidaemia (the metabolic syndrome), which are powerful predictors of cardiovascular disease. Without adequate blood-glucose-lowering treatment, blood glucose levels may rise progressively over time in people with type 2 diabetes. Microvascular and macrovascular complications may develop., Methods and Outcomes: We conducted a systematic review and aimed to answer the following clinical question: What are the effects of blood-glucose-lowering medications in adults with type 2 diabetes? We searched: Medline, Embase, The Cochrane Library, and other important databases up to February 2010 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA)., Results: We found 194 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions., Conclusions: In this systematic review we present information relating to the effectiveness and safety of the following interventions: alpha-glucosidase inhibitors (AGIs), combination treatment (single, double, and triple), dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 (GLP-1) analogues, insulins (including conventional [human] and analogue, different regimens, different length of action), meglitinides, metformin, sulphonylureas, and thiazolidinediones.

Background: There is a push to make clinical decision making more evidence based and patient oriented. However, current systematic reviews are limited by the lack of consideration of generalizability., Objective: To develop a guide for investigators (systematic reviewers) on how to adapt the methodology of a systematic review to facilitate the exploration of the results to primary care., Methods: We reviewed the method guidelines of five organizations and working groups. Then, we conducted a search of literature in PubMed for articles on external validity of systematic. Based on the literature, we developed general steps to incorporate generalizability in systematic reviews and then integrated main primary care themes as outlined in WONCA definition of primary care and the definition of person-centred medicine across those steps., Results: We identified a wide variety of approaches to address the issue of generalizability in systematic reviews. We extracted four major primary care themes from the two definitions of primary care and person-centred medicine that we mapped across the methods of generalizability. We suggested a two-step approach: Step 1 planning the scope of a review using four-layer schematic model and Step 2 to follow four steps to incorporate the concept of generalizability to primary care in the review., Conclusions: Systematic reviewers can take several steps to improve the generalizability of their review to primary care. However, more research is needed to determine which approach provides better results than others.

Background: Continuity of care is widely acknowledged as a core value in family medicine. In this systematic review, we aimed to identify the instruments measuring continuity of care and to assess the quality of their measurement properties., Methods: We did a systematic review using the PubMed, Embase and PsycINFO databases, with an extensive search strategy including 'continuity of care', 'coordination of care', 'integration of care', 'patient centered care', 'case management' and its linguistic variations. We searched from 1995 to October 2011 and included articles describing the development and/or evaluation of the measurement properties of instruments measuring one or more dimensions of continuity of care (1) care from the same provider who knows and follows the patient (personal continuity), (2) communication and cooperation between care providers in one care setting (team continuity), and (3) communication and cooperation between care providers in different care settings (cross-boundary continuity). We assessed the methodological quality of the measurement properties of each instrument using the COSMIN checklist., Results: We included 24 articles describing the development and/or evaluation of 21 instruments. Ten instruments measured all three dimensions of continuity of care. Instruments were developed for different groups of patients or providers. For most instruments, three or four of the six measurement properties were assessed (mostly internal consistency, content validity, structural validity and construct validity). Six instruments scored positive on the quality of at least three of six measurement properties., Conclusions: Most included instruments have problems with either the number or quality of its assessed measurement properties or the ability to measure all three dimensions of continuity of care. Based on the results of this review, we recommend the use of one of the four most promising instruments, depending on the target population Diabetes Continuity of Care Questionnaire, Alberta Continuity of Services Scale-Mental Health, Heart Continuity of Care Questionnaire, and Nijmegen Continuity Questionnaire.

Background: Acute urinary tract infections (UTI) are one of the most common bacterial infections among women presenting to primary care. However, there is a lack of consensus regarding the optimal reference standard threshold for diagnosing UTI. The objective of this systematic review is to determine the diagnostic accuracy of symptoms and signs in women presenting with suspected UTI, across three different reference standards (10(2) or 10(3) or 10(5) CFU/ml). We also examine the diagnostic value of individual symptoms and signs combined with dipstick test results in terms of clinical decision making., Methods: Searches were performed through PubMed (1966 to April 2010), EMBASE (1973 to April 2010), Cochrane library (1973 to April 2010), Google scholar and reference checking.Studies that assessed the diagnostic accuracy of symptoms and signs of an uncomplicated UTI using a urine culture from a clean-catch or catherised urine specimen as the reference standard, with a reference standard of at least ≥ 10(2) CFU/ml were included. Synthesised data from a high quality systematic review were used regarding dipstick results. Studies were combined using a bivariate random effects model., Results: Sixteen studies incorporating 3,711 patients are included. The weighted prior probability of UTI varies across diagnostic threshold, 65.1% at ≥ 10(2) CFU/ml; 55.4% at ≥ 10(3) CFU/ml and 44.8% at ≥ 10(2) CFU/ml ≥ 10(5) CFU/ml. Six symptoms are identified as useful diagnostic symptoms when a threshold of ≥ 10(2) CFU/ml is the reference standard. Presence of dysuria (+LR 1.30 95% CI 1.20-1.41), frequency (+LR 1.10 95% CI 1.04-1.16), hematuria (+LR 1.72 95%CI 1.30-2.27), nocturia (+LR 1.30 95% CI 1.08-1.56) and urgency (+LR 1.22 95% CI 1.11-1.34) all increase the probability of UTI. The presence of vaginal discharge (+LR 0.65 95% CI 0.51-0.83) decreases the probability of UTI. Presence of hematuria has the highest diagnostic utility, raising the post-test probability of UTI to 75.8% at ≥ 10(2) CFU/ml and 67.4% at ≥ 10(3) CFU/ml. Probability of UTI increases to 93.3% and 90.1% at ≥ 10(2) CFU/ml and ≥ 10(3) CFU/ml respectively when presence of hematuria is combined with a positive dipstick result for nitrites. Subgroup analysis shows improved diagnostic accuracy using lower reference standards ≥ 10(2) CFU/ml and ≥ 10(3) CFU/ml., Conclusions: Individual symptoms and signs have a modest ability to raise the pretest-risk of UTI. Diagnostic accuracy improves considerably when combined with dipstick tests particularly tests for nitrites.

Background: Rectal bleeding is a recognised early symptom of colorectal cancer. This study aimed to assess the diagnostic accuracy of symptoms, signs and diagnostic tests in patients with rectal bleeding in relation to risk of colorectal cancer in primary care., Methods: Diagnostic accuracy systematic review. Medline (1966 to May 2009), Embase (1988 to May 2009), British Nursing Index (1991 to May 2009) and PsychINFO (1970 to May 2009) were searched. We included cohort studies that assessed the diagnostic utility of rectal bleeding in combination with other symptoms, signs and diagnostic tests in primary care. An eight-point quality assessment tool was produced to assess the quality of included studies. Pooled positive likelihood ratios (PLRs), sensitivities and specificities were calculated., Results: Eight studies incorporating 2323 patients were included. Average weighted prior probability of colorectal cancer was 7.0% (range: 3.3-15.4%, median: 8.1%). Age > or = 60 years (pooled PLR: 2.79, 95% confidence interval (CI) 2.00-3.90), weight loss (pooled PLR: 1.89, 95% CI: 1.03-3.07) and change in bowel habit (pooled PLR: 1.92, 95% CI: 0.54-3.57) raise the probability of colorectal cancer into the range of referral to secondary care but do not conclusively 'rule in' the diagnosis. Presence of severe anaemia has the highest diagnostic value (pooled PLR: 3.67, 95% CI: 1.30-10.35), specificity 0.95 (95% CI: 0.93-0.96), but still only generates a post-test probability of 21.6%., Conclusions: In patients with rectal bleeding who present to their general practitioner, additional 'red flag' symptoms have modest diagnostic value. These findings have implications in relation to recommendations contained in clinical practice guidelines.

Background: Gout is one of the most frequently occurring rheumatic diseases, worldwide. Given the well-known drawbacks of the regular treatments for acute gout (non-steroidal anti-inflammatory drugs (NSAIDs), colchicine), systemic corticosteroids might be safe alternatives., Objectives: To assess the efficacy and safety of systemic corticosteroids in the treatment of acute gout in comparison with placebo, NSAIDs, colchicine, other active drugs, other therapies, or no therapy., Search Strategy: Searches were done in the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007); MEDLINE (1966 to 2007) through PubMed; EMBASE (1974 to 2007); Web of Science (1975 to 2007); LILACS (1986 to 2007); and databases of ongoing trials (up to April 2007)., Selection Criteria: Randomized controlled trials and controlled clinical trials investigating the use of systemic corticosteroids in the treatment of acute gout were included., Data Collection and Analysis: Two review authors decided independently which trials to include. The same review authors also collected the data in a standardised form and assessed the methodological quality of the trial using validated criteria. When possible, continuous and dichotomous data were summarised statistically., Main Results: Three head to head trials involving 148 patients (74 systemic corticosteroids; 74 comparator drugs) were included. Placebo-controlled trials were not found. In the studies, different kinds of systemic corticosteroids and different kinds of control drugs were used, both administered in different routes. Intramuscular triamcinolone acetonide was compared respectively to oral indomethacine, and intramuscular adrenocorticotropic hormone (ACTH); oral prednisolone (together with a single intramuscular diclophenac injection) was compared to oral indomethacine (together with a single placebo injection). Outcome measurements varied: average number of days until total relief of signs, mean decrease of pain per unit of time in mm on a visual analogue scale (VAS) - during rest and activity. In the triamcinolone-indomethacine trial the clinical joint status was used as an additional outcome. Clinically relevant differences between the studied systemic corticosteroids and the comparator drugs were not found; important safety problems attributable to the used corticosteroids were not reported. The quality of the three studies was graded as very low to moderate. Statistical pooling of results was not possible., Authors' Conclusions: There is inconclusive evidence for the efficacy and effectiveness of systemic corticosteroids in the treatment of acute gout. Patients with gout did not report serious adverse effects from systemic corticosteroids, when used short term.

Objective: Systematic reviews are an appraised method to summarize research in a concise and transparent way, and may enable to draw conclusions beyond the sum of results of individual studies. We assessed the results, quality and external validity of systematic reviews on diet in patients with type 2 diabetes., Design, Setting, Subjects: We systematically searched for systematic reviews on nutritional interventions in patients with type 2 diabetes that used a reproducible search strategy in at least one major database that applied some form of quality assessment. We assessed quality and the external validity of the retrieved systematic reviews. Outcomes were defined as statistical meta-analyses or narrative results using a predefined and reproducible method., Results: Six systematic reviews met the inclusion criteria, investigating dietary interventions in general (n=3), chromium supplementation (n=1), fish-oil (n=1) or herbs and nutrition supplements (n=1). Quality assessment showed minimal/minor flaws in four cases and major/extensive flaws in two cases. All reviews had insufficient data needed to judge external validity. In reviews with minimal/minor flaws, we found beneficial effects of very-low-calorie diets and fish-oil supplements. However, the external validity of these results could not be assessed sufficiently., Conclusions: Systematic reviews largely failed to produce knowledge beyond the sum of the original studies. Furthermore, judgment of external validity was hampered in most cases owing to missing data. To improve the quality and usefulness of systematic reviews of dietary interventions, we recommend the application of more focused research questions, but with broader inclusion criteria, for example, the use of observational studies., Sponsorship: Internal funding Radboud University Nijmegen Medical Centre.

Background: Alpha-glucosidase inhibitors (AGIs) reduce blood glucose levels and may thus prevent type 2 diabetes and cardiovascular disease in patients with impaired glucose tolerance. These possible effects, and the effects on quality of life, plasma lipids and body weight, have never been investigated in a systematic literature review and meta-analysis., Objectives: To assess the effects of alpha-glucosidase inhibitors in patients with impaired glucose tolerance (IGT) or impaired fasting blood glucose (IFBG), or both., Search Strategy: We searched The Cochrane Library (Clinical Trials database, formerly known as CENTRAL), PUBMED, EMBASE, Web of Science, LILACS, databases of ongoing trials, reference lists of relevant reviews, and we contacted experts and manufacturers. Date of last search was February 2006., Selection Criteria: Randomised controlled trials of at least one-year duration in patients with IGT or IFBG, or both, comparing AGI monotherapy with any other intervention., Data Collection and Analysis: Two reviewers read all abstracts, assessed quality and extracted data independently. Discrepancies were resolved by consensus or by the judgement of a third reviewer., Main Results: We included five trials (2360 participants), all investigating acarbose, that included patients with IGT or patients 'at increased risk for diabetes' (n = 1). Study duration was one, three (n = 2), five and six years. One study was at low risk of bias and four studies at high risk of bias. Except for the outcome incidence of type 2 diabetes in acarbose versus no treatment (two studies), meta-analyses were not possible. Data from the study at low risk of bias suggests that acarbose decreases the occurrence of type 2 diabetes (NNT = 10), cardiovascular events (NNT = 50, based on 47 events, study not initially powered for this outcome), post-load blood glucose (-0.6 mmol/L, 95% CI -1.0 to -0.3) and body mass index (0.3 kg/m(2), 95% CI -0.1 to -0.5). No statistically significant effects were observed on mortality, other morbidity, glycated haemoglobin, fasting blood glucose, lipids and blood pressure. The effects on the incidence of type 2 diabetes were confirmed in two studies at high risk of bias (OR 0.2, 95% CI 0.1 to 0.6). Adverse effects were mostly of gastro-intestinal origin (OR 3.5, 95% CI 2.7 to 4.4)., Authors' Conclusions: There is evidence that acarbose reduces the incidence of type 2 diabetes in patients with IGT. However, it is unclear whether this should be seen as prevention, delay or masking of diabetes. Acarbose may prevent the occurrence of cardiovascular events, but this finding needs to be confirmed in more studies.

Objective: To explore incidence and prevalence rates of nutritional deficiency in adults in general practice., Methods: Six Dutch general practice research and registration networks supplied incidence and prevalence rates of nutritional deficiency by the International Classification of Primary Care (ICPC) or 'E-list' labels ('loss of appetite, feeding problem adult, iron, pernicious/folate deficiency anaemia, vitamin deficiencies and other nutritional disorders, weight loss'). In case of disease-related nutritional deficiency, we asked whether this was labelled separately ('co-registered') or included in the registration of the underlying disease., Results: 'Iron deficiency anaemia' had highest incidence (0.3-8.5/1000 person years), and prevalence rates (2.8-8.9/1000 person years). Nutritional deficiency was mostly documented in the elderly. In two networks 'co-registration' was additional, two only documented the underlying disease and two did not specify 'co-registration'. No clear difference was found between networks considering the difference in 'co-registration'., Conclusion: Nutritional deficiency is little documented in general practice, and generally is not registered separately from the underlying disease.

Objective: Nutritional deficiency is an independent risk factor for mortality. Despite its clinical relevance, the prevalence in a primary care setting is poorly documented. We performed a systematic review of reported prevalence and clinical assessment of nutritional deficiency in general practice., Methods: From MEDLINE, Current Contents and EMBASE, we derived articles and checked the initially included ones for references on prevalence data. Of the eligible articles, we assessed the quality of research and results., Results: We finally included eight studies. The prevalence ranged from 0 to 13%. However, the study populations were heterogeneous and all studies contained methodological flaws, especially selection bias. In addition, the clinical assessment differed between studies., Conclusion: Literature on the prevalence of nutritional deficiency within general practice is rare and provides disputable prevalence assessments.

Background: Alpha-glucosidase inhibitors such as acarbose or miglitol, have the potential to improve glycemic control in type 2 diabetes mellitus. The true value of these agents, especially in relation to diabetes related mortality and morbidity, has never been investigated in a systematic literature review and meta-analysis., Objectives: To assess the effects of alpha-glucosidase inhibitors s in patients with type 2 diabetes mellitus., Search Strategy: We searched The Cochrane Library, MEDLINE, EMBASE, Current Contents, LILACS, databases of ongoing trials, reference lists of reviews on the topic of alpha-glucosidase inhibitors and we contacted experts and manufacturers for additional trials. Date of most recent search: December 2003 (Current Contents) and April 2003 (other databases)., Selection Criteria: Randomised controlled trials of at least 12 weeks duration comparing alpha-glucosidase inhibitor monotherapy in patients with type 2 diabetes with any other intervention and that included at least one of the following outcomes: mortality, morbidity, quality of life, glycemic control, lipids, insulin levels, body weight, adverse events., Data Collection and Analysis: Two reviewers read all abstracts, assessed quality and extracted data independently. Discrepancies were resolved by consensus or by the judgement of a third reviewer. A statistician checked all extracted data entrance in the database. We attempted to contact all authors for data clarification., Main Results: We included 41 trials (8130 participants), 30 investigated acarbose, seven miglitol, one trial voglibose and three trials compared different alpha-glucosidase inhibitors. Study duration was 24 weeks in most cases and only two studies lasted amply longer than one year. We found only few data on mortality, morbidity and quality of life. Acarbose had a clear effect on glycemic control compared to placebo: glycated haemoglobin -0.8% (95% confidence interval -0.9 to -0.7), fasting blood glucose -1.1 mmol/L (95% confidence interval -1.4 to -0.9), post-load blood glucose -2.3 mmol/L (95% confidence interval -2.7 to -1.9). The effect on glycated haemoglobin by acarbose was not dose-dependent. We found a decreasing effect on post-load insulin and no clinically relevant effects on lipids or body weight. Adverse effects were mostly of gastro-intestinal origin and dose dependent. Compared to sulphonylurea, acarbose decreased fasting and post-load insulin levels by -24.8 pmol/L (95% confidence interval -43.3 to -6.3) and -133.2 pmol/L (95% confidence interval -184.5 to -81.8) respectively and acarbose caused more adverse effects., Authors' Conclusions: It remains unclear whether alpha-glucosidase inhibitors influence mortality or morbidity in patients with type 2 diabetes. Conversely, they have a significant effect on glycemic control and insulin levels, but no statistically significant effect on lipids and body weight. These effects are less sure when alpha-glucosidase inhibitors are used for a longer duration. Acarbose dosages higher than 50 mg TID offer no additional effect on glycated hemoglobin but more adverse effects instead. Compared to sulphonylurea, alpha-glucosidase inhibitors lower fasting and post-load insulin levels and have an inferior profile regarding glycemic control and adverse effects.

Background: Although treatment targets for the consumption of dietary fat in patients with type 2 diabetes mellitus are well accepted, little is known about the actual fat consumption by newly diagnosed patients or the dietary adjustments that they make in the following years., Aims: To measure fat intake in patients with type 2 diabetes in general practice at diagnosis, shortly after dietary consultation, and after 4 years., Design of Study: A prospective cohort study., Setting: Thirty-three general practices in The Netherlands., Method: One hundred and forty-four patients with newly diagnosed type 2 diabetes were referred to a dietician, and fat consumption (the main outcome measure) was assessed with a 104-item food frequency questionnaire at diagnosis, 8 weeks following diagnosis, and after 4 years. Reference values for fat consumption were obtained from an age-matched sample of a population-based survey., Results: At diagnosis, total energy intake was 10.6 MJ/day and cholesterol intake was 300 mg/day. Total fat consumption was 40.9% of energy intake, with saturated fatty acids 15.0%, monounsaturated fatty acids 14.3%, and polyunsaturated fatty acids 9.2% of energy intake. All levels, except for polyunsaturated fatty acids, were significantly unfavourable compared with those for the general population. After 8 weeks, consumption of saturated fatty acids had decreased to a lower level than in the general population and all other levels measured were similar to those for the general population. After 4 years there was a slight increase in the consumption of total fat and monounsaturated fatty acids, but cholesterol and saturated fatty acid consumption had decreased further., Conclusions: Patients with newly diagnosed type 2 diabetes have an unfavourable fat consumption at diagnosis. They adapt to a more desirable consumption shortly after diagnosis, and this improved dietary behaviour is sustained for 4 years. Recommendations regarding consumption of total and saturated fat are, in contrast to those for cholesterol, not met by patients in general practice.