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The multidisciplinary guideline 'Diagnostics and treatment of irritable bowel syndrome (IBS)' provides the basis for a properly coordinated collaboration between the patient suffering from IBS and all healthcare providers involved in his or her treatment, such as the general practitioner, gastroenterologist, internist, occupational-health physician, dietitian and psychologist. The diagnosis 'IBS' is often made in accordance with diagnostic criteria, such as the Rome III criteria, but a somatic condition needs to be excluded first. If there are no indications for this, additional diagnostic tests are not necessary. Management of the condition consists primarily of advice on life-style plus non-pharmacological interventions, in addition to explaining the condition and providing information. Drug treatment is rarely indicated. If the IBS symptoms have a significant impact on quality of life and patients do not respond to the measures taken in accordance with this general policy, there are three options for psychotherapeutic treatment. When the symptoms result in absenteeism or other work-related problems, the doctor can advise the patient to contact the occupational-health physician and to search for specific solutions in consultation with the employer. When individual advice is required or if the patient's diet is not well-balanced, a referral to the dietitian will follow.

Objectives: To investigate the 6-month functional prognosis of dizziness in older adults in primary care, to identify important predictors of dizziness-related impairment, and to construct a score to assist risk prediction., Design: Prospective cohort study with 6-month follow-up., Setting: Twenty-four primary care practices in the Netherlands., Participants: Four hundred seventeen older adults (mean age 78.5, range 65-95, 74% female) presenting consecutively to primary care with dizziness., Measurements: Tests, including history and physical and additional examination, previously selected by an international expert panel and based on an earlier systematic review, were performed. The main outcome measure was 6-month dizziness-related impairment score measured using the Dizziness Handicap Inventory., Results: Follow-up was complete for 92% of participants. Although 61% of participants experienced less impairment at 6 months, 130 participants (34%) showed persistent dizziness-related impairment. Factors most predictive of dizziness-related impairment at 6 months were onset of dizziness at least 6 months before inclusion, standing still as a dizziness-provoking circumstance, trouble with walking or (almost) falling (associated symptom), polypharmacy, absence of diabetes mellitus, presence of anxiety or depressive disorder, and impaired functional mobility. A score was constructed using these predictors to estimate the functional prognosis of dizziness at 6 months., Conclusion: A score based on the presence of easily obtainable clinical information facilitates identification of older adults in primary care with poor functional prognosis of their dizziness without exactly knowing the cause(s) of their dizziness. Clinical management might be most effective by treating factors that can be influenced, such as polypharmacy, anxiety and depression, and functional mobility., (© 2012, Copyright the Authors Journal compilation © 2012, The American Geriatrics Society.)

Objective: Optimising care for dementia patients and their informal carers is imperative in light of the impending dementia epidemic. An important aspect of care is accurate recognition and diagnosis of dementia. The aim of this review was to estimate family physicians' diagnostic accuracy at the different stages of dementia., Methods: Pubmed, Embase, CINAHL, PsycINFO and the Cochrane Library were searched for articles comparing family physicians' 'dementia' and 'cognitive impairment' diagnoses in the primary care setting to reference standard dementia diagnoses., Results: Data from six cross-sectional studies of moderate to reasonable methodological quality were extracted for the analysis. One study considered the accuracy of family physicians' recollected diagnoses, and three studies focussed on documented diagnoses. In these four studies, the sensitivity of family physicians' combined diagnostic categories of 'cognitive impairment' together with 'dementia' was 0.48-0.67 for mild dementia and 0.76-0.85 for moderate to severe dementia. The sensitivity of their diagnostic category 'dementia' alone was 0.14-0.33 for mild and 0.28-0.61 for moderate to severe dementia. Specificity was excellent for all severity stages in both comparisons. Three studies examined the accuracy of family physicians' judgement of cognition during consultation. Compared with the studies on recollection and documentation, these studies reported higher sensitivity and lower specificity., Conclusion: Many individuals with dementia are not recognised or not diagnosed as such; particularly mild dementia is under-diagnosed. Collaboration within primary care and education focussing both on knowledge and attitude are recommended to improve the accuracy of family physicians' dementia diagnosis., (Copyright © 2011 John Wiley & Sons, Ltd.)

Doctors often feel pressured by patients to prescribe antibiotics for a common cold or a sore throat, against their better judgment. Yet do patients really put pressure on their doctor or even expect a prescription for an antibiotic or some other medicine? Several interesting studies shed some light on this issue. Doctors in an emergency department, for example, prescribed an antibiotic much more frequently than their patients expected them to. Only in 25% of cases were the doctors correct in their assumptions about patient expectations. In a Norwegian study, the authors found that parents wanted more time and explanation for their coughing children and fewer prescriptions. So instead of assuming that patients want antibiotics for innocent symptoms, we should put more effort into exploring patients' expectations and providing them with relevant information. That way we can step out of the folie a deux.

Background: Previous estimates of depression recognition in primary care are low and inconsistent. This may be due to registration artifacts and limited extraction efforts. This study investigated a) whether GPs' medical records demonstrate an accurate recognition of depression and b) which combinations of indications within the record most accurately reflect a diagnosis of depression., Methods: GPs' registrations were compared with a reference standard, the Composite International Diagnostic Interview (CIDI), according to DSM-IV criteria. Six definitions of GPs' recognition of depression were tested using diagnostic codes, medication data, referral data and free text in the medical records. The Youden-index was used to select the optimal definition of recognition. Data were derived from the Netherlands Study of Depression and Anxiety. 816 primary care patients from 33 general practitioners were included in the vicinities of Amsterdam and Leiden, The Netherlands., Results: Registration of antidepressant prescriptions was the best single indicator of GPs' recognition of CIDI depression with a recognition rate of 0.43. The best combination of indicators increased the recognition rate to 0.69. All indications except the specific diagnostic codes for 'depressive disorder' and 'depressive feelings' were included in this definition., Limitations: Potential bias due to the selection of participating GPs might have influenced our recognition rates., Conclusion: GPs are aware of mental health problems in most depressed patients, but labeling with specific diagnostic codes is weak. Researchers should consider that diagnostic coding alone is not an accurate measure of the diagnostic ability of depression and strongly underestimates the accuracy of the GP., (Copyright © 2011 Elsevier B.V. All rights reserved.)

Objective: Depressive and anxiety disorders in later life have a high incidence and are associated with reduced quality of life. Elsewhere, we demonstrated that a stepped-care prevention approach was successful in halving the incidence of these disorders over a period of 12 months. As a decreasing effect over time is to be expected, our aim was to investigate the longer-term effects., Design: Randomized controlled trial., Setting: Thirty-three primary care practices in the Netherlands., Participants: One hundred seventy consenting individuals, age 75 years and older, presenting with subthreshold depression or anxiety, not meeting the diagnostic criteria., Intervention: Participants were randomized to a preventive intervention or usual care. In the first 12 months, the preventive intervention entailed watchful waiting, minimally supported CBT-based self-help intervention, problem-solving treatment, and referral to a primary care physician for medication, if required. In the last 12 months, 95% of the participants ceased to receive such support., Measurements: Mini International Neuropsychiatric Interview., Results: The cumulative incidence rate of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, major depression or anxiety disorder over a period of 24 months was halved by the intervention, from 33 of 84 (39.3%) in the usual care group to 17 of 86 (19.8%) in the intervention group (odds ratio = 0.38; 95% confidence interval = 0.19–0.76), which was significant (z = 2.75; p = 0.006). The corresponding number needed to treat was 5 (95% confidence interval = 3–16)., Conclusions: A stepped-care approach to the prevention of depression and anxiety in late life was not only successful in halving the incidence of depressive and anxiety disorders after 1 year, but these favorable effects were also sustained over 24 months.

The syndrome diagnosis 'irritable bowel syndrome' (IBS) is often made on the basis of exclusion, but the question is how many diagnostic tests should be performed in order to establish this diagnosis with a degree of confidence. We present the diagnostic value of various IBS criteria for excluding IBS, based on a systematic review. The potential of the various criteria for distinguishing IBS from organic disease is extremely variable and disappointing. Patients fulfilling IBS criteria have, however, a lower risk of organic disease than patients with abdominal symptoms who do not fulfil the criteria. The same holds true for the diagnostic performance of individual alerting symptoms. These seem to be present frequently in IBS patients in whom there is no underlying organic bowel condition. An organic condition cannot be accurately excluded on the basis of symptom criteria. However, the low prior risk of organic conditions among patients who consult a primary care doctor and who meet IBS criteria argues against exhaustive diagnostic evaluation.

Purpose: Although fatigue is a common presenting symptom in primary care and its course and outcomes often remain unclear, cohort studies among patients seeking care for fatigue are scarce. We therefore aimed to investigate patterns in the course of fatigue and relevant secondary outcomes in a large cohort of patients who sought care for a main symptom of fatigue., Methods: We performed an observational cohort study in 147 primary care practices. Patients consulting their general practitioner for a new episode of fatigue were sent questionnaires at 1, 4, 8, and 12 months after baseline. We collected measures of fatigue, perceived health and functioning, absenteeism, psychological symptoms, and sleep using the Checklist Individual Strength, the 36-Item Short Form Health Survey, the Four-Dimensional Symptoms Questionnaire, and the Pittsburgh Sleep Questionnaire Inventory. Patients were classified into 4 subgroups based on fatigue severity scores over time. We assessed patterns in the course of all outcomes in these subgroups and in the total population, and tested changes over time and differences between subgroups., Results: A total of 642 patients were enrolled in the study. Response rates during follow-up ranged between 82% and 88%. For 75% of the patients, 4 distinct groups could be discerned: 26% of patients had continuously high scores for fatigue, 17% had a fast recovery, 25% had a slow recovery, and 32% initially improved but then had a recurrence of fatigue. Patterns for the secondary outcomes of symptoms and functioning were all similar to the pattern for fatigue within each of the subgroups., Conclusions: The findings of this study suggest a longitudinal relationship between the severity of fatigue, impaired functioning, psychological symptoms, and poor sleep. Physicians should be aware that a substantial proportion of patients seeking care for fatigue have these additional health and psychosocial problems.

Background: Several instruments can be used to identify patients with an unfavourable course of low back pain in general practice. However, it is unclear which instrument is the predictor of outcome., Aim: To compare the predictive performance (that is, calibration and discrimination) of risk estimation by GPs with assessments using the Orebro Musculoskeletal Pain Screening Questionnaire, the Low Back Pain Perception Scale (LBPPS), and a prediction rule developed for this purpose., Design of Study: A prospective cohort study with 1-year follow-up., Setting: General practice in The Netherlands., Method: The outcome 'unfavourable course of low back pain' was defined as having no clinically important improvement at minimally 50% of the measurements at 6, 13, 26, and 52 weeks. Logistic regression analyses were used to study associations between potential predictors and outcome., Results: In total, 60 GPs recruited 314 patients to the study (16 patients were excluded from analysis due to missing data on the course of low back pain). Over a third of patients (112/298) showed an unfavourable course of low back pain on follow-up. Risk estimation by GPs, the Orebro questionnaire, the LBPPS, and the prediction rule had discriminative ability (area under the curve) of 0.59 (95% CI [confidence intervals] = 0.52 to 0.66); 0.61 (95% CI = 0.54 to 0.67); 0.59 (95% CI = 0.52 to 0.66); and 0.75 (95% CI = 0.69 to 0.81) respectively. The prediction rule included history of low back pain, self-perceived risk to develop chronic low back pain, no solicitous responses of the patient's partner (as reported by the patient), frequent walking at work, and 'pain catastrophising'., Conclusion: Although the prediction rule performed best with regard to calibration and discrimination, it needs to be externally validated. Risk estimation by GPs performs as well as other instruments and, at present, seems to be the best available option.

Objective: To compare the effects of a minimal intervention strategy aimed at assessment and modification of psychosocial prognostic factors and usual care for treatment of (sub)acute low back pain in general practice., Design: Cluster randomised clinical trial., Setting: 60 general practitioners in 41 general practices., Participants: 314 patients with non-specific low back pain of less than 12 weeks' duration, recruited by their general practitioner., Interventions: In the minimal intervention strategy group the general practitioner explored the presence of psychosocial prognostic factors, discussed these factors, set specific goals for reactivation, and provided an educational booklet. The consultation took about 20 minutes. Usual care was not standardised., Main Outcome Measures: Functional disability (Roland-Morris disability questionnaire), perceived recovery, and sick leave because of low back pain assessed at baseline and after 6, 13, 26, and 52 weeks., Results: The dropout rate was 8% in the minimal intervention strategy group and 9% in the usual care group. Multilevel analyses showed no significant differences between the groups on any outcome measure during 12 months of follow-up in the whole group or in relevant subgroups (patients with high scores on psychosocial measures at baseline or a history of frequent or prolonged low back pain)., Conclusion: This study provides no evidence that (Dutch) general practitioners should adopt our new treatment strategy aimed at psychosocial prognostic factors in patients with (sub)acute low back pain. Further research should examine why our new strategy was not more effective than usual care.