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Background: Allergic rhinitis (AR) and asthma are both inflammatory diseases and are often associated. Relationships between fractional exhaled nitric oxide (FeNO) and asthma, atopy, and quality of life have been shown.Aims: This study aimed to determine whether FeNO in children with AR (n=158) or combined AR and asthma (n=93) was associated with clinical symptoms, house dust mite (HDM)-specific IgE, and rhinitis-specific quality of life, both cross-sectionally and longitudinally.Methods: Children with AR aged 6-18 years (n=251) in primary care were assessed for FeNO, nasal symptom scores, asthma symptom scores, quality of life, and HDM-specific IgE at baseline and 2 years later.Results: We found similarly elevated FeNO in children with only AR and in those with combined AR and asthma. No correlations were found between FeNO and nasal or asthma symptoms and rhinitis-related quality of life. Longitudinal correlations were strongest for HDM-specific IgE (r=0.91, pConclusions: FeNO was similar in a selected group of children with AR with and without asthma in primary care and was unrelated to symptoms or quality of life in both groups. FeNO is unlikely to be a useful biomarker of the clinical severity of upper or lower airway disease in primary care. (C) 2013 Primary Care Respiratory Society UK. All rights reserved. CMA de Bot etal. Prim Care Respir J 2013; 22(1): 44-50 http://dx.doi.org/10.4104/pcrj.2013.00009

The aim of the current study was to determine the course of back pain in older patients and identify prognostic factors for non-recovery at 3 months' follow-up. We conducted a prospective cohort study (the BACE study) of patients aged >55 years visiting a general practitioner (GP) with a new episode of back pain in the Netherlands. The course of back pain was described in terms of self-perceived recovery, pain severity, disability, pain medication, and GP visits at 6 weeks' and 3 months' follow-up. Prognostic factors for non-recovery at 3 months' follow-up were derived from the baseline questionnaire and physical examination. Variables with a prognostic value were identified with multivariable logistic regression analysis (method backward), and an area under the receiver operating curve (AUC) was calculated for the prognostic model. A total of 675 back pain patients (mean age 66.4 (SD 7.6) years) participated in the BACE cohort study. At 6 weeks' follow-up 64% of the patients reported non-recovery from back pain. At 3 months' follow-up 61% still reported non-recovery, but only 26% of these patients had revisited the GP. Longer duration of the back pain, severity of back pain, history of back pain, absence of radiating pain in the leg below the knee, number of comorbidities, patients' expectation of non-recovery, and a longer duration of the timed 'Up and Go' test were significantly associated with non-recovery in a multiple regression model (AUC 0.79). This information can help GPs identify older back pain patients at risk for non-recovery. (C) 2013 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.

Purpose: Traditionally, general practitioners (GPs) are not involved in cancer-related treatment decisions, despite their often long relationship with patients, and their unique position to explore patients' values, especially with older patients. Therefore, we designed a randomised controlled trial to study the effect, on self-efficacy related to treatment decisions, of a conversation about treatment goals between GPs and patients with cancer in a palliative setting.Methods: We aim to include 168 patients aged >= 70 years with a diagnosis of non-curable cancer, due to consult their oncologist about treatment options. In the intervention group, patients will consult their GP using an Outcome Prioritisation Tool (OPT). The control group will receive care as usual. The primary outcome will be the score on a decision self-efficacy scale after the consultation with the oncologist. Secondary outcomes will be symptoms of depression, anxiety, or fatigue. In an embedded observational study of the intervention group, we aim to assess the prioritisation of treatment goals (i.e., OPT scores), and their determinants, over a six-month period.Conclusions: The OPTion study should provide relevant information about the effect on self-efficacy of a consultation between GPs and older patients with cancer, concerning preferred treatment goals in a palliative setting. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

Background Impetigo is a common, superficial bacterial skin infection, which is most frequently encountered in children. There is no generally agreed standard therapy, and guidelines for treatment differ widely. Treatment options include many different oral and topical antibiotics as well as disinfectants. This is an updated version of the original review published in 2003. Objectives To assess the effects of treatments for impetigo, including non-pharmacological interventions and 'waiting for natural resolution'. Search methods We updated our searches of the following databases to July 2010: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (from 2005), EMBASE (from 2007), and LILACS (from 1982). We also searched online trials registries for ongoing trials, and we handsearched the reference lists of new studies found in the updated search. Selection criteria Randomised controlled trials of treatments for non-bullous, bullous, primary, and secondary impetigo. Data collection and analysis Two independent authors undertook all steps in data collection. We performed quality assessments and data collection in two separate stages. Main results We included 57 trials in the first version of this review. For this update 1 of those trials was excluded and 12 new trials were added. The total number of included trials was, thus, 68, with 5578 participants, reporting on 50 different treatments, including placebo. Most trials were in primary impetigo or did not specify this. For many of the items that were assessed for risk of bias, most studies did not provide enough information. Fifteen studies reported blinding of participants and outcome assessors. Topical antibiotic treatment showed better cure rates than placebo (pooled risk ratio (RR) 2. 24, 95% confidence interval (CI) 1.61 to 3.13) in 6 studies with 575 participants. In 4 studies with 440 participants, there was no clear evidence that either of the most commonly studied topical antibiotics (mupirocin and fusidic acid) was more effective than the other (RR 1.03, 95% CI 0.95 to 1.11). In 10 studies with 581 participants, topical mupirocin was shown to be slightly superior to oral erythromycin (pooled RR 1.07, 95% CI 1.01 to 1.13). There were no significant differences in cure rates from treatment with topical versus other oral antibiotics. There were, however, differences in the outcome from treatment with different oral antibiotics: penicillin was inferior to erythromycin, in 2 studies with 79 participants (pooled RR 1.29, 95% CI 1.07 to 1.56), and cloxacillin, in 2 studies with 166 participants (pooled RR 1.59, 95% CI 1.21 to 2.08). There was a lack of evidence for the benefit of using disinfectant solutions. When 2 studies with 292 participants were pooled, topical antibiotics were significantly better than disinfecting treatments (RR 1.15, 95% CI 1.01 to 1.32). The reported number of side-effects was low, and most of these were mild. Side-effects were more common for oral antibiotic treatment compared to topical treatment. Gastrointestinal effects accounted for most of the difference. Worldwide, bacteria causing impetigo show growing resistance rates for commonly used antibiotics. For a newly developed topical treatment, retapamulin, no resistance has yet been reported. Authors' conclusions There is good evidence that topical mupirocin and topical fusidic acid are equally, or more, effective than oral treatment. Due to the lack of studies in people with extensive impetigo, it is unclear if oral antibiotics are superior to topical antibiotics in this group. Fusidic acid and mupirocin are of similar efficacy. Penicillin was not as effective as most other antibiotics. There is a lack of evidence to support disinfection measures to manage impetigo.

Background: It is unclear how well a C-reactive protein (CRP) value predicts a serious infection (SI) in young febrile children in general practice. Methods: This prospective cohort study with 1-week follow-up included children, aged 3 months to 6 years, presenting with fever to a general practitioner out-of-hours service. We evaluate whether CRP level has predictive value for diagnosing a child at risk for an SI either at presentation or during follow-up. The index test was CRP 80 mg/L (rule in an SI). The reference standard was referral to a pediatric emergency department or diagnosis of an SI. The main outcome measure was CRP value. Results: CRP level was available for 440 children. To rule out an SI, CRP 80 mg/L increased the probability of having an SI from 11.4% (pretest probability) to 21.2% (posttest probability). In children without a diagnosis of SI at presentation, CRP could not predict an SI during follow-up (CRP >80 mg/L: positive likelihood ratio, 2.1, 95% confidence interval, 1.3-3.5; CRP

BACKGROUND: The clinical presentation of pediatric inflammatory bowel disease (IBD) is often nonspecific and overlaps with functional gastrointestinal disorders. OBJECTIVE: To determine the diagnostic accuracy of symptoms, signs, noninvasive tests, and test combinations that can assist the clinician with the diagnosis of IBD in symptomatic children. METHODS: A literature search was conducted of Medline and Embase. Two reviewers independently selected studies reporting on the diagnostic accuracy of tests for IBD, with confirmation by endoscopy and histopathology or clinical follow-up, in children with chronic gastrointestinal symptoms. Two reviewers independently extracted data and assessed study quality with the QUADAS-2, an evidence-based quality assessment tool for diagnostic accuracy studies. RESULTS: Nineteen studies were included (N = 2806). Symptoms (abdominal pain, diarrhea, rectal bleeding, and weight loss) had pooled sensitivities ranging from 0.48 to 0.82 and specificities ranging from 0.17 to 0.78. Of all the blood markers, C-reactive protein (CRP) (9 studies) and albumin (6 studies) had the best performance, with pooled sensitivities of 0.63 (0.51–0.73) and 0.48 (0.31–0.66), respectively, and specificities of 0.88 (0.80–0.93) and 0.94 (0.86–0.98). Assessment of fecal calprotectin (FCal) (10 studies) had a pooled sensitivity of 0.99 (0.92–1.00) and a specificity of 0.65 (0.54–0.74). One limitation was that none of the studies was conducted in nonreferred children. CONCLUSIONS: In children whose pediatrician is considering an endoscopy, symptoms are not accurate enough to identify low-risk patients in whom an endoscopy can be avoided. FCal, CRP, and albumin findings are potentially of clinical value, given their ability to select children at low risk (negative FCal test result) or high risk (positive CRP or albumin test result) for IBD.

Background: Patient-reported outcomes (PROs) are the only instruments available to assess the efficacy of an intervention in patients with allergic rhinoconjunctivitis. As allergic rhinoconjunctivitis is a systemic disease, it is now recommended to use not only PROs focusing at classical symptoms, but also health-related quality of life (HRQL) instruments in immunotherapy trials. Methods: A previously published immunotherapy trial in children and adolescents (618 yr) with hay fever provided us with data to assess the relevance of two of these additional outcome measures, the disease-specific rhinoconjunctivitis quality of life questionnaire (RQLQ) and the generic COOP/WONCA-charts (CWC). A PRO was considered relevant if it was responsive to pollen exposure and at least had a moderate correlation with the classical symptoms of allergic rhinoconjunctivitis. Furthermore, we evaluated a post-season PRO, that is, a global assessment of symptoms (GAS). This assessment is used in clinical trials as a tool for selecting participants with sufficient symptoms and in daily practice to evaluate the patients complaints during the preceding season. We assessed the correlation of this retrospective score with the actual symptoms during the previous pollen season. Results: Data from 36 children and 63 adolescents were analysed. On the basis of the total scores of the paediatric and adolescent version of the RQLQ, both questionnaires were considered relevant as they were responsive to exposure and showed a moderate to strong correlation with the rhinoconjunctivitis symptoms. However, in both children and adolescents, 40% of the RQLQ items were not relevant according to our definition. The CWC as a whole and the separate charts appear less relevant because of the weak correlations with the daily symptom score from the diary. The correlation between our post-season GAS and the in season daily symptom score was weak. Conclusion: The paediatric and adolescent RQLQ are relevant, but could be shortened as they contain a substantial number of irrelevant items. The CWC are not relevant in the monitoring of children and adolescents with allergic rhinoconjunctivitis caused by grass pollen. The retrospective GAS does not sufficiently reflect the actual symptoms during the preceding season.

Objective. To identify women who are suffering from urinary incontinence but do not consult a physician and to identify reasons for this. Design. Survey study as part of a randomized controlled trial that investigates the effects of a standardized assessment and evidence-based treatment on urinary incontinence in older women, the URINO project. Setting. Female patients from general practices in the Northern part of the Netherlands. Patients. A total of 225 women of 55 years and older suffering from urinary incontinence. Main outcome measures. Number of patients with urinary incontinence who are not registered by their GP as suffering from this, factors associated with help-seeking behaviour, and reasons for not seeking help. Results. Of the 225 patients, 143 (64%) were not registered by their GP as suffering from urinary incontinence. These women were more often younger and had lower levels of distress due to their urogynaecological symptoms. The most common reason for not consulting a GP was that patients considered their symptoms not to be serious enough. Conclusion. The prevalence of older women with urinary incontinence who do not seek help is high. Help-seeking behaviour is associated with increasing age and higher levels of distress caused by the symptoms. Younger patients more often hesitate to consult their GP if they perceive their symptoms to be relatively mild.

Background: Sublingual immunotherapy (SLIT) as a therapy for the treatment of allergic rhinitis in children might be acceptable as an alternative for subcutaneous immunotherapy. However, the efficacy of SLIT with house dust mite extract is not well established. Objective: To investigate whether SLIT in house dust mite–allergic children recruited in primary care is effective and safe. Methods: Children aged 6–18 years (n = 251) recruited in primary care with a house dust mite–induced allergic rhinitis received either SLIT or placebo for 2 years. Symptoms and medication use were assessed throughout the study. Primary outcome parameter was the mean total nose symptom score (scales 0–12) during the autumn of the second treatment year. Safety was assessed by recording any adverse event. Results: Overall, the mean nose symptom score ± s.d. after 2 years of treatment showed no significant effect of SLIT (symptom score intervention group 2.26 ± 1.84 vs. placebo group, 2.02 ± 1.67; p = 0.08). There were no significant differences in secondary outcomes, nor in subgroup analyses. The number of patients reporting adverse events was comparable between both groups. Conclusions: Sublingual immunotherapy with house dust mite allergen was not better than placebo in reducing rhinitis symptoms in house dust mite–allergic children in primary care. SLIT as administered in this study can be considered safe.

Berger MY, De Wit NJ, Vogelenzang R, Wetzels RV, Van Rijn-van Kortenhof NMM, Opstelten W. The NHG Guideline Diverticulitis. Huisarts Wet 2011:54(9):492-9.

Systematic reviews have gained popularity as a way to combine the increasing amount of research information. This study assessed the quality of systematic reviews and meta-analyses of sublingual immunotherapy (SLIT) for allergic rhinitis in children, published since 2000. Eligible reviews were identified by searching Medline/Pubmed, Embase, and the Cochrane Library, from 2000 through 2008. Methodological quality was assessed using the assessment of multiple systematic reviews instrument. Ten systematic reviews were included, one of which was published in the Cochrane Library. Eight reviews gave some details about the search strategy. None of the reviews included measures to avoid selection bias. In 60% of the reviews, the methodological quality of the included studies was (partly) assessed. Four reviews pooled the results of individual studies, neglecting clinical heterogeneity. Three of the 10 reviews provided information about sources of funding or grants from industry. Of the 10 reviews, the six reviews with the highest overall score scored 5-8 points, indicating moderate quality. Systematic reviews are useful to evaluate the efficacy of SLIT in children. Although more reviews have become available, the methodological quality could be improved. SLIT for children could be promising, but methodological flaws in the reviews and individual studies are too serious to draw definite conclusions.

Background Molluscum contagiosum is a common skin infection, caused by a pox virus. The infection will usually resolve within months in people with a normal immune system. Many treatments have been used for molluscum contagiosum but a clear evidence base supporting them is lacking. This is an updated version of the original Cochrane Review published in Issue 2, 2006. Objectives To assess the effects of management strategies (including waiting for natural resolution) for cutaneous, non-genital molluscum contagiosum in otherwise healthy people. Search strategy In June 2009 we updated our searches of the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 2, 2009), MEDLINE, EMBASE, and LILACS. We also searched ongoing trials registers, reference lists, and contacted pharmaceutical companies and experts in the field. Selection criteria We investigated randomised controlled trials (RCTs) for the treatment of molluscum contagiosum. We excluded trials on sexually transmitted molluscum contagiosum and in people with lowered immunity (including those with HIV infection). Data collection and analysis Two authors independently selected studies, assessed methodological quality, and extracted data from selected studies. Main results Eleven studies, with a total number of 495 participants, examined the effects of topical (9 studies), systemic, and homoeopathic interventions (1 study each). Limited evidence was found for the efficacy of sodium nitrite co-applied with salicylic acid compared to salicylic acid alone (risk ratio (RR) 3.50, 95% confidence interval (CI) 1.23 to 9.92); for Australian lemon myrtle oil compared to its vehicle, olive oil (RR 17.88, 95% CI 1.13 to 282.72); and for benzoyl peroxide cream compared to tretinoin (RR 2.20, 95% CI 1.01 to 4.79). No statistically significant differences were found for 10 other comparisons, most of which addressed 2 topical treatments. Study limitations included no blinding (four studies), many dropouts (three studies), and no intention-to-treat analysis; small study sizes may have led to important differences being missed. None of the evaluated treatment options were associated with serious adverse effects. Authors' conclusions No single intervention has been shown to be convincingly effective in the treatment of molluscum contagiosum. The update identified six new studies, most of them reporting on interventions not included in the original version. However, the conclusions of the review did not change. Plain Language Summary There is not enough evidence to show that any particular treatment is effective for treating molluscum infection. Molluscum contagiosum, in healthy people, is a self limiting, relatively harmless viral skin infection. It affects mainly children and adolescents. It occurs worldwide but is much more frequent in certain geographic areas with warm climates. Molluscum contagiosum usually presents as single or multiple pimples filled with fluid. People may seek treatment for social and aesthetic reasons and because of concerns about spreading the disease to others. Treatment is intended to speed up the healing process. Eleven studies with 495 patients were included in this review. This review found that many common treatments for molluscum, such as physical destruction, have not been adequately evaluated. Several of the treatments that we studied are not part of daily practice. Limitations of several of these studies were: small numbers of patients, the investigators were not blinded, and patients who did not complete the study (which were numerous in some studies) were not included in the analysis. None of the evaluated treatment options were associated with serious adverse effects. Since most lesions will resolve within months, molluscum contagiosum can be left to heal naturally unless better evidence for the superiority of other treatment options emerges.

Childhood functional constipation has an estimated prevalence of 3% in the Western world and is probably the most common gastrointestinal complaint in children. It is characterized by infrequent painful defecation, faecal incontinence and abdominal pain. Only less than 5% of children with constipation have an underlying disease. Only recently two evidence-based guidelines (the Netherlands and Great Britain) have been developed concerning the diagnostic and therapeutic approach for childhood constipation which we both discuss in this article. At present, a thorough medical history and complete physical exam are usually sufficient to confirm the diagnosis of functional constipation. Further laboratory or radiological investigations should only be performed in case of doubt, to exclude an underlying disease. Treatment of childhood constipation consists of four steps: (1) education, (2) disimpaction, (3) prevention of re-accumulation of faeces and (4) follow-up. Surprisingly, there is only limited evidence that laxative treatment is better than placebo in children with constipation. However, according to the available evidence, the Dutch guideline recommends lactulose for children

Objectives: The aim of the study was to identify prognostic factors for the persistence of chronic abdominal pain (CAP) in children. Materials and Methods: For this systematic review, MEDLINE, EMBASE, and PsycINFO were searched up to June 2008 for prospective follow-up studies of pediatric CAP as defined by the criteria of Apley, von Baeyer, or the Rome Committee. The outcome measure of interest was persistence of CAP. Persistent CAP was considered only when the abdominal pain of children with CAP persisted during follow-up at the same level of frequency and severity. For each study the risk for bias was assessed. The evidence for prognostic factors was summarized according to a best-evidence synthesis. Results: Eight studies, which examined 17 prognostic factors, were included. Moderate evidence was found that having a parent with gastrointestinal symptoms predicts the persistence of CAP. Strong evidence was found for no association between female sex and the duration of CAP, and moderate evidence that the severity of abdominal pain does not predict persistence of CAP. There is conflicting evidence as to whether psychological factors prevent, or have no relation to, persistence of CAP. Conclusions: Because there are few prognostic follow-up studies on pediatric CAP, the evidence for prognostic factors is limited. Physicians should ask about parental gastrointestinal problems because this is a risk factor for persistence of CAP in children. The hypothesis that psychological factors of the child predict persistence of CAP is not supported by evidence from follow-up studies.

Van Linschoten R, Van Middelkoop M, Berger MY, Heintjes EM, Verhaar JAN, Willemsen SP, et al. Gesuperviseerde oefentherapie versus gebruikelijke zorg voor het patellofemorale pijnsyndroom. Huisarts Wet 2010;53(5):248-56.

To assess the efficacy and tolerability of prophylactic drugs for chronic tension-type headache (TTH) in adults.We searched several databases from inception to August 2009. We selected randomized trials that reported the effects of prophylactic drugs in patients with TTH, with a pain measure (intensity, frequency, duration, improvement or index) as outcome measure. Two authors independently assessed risk of bias and extracted data from the original reports. A data synthesis was carried out according to the type of medication.We included 44 trials (3399 patients), of which 15 (34.1%) were considered to be of low risk of bias. Main types of medications studied were antidepressants, muscle relaxants, benzodiazepines and vasodilator agents. Overall, antidepressants were no more effective than placebo, and there were no significant differences between different types of antidepressants. There was conflicting evidence about the effectiveness of benzodiazepines and vasodilator agents compared with placebo. Furthermore, there was limited evidence that propranolol had negative effects on depression in TTH patients, when compared with placebo or biofeedback. There was no evidence concerning the effectiveness of muscle relaxants alone or 5-HT receptor agonist compared with placebo.Overall, antidepressants were no more effective on headache intensity or frequency and analgesic use than placebo. Propranolol seemed to have negative effects on depression in TTH patients when compared with placebo or biofeedback. No evidence was found for the use of muscle relaxants alone or 5-HT receptor agonist.

Bij kinderen is functionele obstipatie de meest voorkomende gastrointestinale aandoening. PEG en lactulose zijn doorgaans de laxantia die worden gebruikt. Het doel van dit artikel is weer te geven hoe een wetenschappelijk onderbouwde aanbeveling geformuleerd wordt op de vraag wat bij kinderen met functionele obstipatie de meest effectieve en veilige medicamenteuze behandeling is: PEG of lactulose? Ook wordt een, met name voor verpleegkundigen, interessante selectie van aanbevelingen uit de richtlijn ‘Obstipatie bij kinderen’ gegeven.

OBJECTIVE:Recurrent abdominal pain (RAP) and other gastrointestinal (GI) symptoms are common complaints among children. The role of Helicobacter pylori in the cause of these complaints remains controversial. Nevertheless, there is an increasing pressure on primary care clinicians to screen for H pylori infection in symptomatic children. We systematically reviewed the published evidence for an association between H pylori infection and GI symptoms in children.METHODS:Medline and Embase databases up to July 2009 were searched to identify studies that evaluated the association between H pylori and GI symptoms in children aged up to 18 years. When studies reported on abdominal pain without additional definition, thus not fulfilling Apley's criteria, we grouped these outcomes as unspecified abdominal pain (UAP). Methodologic quality was scored by using a standardized list of criteria, and crude odds ratios (ORs) with 95% confidence intervals (CIs) were calculated and pooled.RESULTS:Thirty-eight studies met our inclusion criteria: 23 case-control studies, 14 cross-sectional studies, and 1 prospective cohort study. The overall methodologic quality was low. Pooled ORs for the association between RAP and H pylori infection in children were 1.21 (95% CI: 0.82–1.78) in 12 case-control studies and 1.00 (95% CI: 0.76–1.31) in 7 cross-sectional studies. Meta-analysis of the association between UAP and H pylori infection in 6 hospital-based studies resulted in a pooled OR of 2.87 (95% CI: 1.62–5.09) compared with 0.99 (95% CI: 0.46–2.11) in 5 population-based studies. Two of 3 studies concerning epigastric pain reported a statistically significant positive association with H pylori infection.CONCLUSIONS:We found no association between RAP and H pylori infection in children and conflicting evidence for an association between epigastric pain and H pylori infection. We found evidence for an association between UAP but could not confirm this finding in children seen in primary care.

BackgroundKnee injuries may lead to pain and to functional limitations in the activities of daily living. Patients with knee injuries are frequently seen in general practice; however, the outcome and management in these patients is not known.AimTo assess the outcome and management of knee injuries at 12 months' follow-up in general practice.Design of studyA prospective observational cohort study with a 1-year follow-up.Setting.Primary health care.MethodAdult patients consulting their GP after knee injury (n = 134) participated in the cohort. A magnetic resonance imaging scan was carried out and patients were diagnosed as either no lesion or an isolated meniscal tear, an isolated collateral or cruciate ligament lesion, or a combination. Follow-up questionnaires were filled in up to 12 months' follow-up.ResultsAt 12 months' follow-up, 34 patients reported full recovery and 67 patients reported major improvement. At baseline, 37 patients (28%) were referred to physical therapy and 17 patients (13%) were referred to secondary care. During 1 year of follow-up, another 21 referrals to physical therapy and 11 referrals to secondary care took place. The pain severity decreased the most, and the Lysholm knee score increased in the majority of patients during the first 3 months after injury. In total, 18 arthroscopies were performed in 15 patients One patient underwent an anterior cruciate ligament reconstruction.ConclusionThe vast majority of patients report clinically relevant recovery. There is no clear difference in outcomes between patients with meniscal tears or ligament lesions and patients without these diagnoses.

Wagemakers HP, Luijsterburg PA, Boks SS, Heintjes EM, Berger MY, Verhaar JA, Koes BK, Bierma-Zeinstra SM. Diagnostic accuracy of history taking and physical examination for assessing anterior cruciate ligament lesions of the knee in primary care. Arch Phys Med Rehabil 2010;91:1452-9. Objective: To assess the diagnostic accuracy of history taking and physical examination for assessing anterior cruciate ligament (ACL) lesions in primary care. Design: Cross-sectional diagnostic study. Setting: Primary care. Participants: Patients (N=134; age, 18-65y) who consulted their general practitioner (GP) within 5 weeks after injury. Interventions: Not applicable. Main Outcome Measures: Index tests were obtained with a questionnaire and physical examination. Magnetic resonance imaging (MRI) was used as the reference test. Logistic regression analysis was used to determine associations with ACL lesions. Diagnostic accuracy was determined by calculating sensitivity (Se), specificity (Sp), predictive values, and likelihood ratio (LR). Results: MRI showed an ACL lesion in 28 of 134 included patients. "Effusion," "popping sensation," "giving way," and "anterior drawer test (ADT)" showed associations with an ACL lesion (P

Background: Cryotherapy is widely used for the treatment of cutaneous warts in primary care. However, evidence favours salicylic acid application. We compared the effectiveness of these treatments as well as a wait-and-see approach.Methods: Consecutive patients with new cutaneous warts were recruited in 30 primary care practices in the Netherlands between May 1, 2006, and Jan. 26, 2007. We randomly allocated eligible patients to one of three groups: cryotherapy with liquid nitrogen every two weeks, self-application of salicylic acid daily or a wait-and-see approach. The primary outcome was the proportion of participants whose warts were all cured at 13 weeks. Analysis was on an intention-to-treat basis. Secondary outcomes included treatment adherence, side effects and treatment satisfaction. Research nurses assessed outcomes during home visits at 4, 13 and 26 weeks.Results: Of the 250 participants (age 4 to 79 years), 240 were included in the analysis at 13 weeks (loss to follow-up 4%). Cure rates were 39% (95% confidence interval [CI] 29%-51%) in the cryotherapy group, 24% (95% CI 16%-35%) in the salicylic acid group and 16% (95% CI 9.5%-25%) in the wait-and-see group. Differences in effectiveness were most pronounced among participants with common warts (n = 116): cure rates were 49% (95% CI 34%-64%) in the cryotherapy group, 15% (95% CI 7%-30%) in the salicylic acid group and 8% (95% CI 3%-21%) in the wait-and-see group. Cure rates among the participants with plantar warts (n = 124) did not differ significantly between treatment groups.Interpretation: For common warts, cryotherapy was the most effective therapy in primary care. For plantar warts, we found no clinically relevant difference in effectiveness between cryotherapy, topical application of salicylic acid or a wait-and-see approach after 13 weeks. (ClinicalTrial.gov registration no. ISRCTN42730629)

31 Background: Lung cancer is associated with significant distress, poor quality of life, and a median prognosis of less than one year. Shared decision making (SDM) has been recommended as a strategy to help guide patients facing difficult treatment trade-offs. Potential benefits of SDM include enhanced knowledge and better congruence between treatment decisions and patients’ personal values and have been described in multiple diseases. We investigated the impact of SDM on distress and healthcare utilization among patients with lung cancer. Methods: We performed a systematic literature search in the CINAHL, Cochrane, EMBASE, MEDLINE, and PsychINFO databases. Studies were eligible when conducted among patients with lung cancer, evaluated SDM, and measured distress and/or health care utilization as outcomes. Risk of bias was assessed using the Cochrane risk of bias tool. Results: A total of 11 articles were identified: two retrospective cohort studies and nine articles reporting on eight randomized controlled trials. Overall, the risk of bias of included studies was low, except for a high risk of bias concerning blinding of participants or personnel. All studies reported on a broad supportive care intervention with SDM as a component of the intervention. No beneficial effect was found in five studies measuring generic distress, while one study reported beneficial effects on depression. There was conflicting evidence regarding the effects of SDM on healthcare utilization; of the seven studies analyzing this, five studies found evidence for a reduction in healthcare utilization. Conclusions: Although relevant, only scarce evidence is currently available on the effects of SDM on distress and healthcare utilization among patients with lung cancer. Thus, additional research is needed before SDM can be recommended in the lung cancer context.

Objective. To predict the 1-year outcome of incident nontraumatic knee symptoms in adults presenting in general practice.Methods. Adults age >35 years with nontraumatic knee symptoms (n = 480) were followed for 1 year. At baseline, data on knee symptoms and demographics were collected and a physical examination performed. Knee symptoms were assessed by self-report questionnaires at 3-month intervals. After 1 year the physical examination was repeated. Multivariate prognostic regression models of patient characteristics, symptom characteristics, and physical examination were used to predict persisting knee symptoms after 1 year. Areas under receiving operating characteristic curves (AUCs) were used to determine the predictive value of the model. To assess the added predictive value of symptom characteristics and physical examination, these models were added to the model of patient characteristics. The improvement was expressed as the difference between the 2 AUCs.Results. In the multivariate prognostic model of patient characteristics, age >60 years, educational level, kinesophobia, and comorbidity of the skeletal system were associated with persistent knee symptoms after 1 year (AUC 0.67). Of the symptom characteristics, history of nontraumatic knee symptoms, bilateral symptoms, and duration of symptoms >3 months were associated (AUC 0.73). For determinants of physical examination, crepitus of passive extension was associated (AUC 0.55). The added value of the symptom characteristics model to the patient characteristics model was 0.09 (AUC 0.76). Physical examination added no further value.Conclusion. Symptom characteristics are the strongest predictors of persisting knee symptoms at 1-year follow-up. Physical examination has no added value in predicting persistent knee symptoms in general practice.

Kastelein M, Luijsterburg PA, Wagemakers HP, Bansraj SC, Berger MY, Koes BW, Bierma-Zeinstra SM. Diagnostic value of history taking and physical examination to assess effusion of the knee in traumatic knee patients in general practice. Objective To assess the diagnostic value of history taking and physical examination for knee joint effusion in patients with a knee injury who consult their general practitioner (GP). In addition, to determine the association between effusion seen on magnetic resonance imaging (MRI) and internal derangement of the knee. Design Prospective, observational cohort study. Setting Primary care. Participants Patients (N=134) aged 18 to 65 years with a traumatic knee injury who consulted their GP. Interventions Not applicable. Main Outcome Measures Patients filled out a questionnaire, underwent a standardized physical examination and underwent an MRI scan to assess the presence of effusion. Multivariate logistic regression analysis was used to determine the diagnostic value of history taking and physical examination ( P Results Of the 134 participating patients, 42 had knee joint effusion seen on MRI. Multivariate analysis showed an association with knee joint effusion for the symptom "self-noticed swelling" (history taking) and for the "ballottement test" (physical examination). The likelihood ratio positive (LR+) was 1.5 for self-noticed swelling and 1.6 for the ballottement test. These 2 combined improved the diagnostic value to an LR+ of 3.6. Effusion showed a positive association with internal derangement of the knee (chi-square 9.5); 31 of the 42 patients with knee joint effusion had internal derangement of the knee. Conclusions In patients with traumatic knee injury, knee joint effusion is frequently seen on MRI. The combination of self-noticed swelling and the ballottement test was of diagnostic value. Knee joint effusion was associated with internal derangement of the knee.

Objective: To assess the prognostic value of the clinical American College of Rheumatism (ACR) classification criteria of knee osteoarthritis (OA) on persisting knee complaints and increase of disability in adult patients with knee pain in general practice after 1-year follow-up.Methods: Patients (aged > 35 years) consulting for non-traumatic knee complaints in general practice were enrolled in the study. At baseline and 1-year follow-up knee complaints and function were assessed by questionnaires and a physical examination was performed. The prognostic value of fulfilling the clinical ACR criteria of knee OA at baseline on the outcomes persisting knee complaints and increase of disability was determined.Results: 549 patients were included in the study of which 480 (87.4%) were available for follow-up. The studied population consisted of 236 (49.2%) women with mean age 53.6 [standard deviation (sd) 11.3], mean body mass index (BMI) 27.1 (sd 4.2), 288 (60.0%) patients had payed employment, and 292 (60.8%) patients fulfilled the clinical ACR criteria of knee OA. After 1-year follow-up, 236 (49.2%) patients reported persisting knee complaints, and 84 (17.5%) reported an increase of disability. There was no association of fulfilling the clinical ACR criteria of knee OA at baseline with persisting knee complaints [odds ratio (OR) 1.15; 95% Confidence Interval (CI) 0.80; 1.67] or increase of disability (OR 1.05; 95% CI 0.43; 2.58) at follow-up.Conclusion: The clinical ACR classification criteria of knee OA have no prognostic value for predicting persisting knee complaints or an increase of disability at 1-year of follow-up in adult patients with non-traumatic knee complaints in GP. (c) 2009 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.

Background Adherence is essential for effective treatment. Although several trials on the efficacy of sublingual immunotherapy (SLIT) in youngsters have been published, few contain data on medication intake. Objective We aimed to quantify adherence both to study protocol and medication intake as well as to identify factors that may influence adherence to SLIT in youngsters with rhinoconjunctivitis. Methods Two hundred and four youngsters (6-18 years) with hayfever participated in a randomized controlled trial and used grass pollen extract or placebo for 2 years. The primary Outcome of the trial was the mean daily total rhinoconjunctivitis symptom score in the second grass pollen season. Participants having completed the follow-up were considered adherent to the study protocol. Adherence to medication intake was assessed by weighing the study medication. Participants who completed the follow-up and used >= 80% of the prescribed medication were considered adherent to medication intake. Patient-, disease- and treatment-related factors were analysed. Results One hundred and fifty-four youngsters completed the study. The main reason for discontinuation was the inability to take medication according to schedule. Drop-outs were older, had more difficulty following the medication instructions and their overall evaluation of the treatment effect was lower. The number and reasons for drop-out did not differ between treatment groups. In total, 77% of the participants was adherent to medication intake. Self-reported adherence was 99%. Non-adherent participants experienced more severe symptoms before the trial. Symptom scores did not differ between adherent and non-adherent participants. In adherent as well as non-adherent participants, no difference was found between verum and placebo group with respect to symptom scores. Conclusion Adherence to both study protocol and medication intake was good. Drop-out was affected by age, evaluation of the treatment effect and medication instructions. Nonadherence to medication intake was influenced by the severity of the disease before the trial. The ineffectiveness of SLIT could not be explained by non-adherence.

Van Bergeijk H, Berger MY. Behandeling van urineweginfecties binnen en buiten praktijkuren. Huisarts Wet 2008;51(9):430-4. Inleiding Urineweginfecties (uwi’s) komen vaak voor. Tijdens werkzaamheden op een huisartsenpost viel op dat er grote verschillen zijn in medicamenteus beleid bij uwi’s. Doel Met dit onderzoek willen we inzicht krijgen in de mate waarin huisartsen de richtlijnen uit de NHG-Standaard Urineweginfecties volgen. We gingen ook na of de huisartsenzorg in de reguliere praktijk verschilt van die op de huisartsenpost. Methode We voerden een retrospectief onderzoek uit in 24 huisartspraktijken en een huisartsenpost. Resultaten In totaal registreerden we 470 uwi’s voor verdere analyse. Op de huisartsenpost betrof het in 52,3% (34/65) van de gevallen een gecompliceerde uwi, in de reguliere praktijk ging het om 25,9% (105/405, p < 0,001). Van het totale aantal gecompliceerde uwi’s handelde 32,4% (11/34) van de huisartsen op de huisartsenpost conform de richtlijn, tegen 35,2% (37/105) in de reguliere praktijk (p = 0,758). Bij ongecompliceerde uwi’s ging het respectievelijk om 45,2% (14/31) en 58,3% (175/300) (p = 0,158). Bij 45,5% (41/90) van de gecompliceerde uwi’s met een negatieve nitriettest stelde de huisarts een behandeling in zonder verdere diagnostiek. Conclusie In 50,4% van de gevallen handelen de onderzochte huisartsen volgens de NHG-Standaard. Op een huisartsenpost zien huisartsen meer gecompliceerde uwi’s dan in de reguliere praktijk. Huisartsen behandelen gecompliceerde uwi’s minder vaak conform de NHG-Standaard dan ongecompliceerde uwi’s. Er is geen verschil tussen de huisartsenpost en de reguliere praktijk als het gaat om het volgen van de NHG-Standaard.

Background: Chronic abdominal pain (CAP) or recurrent abdominal pain is common in childhood and is rarely associated with organic disease. With modern diagnostic technology, new organic abnormalities are found in children with CAP. Thus far a causal relation between these abnormalities and CAP has not been established. The additional prognostic value of extensive testing of children with CAP is a subject of debate. Objectives: To investigate how often abdominal pain persists in children with CAP and to investigate whether medical tests such as laboratory tests, imaging, and endoscopy have additional prognostic value to history taking and clinical examination. Materials and Methods: A systematic search was conducted in MEDLINE, EMBASE, and PsycINFO for prospective cohort studies published from 1960 until October 2005. The most common medical key words for CAP were used in our search strategy. The methodological quality of studies was determined. Clinical heterogeneity between studies was analyzed. The percentages of children with abdominal pain after follow-up were pooled. Results: The search yielded 2620 citations, of which 18 studies met the inclusion criteria. In total, 1331 children were followed up for 5 years (median, range 1-29 years). In total, 29.1% (95% CI 28.1-30.2) of patients with CAP had abdominal pain after follow-up. The prognosis of CAP diagnosed clinically was similar to that diagnosed after additional medical testing. Conclusions: CAP persisted in 29.1% (95% CI 28.1-30.2) of children. In the absence of alarming symptoms, additional diagnostic testing did not influence the prognosis of CAP.

Objective: To determine the construct validity and responsiveness of the Lysholm knee scoring scale and the WOMAC ostcoarthritis index in adolescents and young adults with knee complaints in general practice.Study Design and Setting: In the framework of a prospective cohort study with 1-year follow-up, we included 314 patients aged 12-35 years consulting the general practitioner for incident knee complaints. Subgroup analyses of traumatic and nontraumatic knee complaints and of adolescents and adults were performed.Results: Construct validity was adequate for both questionnaires both in traumatic and nontraumatic patients (aged 12-35) and in adolescents (12-17) and young adults (18-35). Effect size (ES) and standardized response mean (SRM) for both Lysholm and WOMAC global scores were moderate in nontraumatic patients and high in traumatic patients. Guyatt's responsiveness statistic was high in both sub-populations. Adolescents showed high responsiveness with all measures on the Lysholm scale, and moderate (Guyatt's statistic) to high responsiveness (ES and SRM) on the WOMAC index. Young adults showed high responsiveness with all measures on both instruments.Conclusion: Although neither of the scales was developed for use in adolescents and young adults in general practice, both scales show adequate responsiveness, content, and construct validity in this population. (c) 2008 Elsevier Inc. All rights reserved.

Allergen-specific immunotherapy is one of the cornerstones of allergic rhinoconjunctivitis treatment. Since the development of non-invasive administration forms with better safety profiles, there is an increasing tendency to prescribe immunotherapy in youngsters. However, no overview is available on the efficacy of immunotherapy in all its different administration forms in youngsters. Therefore, we systematically reviewed randomized controlled trials (RCTs) to evaluate the effect of immunotherapy with inhalant allergens on symptoms and medication use in children and adolescents with allergic rhinoconjunctivitis. Medline, EMBASE, the Cochrane Controlled Clinical Trials Register and reference lists of recent reviews and published trials were searched. RCTs including youngsters aged 0-18 yr with allergic rhinoconjunctivitis and comparing immunotherapy with placebo, symptomatic treatment or a different administration form of immunotherapy were included. Primary outcome measures were rhinoconjunctivitis symptom and/or medication scores. Methodological quality was assessed using the validated Delphi list. A method of best evidence synthesis, a rating system with levels of evidence based on the overall quality and the outcome of the trials, was used to assess efficacy. Six subcutaneous (SCIT), four nasal (LNIT), seven oral (OIT) and 11 sublingual (SLIT) immunotherapy trials, comprising 1619 youngsters, were included. Only 39% of the trials were of high methodological quality. For the SCIT and OIT subgroups the level of evidence for efficacy was conflicting. Moderate evidence of effect was found for LNIT. Analysis of the SLIT subgroup showed no evidence of effect. The evidence for the perennial and seasonal allergen trials within the subgroups varied from moderate evidence of effect to no evidence of effect. In conclusion, there is at present insufficient evidence that immunotherapy in any administration form has a positive effect on symptoms and/or medication use in children and adolescents with allergic rhinoconjunctivitis.

Background Most febrile children contacting a GP cooperative are seen by a GP, although the incidence of serious illness is low. The guidelines for triage might not be suitable in primary care. Aim To investigate the determinants related to the outcome of triage in febrile children. Design of study Cross-sectional study. Setting Dutch GP cooperative. Method Receptionists filled out a triage questionnaire when parents called regarding their febrile child (aged between 3 months and 6 years) and estimated the level of concern of the parents. The outcome was either telephone advice, a consultation, or a home visit. Children were divided in subgroups based on age = 18 months, and prognostic models for a consultation were constructed. Results Of 422 children, 73% were seen by a GP. Children aged = 18 months, a duration of fever of >= 3 days, drowsiness, or a pale, ashen, or mottled skin were predictors of consultation. Children with alarm symptoms were seen according to the guideline. In both subgroups, children without alarm symptom's were more likely to be seen when their parents were concerned. Conclusion The available guideline was followed to a large extent at a GP cooperative. Because, surprisingly, most children were reported to have alarm symptoms, the validity of the triage questions asking parents about alarm symptoms is questionable.

Van Dijk C, Davids R, Berger M, Verheij R. Huisartsenzorg voor kinderen verschilt van die voor volwassenen. Huisarts Wet 2008;51(13):643-6. Inleiding Kinderen hebben andere klachten en aandoeningen dan volwassenen. Deze verschillen hebben effect op de huisartsenzorg die wordt geleverd aan nul- tot achttienjarigen en volwassenen. Dit artikel beschrijft de huisartsenzorg die wordt geleverd aan nul- tot vier-, vijf- tot twaalf- en dertien- tot achttienjarigen, en vergelijkt deze met de aan volwassenen geleverde zorg. Methode De gegevens zijn afkomstig van de elektronische patientendossiers van 95 huisartsenpraktijken die deelnemen aan het Landelijk InformatieNetwerk Huisartsen. Resultaten Kinderen hebben minder contact met de huisarts dan volwassenen, met uitzondering van de nul- tot vierjarigen. De klachten waarmee kinderen bij de huisarts komen verschillen sterk tussen de leeftijdscategorieen, en ook van die van volwassenen. Nul- tot twaalfjarigen bezoeken de huisarts vooral in verband met infectieziekten en huidaandoeningen. Dertien- tot achttienjarigen komen veelal voor orale anticonceptiemiddelen. Bij de volwassenen hebben de meeste contacten betrekking op chronische aandoeningen, zoals hypertensie en diabetes mellitus. Het patroon van voorgeschreven geneesmiddelen komt overeen met de geconstateerde klachten en aandoeningen. Kinderen worden minder vaak verwezen naar de medisch specialist dan volwassenen. Conclusie Huisartsenzorg aan kinderen verschilt sterk van die aan volwassenen. Bovendien vertoont de zorg aan kinderen ook per leeftijdscategorie grote verschillen.

De huisarts is het eerste aanspreekpunt voor kinderen en ouders bij somatische en psychische klachten, maar ook bij vragen over gedrag en opvoeding. In september 2007 startte een NHG-werkgroep met het thema huisartsenzorg voor de jeugd en het formuleren van een NHG-Standpunt Huisartsenzorg en jeugd. Dit Standpunt beschrijft de visie van het NHG op de huisartsgeneeskundige zorg voor kinderen en jongeren. Daarnaast doet het aanbevelingen voor het leveren van kwalitatief goede zorg. De werkgroep vertegenwoordigde de kinderrijke huisartsenpraktijk, de huisartsenpraktijk in probleemgebieden, de academische huisartsgeneeskunde, de LHV en de NHG-Verenigingsraad. Het standpunt baseert zich op informatie uit de literatuur, overleg met relevante beroepsgroepen en consensusbesprekingen in de werkgroep. Een concept is voorgelegd aan de achterban en externe organisaties. In dit artikel bespreken we de kern van het Standpunt. We bepleiten een proactief werkende huisarts die oog heeft voor de ontwikkeling en context van het kind. Hij maakt heldere samenwerkingsafspraken met andere zorgverleners, en speelt een duidelijke rol in de zorg voor de jeugd. Beheer van het patientendossier en informatie-uitwisseling met andere betrokkenen is cruciaal om die rol te kunnen vervullen.

Objective: To assess the diagnostic value of history-taking and physical examination of meniscal tears in general practice. Design: An observational study determining diagnostic values (sensitivity, specificity, predictive value, and likelihood ratios). Setting: General practice. Patients: Consecutive patients aged 18 to 65 years with a traumatic knee injury who consulted their general practitioner within 5 weeks after trauma. Assessment: Participating patients filled out a questionnaire (history-taking) followed by a standardized physical examination. Main Outcome: Assessment of meniscal tears. was determined by means of magnetic resonance imaging (MRI) and was performed blinded for the results of physical examination and history-taking. Results: Of the 134 patients included in this study, 47 had a meniscal tear. From history-taking, the determinants "age over 40 year," "continuation of activity impossible," and "weight-bearing during trauma" indicated an association with a meniscal tear after multivariate logistic regression analysis, whereas from physical examination only "pain at passive flexion" indicated an association. These associated determinants from history-taking showed some diagnostic value; the positive likelihood ratio (LR+) reached up to 2.0 for age over 40 years, whereas the isolated test pain at passive flexion from physical examination has less diagnostic value, with an LR+ of 1.3. Combining determinants from history-taking and physical examination improved the diagnostic value with a maximum LR+ of 5.8; however, this combination only applied to a limited number of patients. Conclusion: History-taking has some diagnostic value, whereas physical examination did not add any diagnostic value for detecting meniscal tears in general practice.

Inleiding Ernstige infecties komen weliswaar weinig voor bij kinderen, maar wanneer ouders de huisartsenpost bellen omdat hun kind koorts heeft, zal de huisarts dat kind vaak toch persoonlijk willen zien. De bestaande richtlijnen voor triage zijn echter bedoeld voor kinderen die al verwezen zijn, en dus niet per se geschikt voor gebruik op de huisartsenpost. Wij onderzochten welke factoren bij de triage op de huisartsenpost van invloed zijn op de uiteindelijke contactvorm. Methode Assistentes op de huisartsenpost in Rotterdam-Zuid vulden een korte vragenlijst in wanneer ouders opbelden omdat hun kind (tussen drie maanden en zes jaar oud) koorts had. De assistentes gingen ook na hoe bezorgd de ouders waren. Wij onderzochten of de telefonische triage uiteindelijk leidde tot een telefonisch advies, een consult op de post of een huisbezoek. Dekinderen waarom het ging, verdeelden we in twee leeftijdsgroepen: jonger dan anderhalf jaar en ouder dan anderhalf jaar. Voor beide leeftijdsgroepen ontwikkelden we een prognostisch model. Resultaten Op de huisartsenpost meldden zich 422 kinderen met koorts. Van hen kwam 73% uiteindelijk naar de post voor een consult. De jongste leeftijdsgroep maakte de grootste kans op een consult wanneer de ouders meldden dat hun kind minder dronk en benauwd was. Bij kinderen ouder dan anderhalf jaar was die kans het grootst wanneer de koorts langer dan twee dagen duurde, wanneer het kind volgens de ouders suf was of wanneer het volgens de ouders een bleke, grauwe of gevlekte huid had. Bij alle kinderen met deze alarmsymptomen verliep de triage conform de richtlijn. Kinderen die géén alarmsymptomen hadden, werden vaker ingepland voor een consult als de ouders zich zorgen maakten, ongeacht hun leeftijd. Conclusie De assistentes op de huisartsenpost volgden in grote lijnen de richtlijn. Verrassend genoeg bleek dat de meeste kinderen volgens de ouders alarmsymptomen hadden, hetgeen de validiteit van het vragen naar deze symptomen aan de ouders twijfelachtig maakt.

Roder E, Berger MY, Hop WCJ, Bernsen RMD, De Groot H, Gerth van Wijk R. Sublinguale immunotherapie met graspollen is niet effectief bij jongeren met hooikoorts. Huisarts Wet 2007;50(12):586-92. Inleiding Sublinguale immunotherapie (SLIT) wordt beschouwd als een veiligere en gebruikersvriendelijkere methode dan subcutane immunotherapie. Daarom lijkt SLIT vooral geschikt voor de behandeling van kinderen en voor toepassing in de huisartsenpraktijk. Effectiviteitsonderzoeken bij kinderen hadden echter onvoldoende zeggingskracht om een uitspraak te doen over de effectiviteit van SLIT, en werden uitgevoerd bij kinderen die waren doorverwezen. Doel Het onderzoeken van de effectiviteit van SLIT bij kinderen bekend met een graspollenallergie bij de huisarts. Methoden Kinderen van 6-18 jaar met hooikoorts werden via de huisarts geincludeerd en kregen gedurende 2 jaar gerandomiseerd placebo of graspollen SLIT voorgeschreven. In het hooikoortsseizoen scoorden de kinderen dagelijks de ernst van 5 symptomen – niezen, jeukende neus, waterige loopneus, neusobstructie en jeukende ogen – op een schaal van 0 tot 3. De primaire uitkomst was de gemiddelde dagelijkse totale symptoomscore (schaal 0-15) in de maanden mei-augustus van het tweede behandeljaar. Resultaten Van de 204 gerandomiseerde kinderen hebben we 168 kinderen ingesloten in de intention-to-treatanalyse (91 verum, 77 placebo). De gemiddelde dagelijkse totale symptoomscore van patienten in de verumgroep en patienten in de placebogroep was gelijk (verschil verum minus placebo: –0,08, 95%-BI -0,66 - 0,50; p = 0,78). We vonden geen verschillen tussen de groepen wat betreft dagen zonder symptoommedicatie, ziektespecifieke kwaliteit van leven, en algemene indruk van behandeleffect. Lokale bijwerkingen kwamen meer voor in de verumgroep (39% versus 17% van de deelnemers; p = 0,001). Conclusie Sublinguale immunotherapie met graspollen is niet effectief bij kinderen die met hooikoorts bij de huisarts komen. Op dit moment kan SLIT niet worden aanbevolen als behandeling voor jongeren met een graspollenallergie.

Chronic abdominal pain is a common disorder in children and adolescents worldwide. It affects the child's wellbeing, and the costs from missed school days and use of healthcare resources are high. Children with chronic abdominal pain represent a heterogeneous population comprising both organic and functional gastrointestinal disorders. Functional disorders are those that cannot be explained by structural or biochemical abnormalities. Differences in prevalence of organic disease are reported depending on the setting, ranging from 5% in the general population to 40% in a paediatric gastroenterologist practice.1 General practitioners feel confident in labelling chronic abdominal pain as an easy to manage functional disorder. After minimal further testing, these children and their parents can be reassured by explaining that the symptoms are common and rarely associated with disease. However, when diagnostic uncertainty increases, pain does not resolve over time, or parents are hard to reassure, extensive testing and referral easily set in. As a consequence paediatricians perceive chronic abdominal pain as a time consuming and therapy resistant disorder. #### SUMMARY POINTS #### Sources and selection criteria We used the Cochrane library to identify relevant systematic reviews that evaluated the effectiveness of pharmaceutical, psychological, and complementary interventions for chronic abdominal pain in children. Medline searches were used to find relevant systematic reviews on diagnosis and treatment of abdominal pain in children using the keywords “abdominal …

objective. To provide an overview of prognostic factors of knee osteoarthritis (OA) progression.Methods. We searched Medline and Embase up to December 2003 according to a specified search strategy (keywords for disease, location, and study design). Studies that fulfilled predefined criteria were assessed for methodologic quality. Study characteristics and associations were extracted and the results were summarized according to a best evidence synthesis.Results. Of the 1,004 studies found, 37 met the inclusion criteria. Methodologic quality was assessed and only high-quality studies were included (n = 36). The best evidence synthesis yielded strong evidence that hyaluronic acid serum levels and generalized OA are predictive for progression of knee OA. Sex, knee pain, radiologic severity, knee injury, quadriceps strength, and regular sport activities were not predictive. Conflicting evidence for associations was found for several factors including body mass index and age. Limited evidence for an association with progression of knee OA was found for several factors, including the alignment (varus/valgus) of the joint. Limited evidence for no association with progression of OA was also found for several factors, including meniscectomy, several markers of bone or cartilage turnover, and the clinical diagnosis of localized OA.Conclusion. Generalized OA and level of hyaluronic acid seem to be associated with the radiologic progression of knee OA. Knee pain, radiologic severity at baseline, sex, quadriceps strength, knee injury, and regular sport activities seem not to be related. For other factors, the evidence was limited or conflicting.

Allergic rhinoconjunctivitis is a common chronic disorder in children, especially in developed countries. It does not cause nasal symptoms only (such as congestion and sneezing) but may also cause general complaints such as fatigue and cough (box 1). It can also cause learning problems1 and has a great impact on quality of life. Uncontrolled allergic rhinoconjunctivtis may aggravate the symptoms of asthma.2 Although classic “hay fever” is easily recognised in children who have a runny nose, sneezing, and itchy eyes during the pollen season, the diagnosis of allergic rhinoconjunctivitis is often missed in children with perennial nasal congestion. #### Box 1: Key symptoms of allergic rhinoconjunctivitis in children ##### Nasal ##### General The term allergic rhinoconjunctivitis is preferable to allergic rhinitis because most patients also have ocular symptoms. In this review, we discuss the prevalence of allergic rhinoconjunctivitis in children, its causes, how it is diagnosed, and how it can be treated. We used the Cochrane library to identify relevant systematic reviews on drugs for allergic rhinoconjunctivitis in children. Medline was searched for systematic reviews on diagnosis and treatment of allergic rhinoconjunctivitis in children using the keywords “rhinoconjunctivitis”, “systematic review”, “meta-analysis”, “diagnosis”, and “treatment”. We limited our searches to “all child”. We took additional references from our personal files. #### SUMMARY POINTS

Acute infection is the most common presentation of children in primary care, with only a few having serious infections. To avoid complications, early recognition and appropriate referral are essential. Clinical decision models have the potential to improve diagnostic decision-making for these serious conditions. Although many models have been developed, few have proven cost-effective. A recent model developed in acutely ill children presenting in Belgian primary care and validated in a new cohort has been shown to adequately identify children that are hospitalised with acute infections. The results are impressive but raise questions about generalisability and cost-effectiveness. In conclusion, clinical decision models appear currently incapable of improving decision-making in acutely ill children. As an alternative, we should consider asking the general practitioner to perform telephone triage.

PURPOSE In specialist care, fecal calprotectin (FCal) is a commonly used noninvasive diagnostic test for ruling out inflammatory bowel disease (IBD) in children with chronic gastrointestinal symptoms. The aim of this study was to evaluate the diagnostic accuracy of FCal for IBD in symptomatic children in primary care.METHODS We studied 2 prospective cohorts of children with chronic diarrhea, recurrent abdominal pain, or both: children initially seen in primary care (primary care cohort) and children referred to specialist care (referred cohort). FCal (index test) was measured at baseline and compared with 1 of the 2 reference standards for IBD: endoscopic assessment or 1-year follow-up. Physicians were blinded to FCal results, and values greater than 50 mu g/g feces were considered positive. We determined specificity in the primary care cohort and sensitivity in the referred cohort.RESULTS None of the 114 children in the primary care cohort ultimately received a diagnosis of IBD. The specificity of FCal in the primary care cohort was 0.87 (95% CI, 0.80-0.92). Among the 90 children in the referred cohort, 17 (19%) ultimately received a diagnosis of IBD. The sensitivity of FCal in the referred cohort was 0.99 (95% CI, 0.81-1.00).CONCLUSIONS The findings of this study suggest that a positive FCal result in children with chronic gastrointestinal symptoms seen in primary care is not likely to be indicative of IBD. A negative FCal result is likely to be a true negative, which safely rules out IBD in children in whom a primary care physician considers referral to specialist care.

This article describes two patients with psychosocial problems during and after pregnancy. The first woman suffers from an obsessive-compulsive disorder and developed postnatal depression after her first pregnancy. Her second pregnancy was marked by uncertainty, anxiety and stress. Her caregivers noticed her problems and referred her to a Psychiatry-Obstetrics-Paediatrics(POP)-team, who provided her with successful treatment. The second woman had physical symptoms, which were largely ascribed to antenatal depression and were effectively treated using antidepressants and cognitive behavioural therapy. Although these patients experienced different problems in different situations, the impact on the woman, partner and child(ren) was tremendous in both cases. This article makes clear that early screening and treatment of symptoms of anxiety and depression are relevant during and after pregnancy. Vigilance and screening by midwives, family doctors and gynaecologists help in early recognition and ultimately in earlier treatment, either medicinal and/or using psychotherapy, which may reduce or even prevent harmful consequences.

In children with suspected inflammatory bowel disease, adding calprotectin stool testing to the screening strategy has been recommended to distinguish organic from nonorganic disease. In this cohort study with historical controls, we could not confirm that screening with stool calprotectin improves the diagnostic yield (ratio inflammatory bowel disease-positive endoscopies and total number of endoscopies); however, in patients with normal fecal calprotectin levels (

BackgroundClinical prediction rules (CPRs) to identify children with serious infections lack validation in low-prevalence populations, which hampers their implementation in primary care practice.AimTo evaluate the diagnostic value of published CPRs for febrile children in primary care.Design and settingObservational cohort study among febrile children (MethodAlarm signs of serious infection and clinical management were extracted from routine clinical practice data and manually recoded with a structured electronic data-entry program. Eight CPRs were selected from literature. CPR-variables were matched with alarm signs and CPRs were applied to the GPC-population. 'Referral to emergency department (ED)' was used as a proxy outcome measure for 'serious infection'. CPR performance was assessed by calibration analyses, sensitivity, specificity, and area under the ROC-curve (ROC-area).ResultsA total of 9794 GPC-contacts were eligible, 54% male, median age 2.3 years (interquartile range 1.0-4.6 years) and 8.1% referred to ED. Frequencies of CPR-variables varied from 0.5% (cyanosis, drowsy) to 25% (temperature = 40 degrees C). Alarm signs frequently included in CPRs were 'ill appearance', 'inconsolable', and 'abnormal circulatory or respiratory signs'. The height of the CPR's predicted risks generally corresponded with being (or not being) referred to the ED in practice. However, calibration-slopes indicated that three CPRs underestimated the risk of serious infection in the GPC-population. Sensitivities ranged from 42% to 54%, specificities from 68% to 89%. ROC-areas ranged from 0.52 to 0.81, with best performance of CPRs for children agedConclusionPublished CPRs performed moderately well in the primary out-of-hours care population. Advice is given on how to improve translation of CPRs to primary care practice.

markdownabstract__Background:__ Point-of-care testing for C-reactive protein (CRP) may be helpful in differentiating viral from bacterial infection. Such a device should give results comparable to laboratory testing. The aim was to evaluate two point-of-care CRP tests (Nycocard and QuikRead) in febrile children in general practice, compared to a reference immunoturbidimetric assay. __Methods:__ Cross-sectional study of febrile children aged 3 months to 6 years presented to a general practice out-of-hours service. Children were visited at home, where blood was taken for the tests, within 24 hours of presentation. The Nycocard test was performed at home, whereas the QuikRead and reference test were performed in the laboratory. __Results:__ 76 children were enrolled. All three CRP tests were performed in 59 children. The mean difference between the reference test and Nycocard and QuikRead was 0.6 mg/L and –6.1 mg/L, respectively. The slopes of the Passing and Bablok regression were 0.95 (95% CI 0.9-1.0) and 0.83 (95% CI 0.81-0.85) for Nycocard and QuikRead, respectively. __Conclusion:__ Up to a concentration of 160 mg/L the Nycocard correlated well with the reference test, while the QuikRead underestimated concentrations above 60 mg/L. The Nycocard test seems a good candidate for CRP point-of-care testing in general practice.

Objective To compare the effects of pelvic floor muscle training and watchful waiting on pelvic floor symptoms in a primary care population of women aged 55 years and over with symptomatic mild pelvic organ prolapse. Design Randomised controlled trial. Setting Dutch primary care. Participants Women aged 55 years or over with symptomatic mild prolapse (leading edge above the hymen) were identified by screening. Exclusion criteria were current prolapse treatment or treatment in the previous year, malignancy of pelvic organs, current treatment for another gynaecological disorder, severe/terminal illness, impaired mobility, cognitive impairment, and insufficient command of the Dutch language. Interventions Pelvic floor muscle training versus watchful waiting. Main outcome measures The primary outcome was change in bladder, bowel, and pelvic floor symptoms measured with the Pelvic Floor Distress Inventory-20 (PFDI-20), three months after the start of treatment. Secondary outcomes were changes in condition specific and general quality of life, sexual function, degree of prolapse, pelvic floor muscle function, and patients’ perceived change in symptoms. Results Of the 287 women who were randomised to pelvic floor muscle training (n=145) or watchful waiting (n=142), 250 (87%) completed follow-up. Participants in the intervention group improved by (on average) 9.1 (95% confidence interval 2.8 to 15.4) points more on the PFDI-20 than did participants in the watchful waiting group (P=0.005). Of women in the pelvic floor muscle training group, 57% (82/145) reported an improvement in overall symptoms from the start of the study compared with 13% (18/142) in the watchful waiting group (P

To provide insight into the current use, future needs, and attitudes towards point-of-care testing among Dutch family practitioners.Cross-sectional online survey.We performed a survey among 2129 Dutch family practitioners. We asked respondents to report on the current and desired use of point-of-care tests, frequency of use, their opinions on aspects of point-of-care tests and consequences of point-of-care tests on their practice, acceptable waiting times for test results to come in, the desire for point-of-care tests at out-of-hours services, and conditions for which a point-of-care test could assist in diagnosis.639 family practitioners completed the survey (response rate: 30%). The most common point-of-care tests currently used by family physicians were: blood glucose (96%), urine leucocytes or nitrite (96%), urine pregnancy (94%), haemoglobin (58%), and CRP (48%). The most commonly desired point-of-care tests were: D-dimer (70%), troponin (65%), BNP (62%), chlamydia (60%), and INR (54%). Family practitioners expected point-of-care tests to have a positive effect on patient satisfaction (93%), diagnostic certainty (89%), antibiotics use (84%), and substitution to primary care (78%). They considered the proven effect on clinical management (46%) and the tests' reliability (35%) to be important aspects of point-of-care tests. Respondents wanted point-of-care tests to help them diagnose acute conditions, such as acute thromboembolic disorders (D-dimers), cardiac disorders (troponin, BNP), and infections (CRP, chlamydia).The current use of point-of-care testing in family practice is restricted to a limited number of tests. In the future, Dutch family practitioners wish to use more point-of-care tests, especially in acute conditions in which a diagnostic decision needs to be made immediately.