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Rationale, aims and objectivesThe diagnostic work-up of patients with shoulder pain in general practice is complex. General practitioners' (GPs) guidelines advise a pragmatic diagnostic work-up in which additional imaging has a limited role. However, diagnostic ultrasounds are increasingly ordered by GPs, which seems to reflect complexity in management of shoulder pain. This study aimed to explore GPs' perspectives on the diagnostic work-up of patients with shoulder pain. MethodThis study has a qualitative exploratory design with an inductive approach and was carried out in Dutch general practice. The study population consisted of 18 Dutch GPs who were sampled purposefully with a spread in clinical experience and ordering diagnostic ultrasound. Data were gathered by means of semi-structured interviews and analysed following principles of the constant comparative method. ResultsThree main categories with subcategories emerged that captured the diagnostic work-up of shoulder pain: variety in diagnostic classifications [(non-)specific diagnosis and interdisciplinary differences], establishing strategies for diagnostic work-up (use of existing tools and motives to deviate from existing tools), and strategies dealing with diagnostic uncertainties (accepting diagnostic uncertainties, diagnostic imaging tests, and interdisciplinary consultation and referral). ConclusionsDespite the availability of evidence-based shoulder guidelines, GPs experience uncertainties during diagnostic work-up and apply different strategies when dealing with these uncertainties. At some point, GPs as well as patients seem to have a need for a specific diagnosis. Currently, there appears to be little agreement if, or in which phase of shoulder pain, diagnostic ultrasound is useful or indicated.

Fever in children is very common, and is usually caused by self-limiting upper-respiratory-tract infections. The low incidence of serious infections makes it a challenge to identify children that do have a serious infection and need treatment or observation. The Dutch Society of Paediatrics (NVK) recently presented their guideline for febrile children in secondary care. This is an important, science-based guideline. However, the diagnostic schemes presented, which are based on tests that are not available in primary care, in combination with a different prior chance of serious infections between the primary and secondary care settings make it difficult to translate this guideline to primary care. Nevertheless, the 'traffic light system' presented is a promising potential safety net tool for providing advice for parents in the general practitioner's consultation room. A traffic light system especially developed for primary care should be considered.

Worldwide, paracetamol is the most commonly used antipyretic for children and the drug of first choice for reducing fever named in the majority of practice guidelines. However, whether or not it is necessary or desirable to treat fever is questionable. The provision of accurate information on the causes and treatment of fever can decrease the help-seeking behaviour of parents. Paracetamol is both effective and advisable when there is a combination of fever and pain. Fever on its own does not require treatment and doctors should therefore show caution about advising paracetamol for children who have just this symptom. The effect of paracetamol on the general well-being of children with fever on its own has not been unequivocally proven. Treatment with paracetamol for the prevention of febrile convulsions has been proven ineffective. There are indications that inhibiting fever through paracetamol can adversely affect the immune response. The use of paracetamol can produce mild side effects and hepatotoxicity.

OBJECTIVE: To provide insight into the current use, future needs, and attitudes towards point-of-care testing among Dutch family practitioners. DESIGN: Cross-sectional online survey. METHOD: 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. RESULTS: 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). CONCLUSION: 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.

Acute respiratory tract infection (RTI) are common illnesses among children. RTI are mostly self-limiting, with low risk of complications. Only a fraction of the children with RTI present to their GP. This thesis evaluates different aspects of the diagnosis and management of children with RTI in primary care. Identifying a child with pneumonia in the large group of children presenting to a GP with acute RTI is challenging for GPs. Knowledge on the diagnostic value of specific signs and symptoms may guide GPs and aid in development of future decision rules. We aimed to identify and systematically review available evidence on the diagnostic value of signs, symptoms and additional tests to diagnose pneumonia in children in an ambulatory setting in developed countries. The original search yielded 4665 records, of which 17 articles were eligible for analysis; twelve studies on signs and symptoms, four on additional laboratory tests and six on ultrasonography. All included studies were performed in a secondary care setting, where prevalence of pneumonia varied from 3.4%-71.7%. Risk of bias was present in the majority of studies in the domain of patient selection. The diagnostic value of the available 27 individual signs and symptoms to identify pneumonia was low. In a low prevalence setting (4 studies, pneumonia prevalence 10%) additional diagnostic tests such as oxygen saturation, C-Reactive Protein and White Blood Count are more promising. Chest ultrasonography showed high diagnostic value in settings with higher prevalence of pneumonia. We concluded that single signs and symptoms from medical history and physical examination or individual additional diagnostic tests are insufficient to diagnose pneumonia in ambulant children. Unfortunately, there are very few diagnostic studies conducted in settings with low prevalence of pneumonia, and no studies from primary care could be included. We also describe the results of a cluster randomized trial which assessed whether use of point-of-care CRP by the GP reduces antibiotic prescriptions in children with suspected non-serious LRTI. 309 Children between 3 months and 12 years of age with suspected LRTI were recruited by 148 GPs: 210 children at general practices and 99 at an out-of-hours service. We found no statistically significant reduction in antibiotic prescriptions in the GP use of CRP group (30.9% vs. 39.4%; OR 0.61; 95CI 0.29-1.23). Only the estimated severity of illness was related to antibiotic prescription. Children were more likely to get an antibiotic prescription with increasing CRP level, ranging from 14% in children with a CRP level < 10 mg/L to more than 50% in children with a CRP level > 40mg/L. Point-of-care CRP levels were