Search

Objective: Health care expenditures for children with functional constipation (FC) are high, while conservative management is successful in only 50% of the children. The aim is to evaluate whether adding physiotherapy to conventional treatment (CT) is a cost-effective strategy in the management of children with FC aged 4-18 years in primary care.Methods: A cost-effectiveness analysis was performed alongside a randomized controlled trial (RCT) with 8-month follow-up. Costs were assessed from a societal perspective, effectiveness included both the primary outcome (treatment success defined as the absence of FC and no laxative use) and the secondary outcome (absence of FC irrespective of laxative use). Uncertainty was assessed by bootstrapping and cost-effectiveness acceptability curves (CEACs) were displayed.Results: One hundred and thirty-four children were randomized. The incremental cost-effectiveness ratio (ICER) for one additional successfully treated child in the physiotherapy group compared with the CT group was €24,060 (95% confidence interval [CI] €-16,275 to €31,390) and for the secondary outcome €1,221 (95% CI €-12,905 to €10,956). Subgroup analyses showed that for children with chronic laxative use the ICER was €2,134 (95% CI -24,975 to 17,192) and €571 (95% CI 11 to 3,566), respectively. At a value of €1,000, the CEAC showed a probability of 0.53 of cost-effectiveness for the primary outcome, and 0.90 for the secondary outcome.Conclusions: Physiotherapy added to CT as first-line treatment for all children with FC is not cost-effective compared with CT alone. Future studies should consider the cost-effectiveness of physiotherapy added to CT in children with chronic laxative use.Trial Registration: The RCT is registered in the Netherlands Trial Register (NTR4797), on the 8th of September 2014. The first child was enrolled on the 2nd of December 2014. https://www.trialregister.nl/trial/4654. [ABSTRACT FROM AUTHOR]

Background: Faecal calprotectin is considered to be a valid test for ruling out inflammatory bowel disease (IBD) in children with chronic gastrointestinal symptoms in specialist care. In contrast, faecal lactoferrin has higher specificity. The recent availability of both as point-of-care tests (POCTs) makes them attractive for use in primary care.Objective: To evaluate the test characteristics of calprotectin and lactoferrin POCTs for diagnosing IBD in symptomatic children.Methods: We defined two prospective cohorts of children with chronic gastrointestinal symptoms: (i) children presenting to primary care (primary care cohort); (ii) children referred for specialist care (referred cohort). Baseline POCT results were compared with the outcome of either endoscopic assessment or 12 months follow-up. Clinicians were blinded to the POCT results.Results: In the primary care cohort, none of the 114 children had IBD, and the calprotectin and lactoferrin POCTs had specificities of 0.95 (0.89-0.98) and 0.98 (0.93-0.99), respectively. In the referred cohort, 17 of the 90 children had IBD: the sensitivity of POCT calprotectin and POCT lactoferrin were both 0.94 (0.72-0.99); and the specificity was 0.93 (0.84-0.97) and 0.99 (0.92-1.00), respectively. The POCT calprotectin could reduce the referral rate by 76% and POCT lactoferrin by 81%, while missing one child with IBD (6%).Conclusion: A diagnostic test strategy in primary care using a simple POCT calprotectin or lactoferrin has the potential to reduce the need for referral for further diagnostic work-up in specialist care, with a low risk of missing a child with IBD. [ABSTRACT FROM AUTHOR]

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 μg/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. [ABSTRACT FROM AUTHOR]

PURPOSE Abdominal pain is a frequent symptom among children but is rarely associated with organic disease. Although it may persist for years, no factors have been identified that predict its prognosis. Our aim was to determine whether patient characteristics at initial consultation can predict chronic abdominal pain severe enough to influence the child's well-being at 1 year of follow-up. METHODS We conducted this prospective cohort study in primary care, including consecutive children aged 4 to 17 years seen for abdominal pain by their family physician. Multivariate logistic regression analysis was used to identify prognostic factors that predicted chronic abdominal pain 1 year later. Discriminative ability of identified predictors was assessed using the area under the receiver operating characteristic curve and explained variance. RESULTS The risk of having chronic abdominal pain at 1 year of follow-up was 37.1% in the cohort overall. Increasing age, waking up at night with pain, high levels of other somatic complaints, and chronic abdominal pain at baseline independently predicted chronic abdominal pain at 1 year. These predictors had a poor to moderate discriminative ability, however; the area under the receiver operating characteristic curve was only 0.69, and the predictors collectively explained only 14.3% of variance in the development of chronic abdominal pain. The absolute risk ranged from 19.4% among children having none of the predictors to 65.5% among children having 3 or 4 predictors. CONCLUSIONS Chronic abdominal pain sufficient to affect well-being is common among children initially seen for abdominal pain by family physicians. Although the risk of this outcome increases with number of predictors, these predictors are of limited value in identifying children in whom pain will become chronic, suggesting that other, as yet unidentified factors play an important role. [ABSTRACT FROM AUTHOR]

Background Pelvic floor symptoms are common and are negatively associated with sexual function which, in turn, is an important aspect of quality of life. The majority of older women with pelvic floor symptoms are treated in general practice but evidence from studies in general practice on the sexual functioning of these women is scarce. Aim This study examined predictors of sexual inactivity in older women with pelvic floor symptoms in general practice and of sexual functioning in those women who are sexually active. Design and setting Cross-sectional study in women (aged =55 years) from 20 general practices who screened positive on a pelvic floor symptom questionnaire. Method Logistic and linear regression analyses were used to determine predictors of sexual inactivity and sexual functioning (PISQ-12) by assessing their association with patient characteristics, symptoms (PFDI-20) and degree of prolapse (POP-Q). Results A total of 639 women were included (sexually active n = 393, sexually inactive n = 246). Predictors of sexual inactivity were increasing age (odds ratio [OR] = 1.13; 95% confidence interval [CI] = 1.10 to 1.17) and lower education (OR = 2.31; 95% CI = 1.50 to 3.54; Nagelkerke R² = 0.208). In sexually active women, sexual functioning was associated with pelvic floor symptom distress (P<0.001) and pelvic floor surgery (P = 0.018; R² = 0.138). Conclusion In older women with pelvic floor symptoms, increasing age and lower educational level are predictors of sexual inactivity. Many of these older women are sexually active and pelvic floor symptom distress is negatively associated with sexual functioning. These results may encourage GPs to ask about sexual problems in women with pelvic floor symptoms. [ABSTRACT FROM AUTHOR]

Purpose: Abdominal pain is a common complaint in children. Because few data exist on its natural history, we wanted to investigate the prognosis of abdominal pain in children in general practice.Methods: In a prospective cohort study of children (aged 4 to 17 years) complaining of abdominal pain, follow-up was at 3, 6, 9, and 12 months using standardized questionnaires. The primary outcome measure was chronic abdominal pain: abdominal pain at least 1 time a month during at least 3 consecutive months that had an impact on daily activities. Prevalence, incidence, and duration of chronic abdominal pain were assessed.Results: Three hundred five children (116 boys, 189 girls), with a median age of 7.8 years (interquartile range [IQR] = 5.7-10.5 years) were included. Chronic abdominal pain was present in 142 (46.6%) children at an initial visit to the primary care physician for this complaint. During follow-up, 78.7% fulfilled the criteria for chronic abdominal pain at 1 or more follow-up points. Among 163 children at risk for developing chronic abdominal pain, the cumulative incidence of chronic abdominal pain was 60.1% (95% CI, 52.1%-67.7%) and was higher in girls than in boys (RR = 1.23; 95% CI, 0.94-1.61). Median duration of abdominal pain was 7.5 months (IQR = 4.5-12.0 months). Children aged 10 to 17 years had the longest duration of abdominal pain (median = 9.0 months; IQR = 7.5-12.4 months). Children with symptoms of irritable bowel syndrome seemed to have a less favorable prognosis compared with children with symptoms of functional dyspepsia or functional abdominal pain.Conclusions: The presence and development of chronic abdominal pain is common and of long duration among children consulting in primary care for abdominal pain. These poor outcome data warrant follow-up. [ABSTRACT FROM AUTHOR]

Background: Low disease prevalence and lack of uniform reference standards in primary care induce methodological challenges for investigating the diagnostic accuracy of a test. We present a study design that copes with these methodological challenges and discuss the methodological implications of our choices, using a quality assessment tool for diagnostic accuracy studies (QUADAS-2). Design: The study investigates the diagnostic value of fecal calprotectin for detecting inflammatory bowel disease in children presenting with chronic gastrointestinal symptoms in primary care. It is a prospective cohort study including two cohorts of children: one cohort will be recruited in primary care and the other in secondary/tertiary care. Test results of fecal calprotectin will be compared to one of the two reference standards for inflammatory bowel disease: endoscopy with histopathological examination of mucosal biopsies or assessment of clinical symptoms at 1-year follow-up. Discussion: According to QUADAS-2 the use of two reference standards and the recruitment of patients in two populations may cause differential verification bias and spectrum bias, respectively. The clinical relevance of this potential bias and methods to adjust for this are presented. This study illustrates the importance of awareness of the different kinds of bias that result from choices in the design phase of a diagnostic study in a low prevalence setting. This approach is exemplary for other diagnostic research in primary care. [ABSTRACT FROM AUTHOR]

STUDY QUESTION: Does pelvic floor muscle training lead to a greater change in bladder, bowel, and pelvic floor symptoms than watchful waiting in women aged 55 years or over with symptomatic mild pelvic organ prolapse recruited from primary care? SUMMARY ANSWER: Change in bladder, bowel, and pelvic floor symptoms differed significantly between pelvic floor muscle training and watchful waiting, but the clinical relevance of this difference remains unclear. WHAT IS KNOWN AND WHAT THIS PAPER ADDS: Pelvic floor muscle training seems to be effective in relieving symptoms of prolapse in women with an advanced stage pelvic organ prolapse. This is the first study to investigate the effects of pelvic floor muscle training in a primary care population of women with symptomatic mild pelvic organ prolapse. [ABSTRACT FROM AUTHOR]

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<0.001). Other secondary outcomes showed no significant difference between the groups., Conclusions: Although pelvic floor muscle training led to a significantly greater improvement in PFDI-20 score, the difference between the groups was below the presumed level of clinical relevance (15 points). Nevertheless, 57% of the participants in the intervention group reported an improvement of overall symptoms. More studies are needed to identify factors related to success of pelvic floor muscle training and to investigate long term effects.Trial registration Dutch Trial Register (www.trialregister.nl) identifier: NTR2047., (© Wiegersma et al 2014.)

Objective: To investigate the course of mental health problems in children presenting to general practice with abdominal pain and to evaluate the extent to which abdominal pain characteristics during follow-up predict the presence of mental health problems at 12 months' follow-up., Design: A prospective cohort study with one-year follow-up., Setting: 53 general practices in the Netherlands, between May 2004 and March 2006., Subjects: 281 children aged 4-17 years., Main Outcome Measures: The presence of a depressive problem, an anxiety problem, and multiple non-specific somatic symptoms at follow-up and odds ratios of duration, frequency, and severity of abdominal pain with these mental health problems at follow-up., Results: A depressive problem persisted in 24/74 children (32.9%; 95% CI 22.3-44.9%), an anxiety problem in 13/43 (30.2%; 95% CI 17.2-46.1%) and the presence of multiple non-specific somatic symptoms in 75/170 children (44.1%; 95% CI 36.7-51.6%). None of the abdominal pain characteristics predicted a depressive or an anxiety problem at 12 months' follow-up. More moments of moderate to severe abdominal pain predicted the presence of multiple non-specific somatic symptoms at follow-up., Conclusions: In one-third of the children presenting to general practice for abdominal pain, anxiety and depressive problems persist during one year of follow-up. Characteristics of the abdominal pain during the follow-up period do not predict anxiety or depressive problems after one-year follow-up. We recommend following over time children seen in primary care with abdominal pain.

Purpose: Nonspecific abdominal pain (NSAP) is a common complaint in childhood. In specialist care, childhood NSAP is considered to be a complex and time-consuming problem, and parents are hard to reassure. Little is known about NSAP in family practice, but the impression is that family physicians consider it to be a benign syndrome needing little more than reassurance. This discrepancy calls for a better understanding of NSAP in family practice., Methods: Data were obtained from the Second Dutch National Survey of General Practice (2001). Using registration data of 91 family practices, we identified children aged 4 to 17 years with NSAP. We calculated the incidence, and we studied factors associated with childhood NSAP, referrals, and prescriptions., Results: The incidence of NSAP was 25.0 (95% confidence interval [CI], 23.7-26.3) per 1,000 person years. Most children (92.7%) with newly diagnosed NSAP (N = 1,480) consulted their doctor for this condition once or twice. Factors independently associated with NSAP were female sex (odds ratio [OR] = 1.4; 95% CI, 1.3-1.5), nongastrointestinal-nonspecific somatic symptoms (OR = 1.3; 95% CI, 1.1-1.5), and health care use (OR = 1.04; 95% CI, 1.03-1.05). When NSAP was diagnosed at the first visit, 3% of the patients were referred to specialist care, and 1% received additional testing. Family physicians prescribed medication in 21.3% of the visits for NSAP., Conclusions: Childhood NSAP is a common problem in family practice. Most patients visit their doctor once or twice for this problem. Family physicians use little additional testing and make few referrals in their management of childhood NSAP. Despite the lack of evidence for effectiveness, family physicians commonly prescribe medication for NSAP.

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 with, 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 the follow-up studies.

Objective: To investigate the influence of the general practitioner's style of clothing on the patient's level of confidence in that doctor; is vanity a functional attribute for the GP?, Design: Experimental comparative study., Method: 4 photographic models representing 4 types of GP, namely the older male, younger male, older female and younger female GP, were each photographed dressed in 4 different styles of clothing (business wear, formal, semi-formal and casual). These photos were shown to evaluators with the question 'How much confidence do you have in this doctor?' The level of confidence was allocated a score on a numerical scale from 0 (no confidence) to 10 (complete confidence). There were 2 groups of evaluators: patients aged ≥ 65 years and professionals attending a symposium., Results: The clothing style had a significant impact on the level of confidence in the older and younger male doctor and in the younger female doctor. The assessment by elderly patients (n = 116) differed significantly from the assessment by professionals (n = 59). The professionals had a far more pronounced opinion on style of clothing than the patients did. Business wear and formal clothing generally inspired more confidence than casual clothing., Conclusion: A GP's style of clothing affects the patient's initial level of confidence in that doctor. Vanity therefore seems to be a functional attribute for the GP.