Ruut A de Melker

Primary care based randomised, double blind trial of amoxicillin versus placebo for acute otitis media in children aged under 2 years

Abstract Objective: To determine the effect of antibiotic treatment for acute otitis media in children between 6 months and 2 years of age. Design: Practice based, double blind, randomised, placebo controlled trial. Setting: 53 general practices in the Netherlands. Subjects: 240 children aged 6 months to 2 years with the diagnosis of acute otitis media. Intervention: Amoxicillin 40 mg/kg/day in three doses. Main outcome measures: Persistent symptoms at day four and duration of fever and pain or crying, or both. Otoscopy at days four and 11, tympanometry at six weeks, and use of analgesic. Results: Persistent symptoms at day four were less common in the amoxicillin group (risk difference 13%; 95% confidence interval 1% to 25%). The median duration of fever was two days in the amoxicillin group versus three in the placebo group (P=0.004). No significant difference was observed in duration of pain or crying, but analgesic consumption was higher in the placebo group during the first 10 days (4.1 v 2.3 doses, P=0.004). In addition, no otoscopic differences were observed at days four and 11, and tympanometric findings at six weeks were similar in both groups. Conclusions: Seven to eight children aged 6 to 24 months with acute otitis media needed to be treated with antibiotics to improve symptomatic outcome at day four in one child. This modest effect does not justify prescription of antibiotics at the first visit, provided close surveillance can be guaranteed.

Penicillin for acute sore throat: randomised double blind trial of seven days versus three days treatment or placebo in adults

Abstract Objective: To assess whether treatment with penicillin for three days and the traditional treatment for seven days were equally as effective at accelerating resolution of symptoms in patients with sore throat compared with placebo. Design: Randomised double blind placebo controlled trial. Setting: 43 family practices in the Netherlands. Participants: 561 patients, aged 15-60 years, with sore throat for less than seven days and at least three of the four Centor criteria—that is, history of fever, absence of cough, swollen tender anterior cervical lymph nodes, and tonsillar exudate. 142 patients were excluded for medical reasons and 73 needed penicillin. Interventions: Patients were randomly assigned to penicillin V for seven days, penicillin V for three days followed by placebo for four days, or placebo for seven days. Main outcome measures: Resolution of symptoms in the first week, eradication of bacteria after two weeks, and recurrences of sore throat after two, four, and six months. Results: Symptoms resolved 1.9 and 1.7 days earlier in patients taking penicillin for seven days than in those taking penicillin for three days or placebo respectively. Symptoms resolved 2.5 days earlier in patients with group A streptococci and 1.3 days earlier in patients with high colony counts of non-group A streptococci. 23 (13%) of the placebo group had to be given antibiotics later in the week because of clinical deterioration; three developed a peritonsillar abscess. The eradication rate for group A streptococci was 72% in the seven day penicillin group, 41% in the three day penicillin group, and 7% in the placebo group. Sore throat recurred more often in the three day penicillin group than in the seven day penicillin or placebo groups. Conclusion: Penicillin treatment for seven days was superior to treatment for three days or placebo in resolving symptoms of sore throat in patients with group A streptococcal pharyngitis and, possibly, in those with non-group A streptococcal pharyngitis.

Penicillin for acute sore throat in children: randomised, double blind trial

Abstract ObjectiveTo assess the effectiveness of penicillin for three days and treatment for seven days compared with placebo in resolving symptoms in children with sore throat. DesignRandomised, double blind, placebo controlled trial. Setting43 family practices in the Netherlands Participants156 children aged 4-15 who had a sore throat for less than seven days and at least two of the four Centor criteria (history of fever, absence of cough, swollen tender anterior cervical lymph nodes, and tonsillar exudate). InterventionsPatients were randomly assigned to penicillin for seven days, penicillin for three days followed by placebo for four days, or placebo for seven days. Main outcome measures Duration of symptoms, mean consumption of analgesics, number of days of absence from school, occurrence of streptococcal sequelae, eradication of the initial pathogen, and recurrences of sore throat after six months. Results Penicillin treatment was not more beneficial than placebo in resolving symptoms of sore throat, neither in the total group nor in the 96 children with group A streptococci. In the groups randomised to seven days of penicillin, three days of penicillin, or placebo, one, two, and eight children, respectively, experienced a streptococcal sequela Conclusion Penicillin treatment had no beneficial effect in children with sore throat on the average duration of symptoms. Penicillin may, however, reduce streptococcal sequelae.

Health care utilisation by older people with non-traumatic foot complaints What makes the difference?

OBJECTIVES To determine the factors associated with the type of health care chosen by elderly people suffering from non-traumatic foot complaints. DESIGN Cross-sectional mailed survey. SETTING Population-based random sample of 7200 people aged > or = 65 years in The Netherlands. SUBJECTS 1130 people > or = 65 years with non-traumatic foot complaints for 4 weeks or more. MAIN OUTCOME MEASURES Use of non-(para)medical care (i.e. no care at all, self-care and chiropodial care) versus (para)medical care (i.e. care given by paramedical personnel, general practitioners and medical specialists). RESULTS Six of every 10 respondents sought (para)medical care, half of these visited the GP. Factors associated with the use of (para)medical care were foot-related limitations (adj OR 3.18; 95% CI 2.26-4.46), painful feet (adj OR 1.55; 1.09-2.23), and foot osteoarthritis (adj OR 1.88; 1.32-2.68). (Para)medical care was sought less often than non-(para)medical care for forefoot complaints (adj OR 0.56; 0.41-0.76). CONCLUSIONS Elderly people with non-traumatic foot complaints did not seem to underreport their problems to (para)medical care providers. Furthermore, they appeared to select the appropriate type of care. Future studies will have to assess the effectiveness of the care provided.Objectives - To determine the factors associated with the type of health care chosen by elderly people suffering from non-traumatic foot complaints. Design - Cross-sectional mailed survey. Setting

Referrals to Specialists: An exploratory investigation of referrals by 13 General Practitioners to medical and surgical departments

Several aspects of referrals to medicine and surgery of National Health Service (NHS) patients in thirteen Dutch General Practices were investigated. In The Netherlands active and passive referrals have to be separated. Only one out of three referrals to medicine was an active referral on the initiative of the GP. With regard to surgical referrals about half were active referrals. About half the passive referrals were referrals in retrospect. The thirteen GPs differed in the percentages of active and passive referrals. There was a strong positive correlation between the percentages of passive referrals to medicine and surgery (Spearman Rs = .81). The correlation between the percentages of repeat cards for both groups of specialists was almost as strong (Spearman Rs = .73). In four out of five active referrals the GPs informed the specialist about some aspects of the referral, usually by letter and rarely by telephone. GPs who sent information along with a referral to medicine often did the same with a referral to surgery (Rs = .60). The legibility of the written information was, in general, moderate to poor. Only occasionally the GPs formulated clearly what they expected from the specialist. Suggestions are formulated to improve the referral process between primary and secondary care.

Difficulties in diagnosing acute sinusitis in a Dutch group practice: Relative value of history, radiography and ultrasound

Objectives: To determine the degree of agreement between (1) history, ultrasound and radiographic examinations, and (2) between two ultrasound and two radiographie examinations in the diagnosis of acute sinusitis in a local situation.Methods: This cross-sectional pilot study was undertaken among patients on the list of a Dutch group practice (six GPs), in cooperation with the ENT and radiography departments of a local hospital. Included were patients aged 15 to 65 years with one or more of the following symptoms: purulent nasal discharge; pain in the sinuses on bending forward; predominantly unilateral maxillary pain and pain in teeth or on mastication; the above symtoms after a common cold or influenza. The main outcome measure was agreement, calculated by Kappa statistics, between the results of diagnosing acute sinusitis from the history, following the guidelines of the Dutch College of General Practitioners (DCGP), and by ultrasound and radiography.Results: Of 60 evaluated patients, acute sinusitis wa...

Vijftig jaar bovensteluchtweginfecties vóór en dóór huisartsen

SamenvattingVenekamp RP, De Melker RA, Kuyvenhoven MM, Damoiseaux RAMJ. Vijftig jaar bovensteluchtweginfecties vóór en dóór huisartsen. Huisarts Wet 2008;51(5):247-50.Inleiding In een eerder artikel hebben we laten zien dat Huisarts &Wetenschap (H&W) de afgelopen vijftig jaar regelmatig aandacht heeft besteed aan bovensteluchtweginfecties. Voor dit vervolgartikel onderzochten we uit welke beroepsgroep de eerste auteur van H&W-artikelen op dit gebied afkomstig is. Vervolgens gingen we na welke soorten onderzoeksvragen in artikelen over huisartsgeneeskundige dissertaties aan bod zijn gekomen.Methode We doorzochten alle jaargangen van H&W en selecteerden artikelen over bovensteluchtweginfecties. Vervolgens achterhaalden we de discipline van de eerste auteur aan de hand van de publicaties zelf en door navraag te doen bij H&W en de betrokken auteurs. We vonden twaalf huisartsgeneeskundige dissertaties over bovensteluchtweginfecties waarover artikelen in H&W zijn verschenen. De onderzoeksvragen van die dissertaties verdeelden we over zes categorieën: ‘incidentie/prevalentie’, ‘etiologie’, ‘diagnostiek’, ‘interventie’, ‘prognostiek’ en ‘overig’. Vervolgens gingen we na in hoeverre deze soorten onderzoeksvragen in H&W aan bod kwamen.Resultaten Huisartsen vormden – met zeven op de tien artikelen – veruit de grootste groep eerste auteurs, gevolgd door co-assistenten en (huis)artsen in opleiding (aios). De meeste onderzoeksvragen uit de betrokken dissertaties kwamen vooral in de beginjaren en in het laatste decennium in H&W aan bod.Conclusie De opmars van publicaties door co-assistenten en aios is mogelijk het gevolg van de vernieuwing van de geneeskundeopleidingen, die aandacht besteden aan het uitvoeren van onderzoek. Verder lijkt het redactiebeleid van H&W bij te dragen aan de verspreiding van nieuwe inzichten dankzij een actief publicatiebeleid ten aanzien van beschouwingen en dubbelpublicaties van huisartsgeneeskundige dissertaties.AbstractVenekamp RP, De Melker RA, Kuyvenhoven MM, Damoiseaux RAMJ. Fifty years of upper respiratory tract infections for and by GPs. Huisarts Wet 2008;51(5):247-50.Background In an earlier article we showed that H&W has dealt with many aspects of upper respiratory tract infections over the past 50 years. The aim of this follow-up article is to explore whether GPs, medical specialists or other disciplines were the first authors throughout the years and what types of research questions included in the theses have been published in Huisarts en Wetenschap (H&W).Method Manual screening of all volumes of H&W, with broadly defined search terms, was followed by a definitive selection. The disciplines of the first authors were retrieved by examining the publications and by consulting H&W and the authors in question. The research questions contained in the twelve theses on upper respiratory tract infections in general practice – articles published in H&W – were divided into six categories: ‘incidence/prevalence’, ‘aetiology’, ‘diagnostic’, ‘intervention’, ‘prognostic’ and ‘other’. Subsequently we examined the extent to which the different research questions were published in H&W.Results With 70% of articles, GPs have been by far the largest group of first authors, followed by graduate medical students and GP trainees. In the early years, as well as in the last decade, most research questions contained in the theses have been published in H&W.Conclusion The boom in publications by graduate medical students and GP trainees might be the result of the renewed medical curricula stressing student involvement in research. Furthermore the editorial policy of H&W might contribute to the spread of new insights by the active publication of reviews and the duplicaite publication of theses.

Antimicrobial treatment of upper respiratory tract infections from the Dutch perspective.

Abstract The worldwide problem of multiple resistant strains should be attacked by a more adequate, rational prescription behaviour of antibiotics. As most upper respiratory tract infections (URTIs) have a viral cause and are selflimiting, antibiotics should be used for certain indications only. The development of evidence based guidelines, based on outcome studies in the field of URTIs carried out in general practice populations is recommended. The general practitioners (GPs) with defined practice populations are in a key position for research and a restrictive antibiotic policy. Several RCTs are carried out in general practice indicating that antibiotic prescriptions can be reduced. This will contribute to the decrease of resistant strains.

Value of a four-item questionnaire in the diagnosis of presbyacusis

Objectives: There is a high prevalence of hearing disorders in the elderly. They may have an enormous impact on quality of life. Therefore, identifying these problems with a quick and easy-to-use test seems very attractive.Such a test should give insight in all aspects of hearing disorders, not just in hearing impairment, but also in hearing disability and hearing handicap (as defined by the WHO).The aim of this study is to assess the value of a short patient questionnaire in screening for hearing disorders.Methods: In a population of 61 elderly people taking part in an experimental home-care project, a four-item questionnaire regarding their hearing was compared with screening audiometry.Results: The question ‘can you carry on a one-to-one conversation?’ had a specificity of 100% and a sensitivity of 40%. The question ‘can you follow the conversation of a small group of people?’ had a specificity of 80% and a sensitivity of 75%.Questions concerning television and telephone showed a poor sensitivity with ...

Vijftig jaar bovensteluchtweginfecties

SamenvattingHuisarts en Wetenschap heeft in deze halve eeuw aan veel ontwikkelingen rond bovensteluchtweginfecties aandacht besteed. Ondanks de toegenomen druk tot internationaal publiceren zijn in het laatste decennium de nieuwe inzichten over de epidemiologie van luchtweginfecties en de effectiviteit van interventies snel onder de Nederlandse huisartsen verspreid.