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PubMed2005

[The practice guideline 'Miscarriage' (second revision) from the Dutch College of General Practitioners; a response from the perspective of general practice].

The practice guideline 'Miscarriage' has been reviewed for the second time in fifteen years. It provides the practitioner with distinct diagnostic tools for vaginal bleeding in the first sixteen weeks of pregnancy and a clear management algorithm. The management of miscarriage is based on a joint decision between the general practitioner and the woman concerned. A more reserved attitude towards the surgical termination of pregnancy is advised. The guideline sufficiently addresses the issue of informing the woman as to the expected amount of bleeding during a miscarriage and the relationship with fertility. However, the risk factors for heavy blood loss are not mentioned in the guideline. The psychological impact of early miscarriage on women is given adequate attention and is part of the counselling during the follow-up period. Finally, the medical treatment of threatened miscarriage seems to result in an earlier miscarriage with less loss of blood compared to expectant management. The guideline pays also attention to medical treatment. Future research will clarify whether medical treatment is feasible in general practice.

Abortion, Spontaneous↗
PubMed2005

[The practice guideline 'TIA' (first revision) from the Dutch College of General Practitioners; a response from the perspective of general practice].

A transient ischaemic attack (TIA) can be seen as an attack of angina of the brain. In the first weeks following a TIA there is a sizeable risk of subsequent stroke. After this period, this increased risk tapers off and an elevated risk of cardiovascular disorders remains, with the emphasis on its cardiac component. The management of a patient with a TIA in general practice focuses on these two risk periods. The long-term cardiovascular risk can easily be reduced by prescribing aspirin, an established procedure in general practice. The immediate threat of obstruction of the carotid artery may, as was only recently firmly established, be averted by a timely referral for additional diagnostics and, when needed, carotid desobstruction. This part of TIA management in general practice, however, is hampered by the current waiting periods for these procedures.

Female↗
PubMed2005

[The practice guideline 'Depressive disorder' (first revision) from the Dutch College of General Practitioners; a response from the perspective of general practice].

The revised Dutch College of General Practitioners' practice guideline 'Depressive disorder' no longer distinguishes between mild and severe depression because the management in both cases is identical. This guideline focuses much attention on diagnosis, support and information, all of this in dialogue with the patient. The choice between the antidepressants, a tricyclic antidepressant or a specific serotonin reuptake inhibitor is based on the contraindications of these drugs.

Antidepressive Agents↗
PubMed2005

[The practice guideline 'Anxiety disorders' (first revision) from the Dutch College of General Practitioners; a response from the perspective of general practice].

The recommendations provided by the revised guideline 'Anxiety disorders' are well suited to every-day practice. The multidisciplinary approach reflects the increasing cooperation between primary and secondary care in the management of mental-health problems. The description of the various anxiety disorders and the questions that can be asked to elicit the symptoms will facilitate recognition. The indications for treatment with medication are clear: a limited number of antidepressants should be used. Although it is agreed that patient education is an important part of treatment, the guidelines could have described in more detail how this should be done. Cognitive-behavioural techniques may be used but this requires extra training; its effectiveness when used by general practitioners needs further study. This guideline will add to existing knowledge and improve the skills of general practitioners in dealing with anxiety.

Antidepressive Agents↗
PubMed2005

[The practice guideline 'Lower urinary-tract symptoms in middle-aged and elderly men' (second revision) from the Dutch College of General Practitioners; a response from the perspective of general practice].

Recent research has shown that the simple pathophysiological concept which explains micturition complaints in elderly men as being caused by benign prostatic hyperplasia needs to be abandoned. It has been shown that there is no clear correlation between prostate volume and voiding problems and also that reductase blocker drugs which specifically decrease prostate volume do not lead to a clinically important reduction in symptoms. The internationally accepted new conceptual umbrella description of these micturition problems is 'lower urinary-tract symptoms', a term that is more suited to research this area where a good understanding of the fundamental underlying mechanisms is lacking. The Dutch general practitioners' guideline for micturition problems in elderly men addresses this paradigm change in a thorough and easily understandable way.

Aged↗
PubMed2005

[The practice guideline 'The STD consultation' from the Dutch College of General Practitioners; a response from the perspective of general practice].

The new guidelines from the Dutch College of General Practitioners on sexually transmitted diseases (STDs) replace three existing practice guidelines covering a number of sexually transmitted diseases. In the Netherlands the general practitioner treats almost 75% of all patients with an STD. These include patients with symptoms, patients who are worried or anxious, and patients at high risk of an STD. STD-risk assessment should be regarded as a high priority. Chlamydia-infection remains the most prevalent STD. It is easily diagnosed by DNA-diagnostic amplification techniques. The new guidelines recommend more proactive and wider testing. There is much emphasis on counselling, prevention and notifying partners. General practice is the ideal setting for this.

Contact Tracing↗
PubMed2005

[The practice guideline 'Heart failure' (first revision) from the Dutch College of General Practitioners; a response from the perspective of general practice].

The practice guideline 'Heart failure' from the Dutch College of General Practitioners will be a source of support for the general practitioner/family physician. Its clear set of diagnostic steps helps the general practitioner to assess heart failure in patients with breathlessness, fatigue, decreased exercise tolerance or ankle swelling. Testing plasma concentrations of natriuretic peptides plays a new and central diagnostic role. This guideline differs from the previous one in another important aspect. Based on many RCT's and reviews the authors have succeeded in developing a detailed but balanced treatment protocol for heart-failure patients in general practice. However, adverse effects from co- and multi-medication in the growing number of frail elderly may reduce the patients' compliance.

Aged↗
PubMed2006

[The practice guideline 'Headache' from the Dutch College of General Practitioners; a response from the perspective of general practice].

The practice guideline 'Headache' from the Dutch College of General Practitioners, which replaces the guideline 'Migraine', is an improvement in many respects: tension headache and substance-induced headache are discussed in detail, the headache diary is given due emphasis and the recommended treatment for migraine is well-balanced. The symptom-oriented approach is, however, not applied consistently in this guideline and too little attention is given, in particular, to the exclusion of serious causes that are less commonly encountered. The guidelines for performing physical examination provide insufficient footing. The exclusion of serious diseases should be based on a limited set of specific physical examinations to be carried out in all cases of new headache. Interrogating the patient about possible social or psychological aspects and the possibility of referral in this area deserve increased emphasis.

Diagnosis, Differential↗
PubMed2006

[The practice guideline 'Urinary-tract infections' (second revision) from the Dutch College of General Practitioners; a response from the perspective of general practice].

The Dutch College of General Practitioners recently published an update of the practice guideline on urinary-tract infections. This guideline provides a clear overview of the medical history, the diagnostic methods and the treatment options. Sixteen management modalities are presented in relation to specific patient characteristics. However, this revised guideline warrants some minor comments. According to the guideline, the dipstick (nitrite) test and dipslide form the two cornerstones of the diagnosis of urinary-tract infections. The value of the dipslide, however, seems to have been overestimated and that of microscopic examination of the urine by skilled physicians to have been underestimated. New in this guideline compared to that of 1999 is that nitrofurantoin (the treatment of first choice in uncomplicated infections) should be given for five instead of three days. The guideline motivates this change in policy on the basis of the numerous treatment failures seen in practice. The most convincing type of evidence, however, is not available due to the lack of relevant randomised clinical trials. The introduction of the prescription of phosphomycin, which is unusual in the Netherlands, as an alternative treatment for uncomplicated infections requires supportive evidence before it will be accepted by general practitioners. This well-documented guideline provides clear guidance for the general practitioner faced with patients with urinary-tract symptoms that could be caused by infection.

Anti-Bacterial Agents↗
PubMed2006

[The practice guideline 'Otitis media with effusion' (second revision) from the Dutch College of General Practitioners; a response from the perspective of general practice].

The usefulness of tympanotomy tubes in children with otitis media with effusion who also have speech and language retardation is doubtful in view of the natural development. The second revision of the practice guideline 'Otitis media with effusion' from the Dutch College of General Practitioners is still not in complete agreement with this. The indications for performing an adenoidectomy are now more limited. Pneumatic otoscopy and tympanometry are diagnostic aids that may deserve a permanent place in the general practitioner's medical practice in the future.

Acoustic Impedance Tests↗
PubMed2006

[The practice guideline 'Diabetes mellitus type 2' (second revision) from the Dutch College of General Practitioners; a response from the perspective of general practice].

The publication of the practice guideline 'Diabetes mellitus' by the Dutch College of General Practitioners in 1989 marked the start of an era of publication of several guidelines that helped general practitioners using evidence-based medicine in clinical practice; the guidelines also helped to teach students. The second revision of this guideline presents many improvements, especially simplifications in the medication-schedules. However, the new recommendation to use thiazolidines is based on only one large study and has some unpractical aspects. The new guidelines do not mention preventive action, nor advice regarding early detection. Clinical practice has changed in recent years with the introduction of nurses specialising in diabetes and, despite published research on this subject, the guidelines do not give any recommendations for this. What is also missing are national clinical guidelines for doctors specialising in internal medicine. When patients do not respond to treatment according to the general practitioners' guidelines and are referred to a specialist in internal medicine, the treatment is diverse and seems to be doctor-dependent. It is important that treatment there be standardised as well so that general practitioners can refer more effectively.

Diabetes Mellitus, Type 2↗
PubMed2006

[The practice guideline 'Problematic alcohol consumption' (second revision) from the Dutch College of General Practitioners; a response from the perspective of general practice].

The recently revised version of the practice guideline 'Problematic alcohol consumption' from the Dutch College of General Practitioners offers realistic advice to general practitioners on how to manage problem drinkers. The number of patients with alcohol problems tends to increase among women of middle age. The proportion of patients that report an alcohol problem themselves is larger than is usually assumed. Questionnaires are oflimited value in the detection of an alcohol problem. The general practitioner should look at problem drinking as a chronic disease that demands structured disease management and monitoring. This perspective will lead to less frustration in handling both the problem and the patients.

Adolescent↗
PubMed2004

General practitioners' response to depression and anxiety in the Australian community: a preliminary analysis.

OBJECTIVES: To examine the uptake by general practitioners (GPs) of the five key components of the Better Outcomes in Mental Health Care (BOiMHC) initiative: education and training for GPs; the three-step mental health process; focussed psychological strategies; access to allied health services; and access to psychiatrist support. SETTING: All Australian states and territories during the first 15 months of the initiative (1 July 2002 - 30 September 2003). DESIGN: Retrospective survey of de-identified registration data held by the General Practice Mental Health Standards Collaboration (training uptake), de-identified Health Insurance Commission (HIC) billing data (provision of the three-step mental health process, focussed psychological strategies and case conferences with psychiatrists), and reports from "access to allied health services" projects to the Australian Department of Health and Ageing (project participation). MAIN OUTCOME MEASURES: Number and percentage of Australian GPs certified as eligible to participate in the initiative; provision of the three-step mental health process and focussed psychological strategies by GPs; participation in allied health pilot projects; and access to psychiatrist support. RESULTS: Within 15 months of the BOiMHC initiative commencing, 3046 GPs (about 15% of Australian GPs) had been certified as eligible to participate, including 387 who had registered to provide focussed psychological strategies. GPs had completed 11 377 three-step mental health processes and 6472 sessions of focussed psychological strategies. Sixty-nine "access to allied health services" projects had been funded, with the original 15 pilot projects enabling 346 GPs to refer 1910 consumers to 134 individual allied health professionals and 10 agencies. In contrast, the "access to psychiatrist support" component was less successful, with the HIC billed for 62 case conferences at which a psychiatrist and a GP were present. CONCLUSION: The level of uptake of the main components of the BOiMHC initiative has expanded the national capacity to respond to the needs of people with common mental disorders, such as depression and anxiety.

Anxiety Disorders↗
PubMed1978

Visual dominance in the pigeon.

In Experiment 1, three pigeons were trained to obtain grain by depressing one foot treadle in the presence of a 746-Hertz tone stimulus and by depressing a second foot treadle in the presence of a red light stimulus. Intertrial stimuli included white light and the absence of tone. The latencies to respond on auditory element trials were as fast, or faster, than on visual element trials, but pigeons always responded on the visual treadle when presented with a compound stimulus composed of the auditory and visual elements. In Experiment 2, pigeons were trained on the auditory-visual discrimination task using as trial stimuli increases in the intensity of auditory or visual intertrial stimuli. Again, pigeons showed visual dominance on subsequent compound stimulus test trials. In Experiment 3, on compound test trials, the onset of the visual stimulus was delayed relative to the onset of the auditory stimulus. Visual treadle responses generally occurred with delay intervals of less than 500 milliseconds, and auditory treadle responses generally occurred with delay intervals of greater than 500 milliseconds. The results are discussed in terms of Posner, Nissen, and Klein's (1976) theory of visual dominance in humans.

Journal Article↗