Fatigue in Primary Care : Course, Prognosis and Diagnoses

Horst, H.E. van der [Promotor]Windt, D.A.W.M. van der [Copromotor

Symptom attribution and presentation in general practice after an extreme life event

Background. A serious life event is likely to shape attributions relating to symptoms experienced afterwards. While they may play an important role in prognosis and seeking care, such perceptions have hardly been studied among survivors of a disaster. Objective. To investigate the association between self-reported health problems that have been attributed to an extreme life event and the symptoms presented to GPs. Methods. A two-wave longitudinal survey (2–3 weeks and 18 months) among survivors of a fireworks disaster was combined with a continuous morbidity surveillance in general practice. Symptoms attributed to the disaster reported in an open-ended question in the two waves were analysed using descriptive statistics. Differences in presented symptoms over time were analysed using logistic multilevel analysis. Results. More than half of the respondents reported health problems, which were, in their opinion, related to the disaster. Psychological problems were most frequently reported in association with the disaster, and in contrast to physical attributed symptoms, presentation of these problems in general practice decreased over time. In the total sample, musculoskeletal symptoms were less frequently presented in the longer term. Survivors who attributed symptoms to the disaster at both waves or after 18 months only most often presented such symptoms to the GP. Conclusion. Survivors attributed psychological problems and physical symptoms to the disaster at short-term and midterm post-disaster. Most of these survivors presented such symptoms to the GP. Attribution of symptoms to an extreme life event such as a disaster may therefore require special attention from the GP. (aut. ref

The effect of watchful waiting compared to immediate test ordering instructions on general practitioners' blood test ordering behaviour for patients with unexplained complaints; a randomized clinical trial (ISRCTN55755886)

<p>Abstract</p> <p>Background</p> <p>Immediate blood testing for patients presenting with unexplained complaints in family practice is superfluous from a diagnostic point of view. However, many general pracitioners (GPs) order tests immediately. Watchful waiting reduces the number of patients to be tested and the number of false-positive results. The objectives of this study are: to determine the feasibility of watchful waiting compared to immediate test ordering; to determine if a special quality improvement strategy can improve this feasibility; and to determine if watchful waiting leads to testing at a later time.</p> <p>Methods</p> <p>The study is a cluster-randomized clinical trial with three groups, on blood test ordering strategies in patients with unexplained complaints. GPs in group one were instructed to order tests immediately and GPs in group two to apply a watchful waiting approach. GPs in group three received the same instruction as group two, but they were supported by a systematically designed quality improvement strategy. A total of 498 patients with unexplained complaints from 63 practices of Dutch GPs participated. We measured: the percentage of patients for whom tests were ordered and number of tests ordered at the first consultation; performance on the strategy's performance objectives (i.e., ordering fewer tests and specific communication skills); the number of tests ordered after four weeks; and GP and patient characteristics.</p> <p>Results</p> <p>Immediate test ordering proved feasible in 92% of the patients; watchful waiting in 86% and 84%, respectively, for groups two and three. The two watchful waiting groups did not differ significantly in the achievement of any of the performance objectives. Of the patients who returned after four weeks, none from group one and six from the two watchful waiting groups had tests ordered for them.</p> <p>Conclusions</p> <p>Watchful waiting is a feasible approach. It does not lead to testing immediately afterwards. Furthermore, watchful waiting was not improved by the quality improvement strategy.</p> <p>Trial registration</p> <p>Clinical trial registration: <a href="http://www.controlled-trials.com/ISRCTN55755886">ISRCTN55755886</a></p

Detectability of testosterone esters and estradiol benzoate in bovine hair and plasma following pour-on treatment

The abuse of synthetic esters of natural steroids such as testosterone and estradiol in cattle fattening and sports is hard to detect via routine urine testing. The esters are rapidly hydrolysed in vivo into substances which are also endogenously present in urine. An interesting alternative can be provided by the analysis of the administered synthetic steroids themselves, i.e., the analysis of intact steroid esters in hair by liquid chromatography tandem mass spectrometry (LC/MS/MS). However, retrospective estimation of the application date following a non-compliant finding is hindered by the complexity of the kinetics of the incorporation of steroid esters in hair. In this study, the incorporation of intact steroid esters in hair following pour-on treatment has been studied and critically compared with results from intramuscular treatment. To this end animals were pour-on treated with a hormone cocktail containing testosterone cypionate, testosterone decanoate and estradiol benzoate in different carriers. The animals were either treated using injection and pour-on application once or three times having 1 week between treatments using injection and pour-on application. Animals were slaughtered from 10–12 weeks after the last treatment. Both hair and blood plasma samples were collected and analysed by LC/MS/MS. From the results, it is concluded that after single treatment the levels of steroid esters in hair drop to CCβ levels (5–20 µg/kg) after 5–7 weeks. When treatment is repeated two times, the CCβ levels are reached after 9–11 weeks. Furthermore, in plasma, no steroid esters were detected; not even at the low microgramme per litre level but—in contrast with the pour-on application—after i.m. injection, significant increase of 17β-testosterone and 17β-estradiol were observed. These observations suggest that transport of steroid esters after pour-on application is not only performed by blood but also by alternative fluids in the animal so probably the steroid esters are already hydrolysed and epimerized before entering the blood

Overview of data-synthesis in systematic reviews of studies on outcome prediction models

Background: Many prognostic models have been developed. Different types of models, i.e. prognostic factor and outcome prediction studies, serve different purposes, which should be reflected in how the results are summarized in reviews. Therefore we set out to investigate how authors of reviews synthesize and report the results of primary outcome prediction studies. Methods: Outcome prediction reviews published in MEDLINE between October 2005 and March 2011 were eligible and 127 Systematic reviews with the aim to summarize outcome prediction studies written in English were identified for inclusion. Characteristics of the reviews and the primary studies that were included were independently assessed by 2 review authors, using standardized forms. Results: After consensus meetings a total of 50 systematic reviews that met the inclusion criteria were included. The type of primary studies included (prognostic factor or outcome prediction) was unclear in two-thirds of the reviews. A minority of the reviews reported univariable or multivariable point estimates and measures of dispersion from the primary studies. Moreover, the variables considered for outcome prediction model development were often not reported, or were unclear. In most reviews there was no information about model performance. Quantitative analysis was performed in 10 reviews, and 49 reviews assessed the primary studies qualitatively. In both analyses types a range of different methods was used to present the results of the outcome prediction studies. Conclusions: Different methods are applied to synthesize primary study results but quantitative analysis is rarely performed. The description of its objectives and of the primary studies is suboptimal and performance parameters of the outcome prediction models are rarely mentioned. The poor reporting and the wide variety of data synthesis strategies are prone to influence the conclusions of outcome prediction reviews. Therefore, there is much room for improvement in reviews of outcome prediction studies. (aut.ref.

Prediction of outcome in patients presenting with fatigue in primary care.

BACKGROUND: Although fatigue is a common problem presenting to primary care, few prospective studies have examined the contribution of a wide range of prognostic factors. AIM: To determine the combination of factors most strongly associated with a favourable or unfavourable course of fatigue, when fatigue is presented as a main symptom in primary care. DESIGN OF STUDY: Prospective, observational cohort study with a 1-year follow-up. SETTING: A total of 147 primary care practices in the Netherlands. METHOD: Patients presenting with fatigue as a main symptom completed questionnaires at baseline, and 1, 4, 8, and 12 months later. The prognostic value of potential predictors was assessed by applying multivariable logistic regression analysis. The outcome was severity of fatigue, defined as a combination of dichotomised scores on several repeated measurements with the Checklist Individual Strength. Separate models were used to predict either a favourable or an unfavourable course of fatigue. RESULTS: Baseline severity of fatigue and patient expectations of chronicity consistently predicted a poor outcome. Additional factors predicting a chronic course were baseline pain intensity and less social support. Baseline characteristics predicting a fast recovery were: male sex, not providing care for others (for example, for older people), better perceived health, and fewer (serious) prolonged difficulties. Both models had good reliability and discriminative validity (area under the receiver operating characteristic curve after internal validation: 0.78 and 0.79). CONCLUSION: The identified combination of predictors reflects the multidimensionality of fatigue, with a significant contribution of patient expectations of chronicity in the prediction of a poor prognosis. These negative perceptions are modifiable, and should receive more attention in the initial assessment of patients presenting with fatigue. (aut. ref.

Fatigue in primary care: longitudinal associations with pain

So far, most studies on the association between pain and fatigue have used cross-sectional data. We analysed the possibilities for a temporal relationship between pain and fatigue in a cohort study of patients presenting with fatigue in primary care. Of 856 recruited patients, 642 (75%) completed postal questionnaires after the consultation, and at one, four, eight and 12months follow-up, with completion rates ranging from 82% to 88%. Pain was measured using the Short-Form health survey (SF-36) and fatigue using the severity scale of the Checklist Individual Strength (CIS). Longitudinal associations were analysed using generalised estimated equations (GEE). We used three different models assessing possible relationships between the symptoms in time, either in the same intervals or with a time-lag, suggesting either a synchronous or temporal association. The regression coefficients were strongest in the model assessing synchronous change, indicating that a one-point improvement in pain was associated with a 0.25 improvement in fatigue in the same time interval (adjusted for potential confounding). Baseline duration of fatigue and expectations of its future course significantly modified the association in this model, with stronger associations between changes in pain and fatigue found in patients with a shorter duration of fatigue or more positive expectations. The models using a time lag showed a significant but inverse association between changes in pain and subsequent changes in fatigue. The results indicate that changes in pain and fatigue are directly related in time, rather than showing temporal associations. (aut. ref.