The practice guideline 'The red eye' (first revision) of the Dutch College of General Practitioners; a response from the perspective ofthe ophthalmologist

The revised guideline 'The red eye' of the Dutch College of General Practitioners contains adequate and scientifically well-supported recommendations for the diagnosis and management of patients with minor ocular trauma and red eyes. Unfortunately the guideline lacks a roadmap for implementation of these recommendations, as well as a definition of indicators for the measurement of implementation. This is important in the light of the limited implementation of the previous guideline 'The red eye' published in 1996.     

Summary of the practice guideline 'Miscarriage' (second revision) from the Dutch College of General Practitioners (NHG)

The NHG practice guideline 'Miscarriage' provides guidelines for the diagnosis and management of pregnant women with vaginal bleeding during the period up to and including the 16th week after the first day of the last menstruation. The guideline has been revised on the basis of the developments over the last few years. The most important modifications are: In case of an imminent miscarriage, more consideration than before is given to the patient's preference with regard to ultrasonography, expectant management and curettage. The GP should therefore discuss the advantages and disadvantages of these options with the patient. A midwife was involved in the formulation of the new guideline. Referral from a GP to a midwife for transvaginal ultrasonography is offered as one of the possibilities. The paragraph on 'information' has been expanded on the basis of the results of a patient focus group.     

Summary of the Dutch College of General Practitioners (NHG) practice guideline on 'Diverticulitis'

The NHG practice guideline on 'Diverticulitis' provides general practitioners with directions on the diagnosis and treatment of uncomplicated and complicated diverticulitis. Diverticulitis is primarily a clinical diagnosis which can be supported by assessment of CRP. Uncomplicated diverticulitis is strongly suspected if the patient reports the development of persistent sharp, stabbing pain in the lower left abdomen within a couple of days; if there is pressure or rebound tenderness only in the lower left abdomen; and if there are no alarm signals. Alarm signals of complicated diverticulitis are: guarded muscle response, signs of intestinal obstruction, locally palpable resistance, rectal loss of blood, hypotension, and high fever. The policy for uncomplicated diverticulitis is waiting without specific measures, provided that the general practitioner monitors the course actively. There is no indication for antibiotics in patients with uncomplicated diverticulitis. Patients with signs of complicated diverticulitis or with persisting symptoms should be referred.     

The practice guideline 'The red eye' (first revision) of the Dutch College of General Practitioners; a response from the perspective of the general practitioner

The revised version of the practice guideline 'The red eye' of the Dutch College ofGeneral Practitioners gives the general practitioner useful information on new insights into diagnosis and therapy for a red eye. An important therapeutic advice is prescribing chloramphenicol ointment instead of fusidic acid ointment in the case of bacterial conjunctivitis after one-week treatment without positive results, since 80% of the conjunctivitis causing bacteria does not react to fusidic acid. A slit lamp is helpful in the diagnosis of a case of red eye, but is not present in every general practitioner's office. Joint efforts of a group of general practitioners in obtaining such a slit lamp may reinforce the diagnosis in general practice.     

Summary of the Dutch College of General Practitioners practice guideline 'The menopause'

In the Dutch College of General Practitioners' practice guideline 'The menopause', the menopause is viewed as a physiological phase of life with its associated discomforts, which sometimes require treatment. The GP should inform women with menopausal symptoms about the extent to which oestrogens can diminish vasomotor symptoms and about the benefits and risks of hormonal therapy on various organ systems. Oestrogens can be used when vasomotor symptoms cause serious limitations in daily life. First choice is a sequential combination of oestrogen and progestagen hormones, in which progestagens are given at least ten days per month. When urogenital complaints need to be treated, vaginally applied oestrogens can be prescribed. Depressive symptoms, fatigue, myalgia or arthralgia should not be treated with hormonal therapy. Nor are oestrogens recommended for the prevention of osteoporosis and cardiovascular diseases.     

Summary of the practice guideline 'Rheumatoid arthritis' (first revision) from the Dutch College of General Practitioners

The guideline covers the evaluation of patients with one or more painful joints without previous injury and focuses on the distinction between rheumatoid arthritis and other joint complaints. In the case of rheumatoid arthritis, the arthritis is based on aseptic synovitis and is nearly always associated with tenderness, warmth, swelling, and impaired function. Redness is not present in most cases. The diagnosis is primarily made on the basis of the case history and physical examination. Laboratory tests and X-ray are only of secondary importance. NSAIDs are recommended as the initial treatment for patients with rheumatoid arthritis or serious indications for this. If the arthritis does not settle within a period of 6 to 12 weeks after the onset of the complaints, the patient should be referred to a rheumatologist to start treatment with one or more disease-modifying antirheumatic drugs (DMARDs). DMARDs suppress the activity of the disease and can prevent joint damage. However, which combination of DMARDs gives the best results is still unclear.     

Summary of the practice guideline 'Anxiety disorders' (first revision) from the Dutch College of General Practitioners

Anxiety disorders are characterised by excessive fears leading to distress or social disability. Anxiety disorders are difficult to recognise. General practitioners (GPs) should consider the possibility more often, especially in patients who make frequent visits with unexplained physical symptoms. The cornerstone of treatment is patient education, which can be supported by information leaflets provided by the Dutch College of General Practitioners. Cognitive behavioural therapy and antidepressants are equally effective therapies in most anxiety disorders. The choice should be made in collaboration with the patient. Pharmacological treatment is the first choice when a comorbid depression is involved. Cognitive behavioural therapy by the GP is optional considering the limitations of skills and time in general practice. Tricyclic antidepressants and selective serotonin re-uptake inhibitors are equally effective with most anxiety disorders. The choice must be made on the basis of side effects, comorbidity, and co-medication. Antidepressant therapy should be given for at least 6-12 months. The GP's choice oftreatment should lead to improvement within 8-12 weeks. Otherwise, consultation of or referral to a specialist in mental health care is mandatory.     

Summary of the practice guideline 'Heart failure' (first revision) from the Dutch College of General Practitioners

The guideline entitled 'Heart failure' from the Dutch College of General Practitioners has been revised. The general practitioner makes the diagnosis of heart failure in a patient with the core symptoms (dyspnoea, fatigue, oedema) in combination with paroxysmal nocturnal dyspnoea, orthopnoea, crepitations, elevated central-venous pressure, a third heart sound or ifictus cordis is visible outside the mid-clavicular line. Further investigations include a panel of laboratory investigations, an ECG and possibly echocardiography and radiographic chest investigations. One new recommendation is that on suspicion of heart failure the plasma concentrations of B-type natriuretic peptide (BNP) or N-terminal pro-BNP should be investigated. The step-by-step medication plan has been changed; beta-blockers have been introduced to the plan. In the treatment of acute heart failure, rapidly working sublingual nitrates should be given first and foremost.     

Summary of the practice guideline 'Depressive disorder' (first revision) from the Dutch College of General Practitioners

In the revised practice guideline for the diagnosis and treatment of patients with a depressive disorder in general practice the distinction between mild and severe depression has been removed. By paying attention to a number of risk factors, the general practitioner can detect patients with a hidden depressive disorder. The general practitioner's strategy is aimed at reducing symptoms and restoring the ability to function normally. Factors that define the strategy are in particular patient's degree of suffering and dysfunctioning, and the patient's preferences and demands. In primary care tricyclic antidepressants and specific serotonin re-uptake inhibitors are the drugs of first choice: both are equally effective; the nature of the side effects differs.     

Summary of the practice guideline 'Atopic dermatitis' (first revision) from the Dutch College of General Practitioners

The 1996 practice guideline on atopic dermatitis from the Dutch College of General Practitioners has been updated. For diagnosing atopic dermatitis, the use of Williams' criteria is recommended. Testing for food allergy is only useful in case of children under the age of 2 who have other food-related allergic complaints together with dermatitis. In the treatment of atopic dermatitis, keeping the skin in good condition with emollients is essential; furthermore, topical corticosteroids are the therapy of first choice. In case of a severe exacerbation of atopic dermatitis, starting with a class 3 corticosteroid is preferred. In case of frequent recurrences, 'pulse-therapy' is indicated: topical corticosteroids on 2-4 consecutive days per week as maintenance therapy. The role of preparations from tar is marginal. The use of the topical immunomodulators tacrolimus and pimecrolimus in general practice is discouraged.     

Summary of the practice guideline 'Otitis externa' (first revision) from the Dutch College of General Practitioners

* The practice guideline 'Otitis externa', first developed by the Dutch College of General Practitioners in 1995, has been revised and updated. * It is no longer recommended to perform a KOH test on material collected from the auditory canal in patients with otitis externa. * Eardrops that contain both acid and corticosteroids are preferred over eardrops that contain acid only. * Suitable options include acidic eardrops with hydrocortisone 1% FNA and acidic eardrops with triamcinolone acetonide 0.1% FNA at a dose of 3 drops thrice daily. * The guideline contains a detailed discussion of the ototoxicity of eardrops in patients with tympanic membrane perforation. * Management of these patients, however, remains unchanged: the preferred approach is aluminium acetotartrate eardrops 1.2% FNA.     

Summary of the practice guideline 'Hearing impairment' (first revision) from the Dutch College of General Practitioners

The Dutch College of General Practitioners recently issued a revised version of the practice guideline 'Hearing impairment'. The modification of the screening for hearing impairment, which now takes place in neonates, has resulted in a much lower number of false-positive diagnoses of perceptive hearing loss than under the previous version of the practice guideline. The expanded diagnostic possibilities for adults, whether or not implemented by the patients themselves, demand an active approach from the general practitioner towards patients with impaired hearing. This guideline helps general practitioners to select patients that will truly benefit from a hearing aid and that will also be more likely to use one. The general practitioner can play an important role by stimulating patients to be referred for a hearing aid.     

Summary of the practice guideline 'Thyroid disorders' (first revision) from the Dutch College of General Practitioners

--The practice guideline 'Thyroid disorders' developed by the Dutch College of General Practitioners replaces the practice guideline 'Functional thyroid disorders' from 1996. Recommendations for palpable thyroid disorders have been added. --Hypothyroidism can often be treated by the general practitioner. The guideline offers specific recommendations for substitution therapy based on the 'start low, go slow'-principle. --Pharmacological treatment of hyperthyroidism is described as an optional activity for general practitioners. --A conservative approach is taken to the treatment of subclinical thyroid dysfunction. The development of symptoms may justify treatment initiation. --Cooperation has improved harmonisation of this practice guideline with the Netherlands Association for Internal Medicine's practice guideline 'Functional thyroid disorders' and the Dutch Institute for Healthcare Improvement's practice guideline 'Thyroid carcinomas'.     

Summary of the practice guideline 'Vaginal discharge' (first revision) from the Dutch College of General Practitioners

The 1996 practice guideline of the Dutch College of General Practitioners (NHG) on vaginal discharge has been updated. Most women who visit their doctor with complaints about vaginal discharge do not have an increased risk of a sexually-transmitted disease. Investigations into vaginal discharge comprise history taking, physical examination and microscopic analysis in the laboratory of the general practitioner. Additional investigation into Chlamydia, gonorrhoea and Trichomonas infection is only necessary if the patient history reveals an increased risk of a sexually-transmitted disease. A Candida infection or bacterial vaginosis should only be treated if the patient experiences bothersome complaints. Treatment of a Candida infection consists of a vaginally applied imidazole compound. Bacterial vaginosis can be treated with oral administration of metronidazole. Patients with vaginal fluor can be examined and, if necessary, treated by their general practitioner. Referral to a gynaecologist is rarely necessary.     

Summary of the practice guideline 'Peripheral vascular disease' (first revision) from the Dutch College of General Practitioners

Peripheral vascular disease is a manifestation of atherosclerosis and may occur with or without signs or symptoms. The local prognosis is worse with signs or symptoms. The concomitant atherosclerosis in heart and brain is responsible for long-term morbidity and mortality. Absence of signs and symptoms almost excludes peripheral vascular disease, but for the diagnosis an ankle-brachial index is mandatory. This implies a protocol in general practice. Treatment of peripheral vascular disease consists of advice on cardiovascular risk factors, stopping smoking, walking exercises, and foot care. For peripheral vascular disease, anti-thrombotic medication is advised.     

Summary of the practice guideline 'Pelvic inflammatory disease' (first revision) from the Dutch College of General Practitioners

The 1995 guideline on pelvic inflammatory disease (PID) has been updated. The general practitioner should consider PID whenever a woman of childbearing age complains of lower abdominal pain; the diagnosis should then be based on 5 criteria: (a) non-acute lower abdominal pain; (b) pain on upward movement or adnexal tenderness during vaginal touch; (c) painful or swollen adnexae; (d) ESR > or = 15 mm in the 1st hour or a temperature > 38 degree C, and (e) no indications for other diseases, such as appendicitis or an extra-uterine pregnancy. In case of diagnostic doubt, a gynaecologist must be consulted. Rapid treatment with antibiotics diminishes symptoms, shortens the course of disease, and may prevent complications such as infertility or extra-uterine pregnancy. Treatment should be started with ofloxacin and metronidazole. Due to the increasing antibiotic resistance of Neisseria gonorrhoeae, when there are indications for this pathogen the medicinal treatment should immediately be directed at it by means of cefotaxim, doxycycline and metronidazole. In his or her information to the patient, the general practitioner should devote attention to the major role of sexually transmissible micro-organisms and give advice, if necessary, regarding high-risk behaviour.     

Summary of the practice guideline 'Bacterial skin infections' (first revision) from the Dutch College of General Practitioners

The revised practice guideline 'Bacterial skin infections' developed by the Dutch College of General Practitioners replaces the previous practice guideline from 1998. Most bacterial skin infections can be diagnosed based on the patient history and clinical findings. Skin cultures and serologic analysis (in the case oferythema migrans) are not necessary. Exceptions are made for patients with bacterial skin infection and a high risk of MRSA involvement, or if nasal treatment is indicated for patients with recurring furunculosis. A superficial skin infection can be treated with local therapy. In case of a deep skin infection, oral antibiotics or surgical intervention is recommended. Antibiotic prophylaxis after a tick bite is not recommended. Erysipelas is considered a specific type of cellulitis and is treated as such.