The practice guideline 'Rheumatoid arthritis' (first revision) from the Dutch College of General Practitioners: a response from the perspective of rheumatology

The guideline from the Dutch College of General Practitioners regarding the early diagnosis and treatment of rheumatoid arthritis is in agreement with present concepts in rheumatology that emphasise a small window of opportunity for the effective treatment of (early) rheumatoid arthritis. Aggressive treatment of early rheumatoid arthritis is indicated, including early referral from the general practitioner to the rheumatologist.     

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.     

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.     

The practice guideline 'Atopic dermatitis' (first revision) from the Dutch College of General Practitioners: a response from the perspective of general practice

Atopic dermatitis is a chronic skin disease that is frequently encountered in general practice. The diagnostic criteria of Williams that the guideline recommends are clear. The reduced role of food-elimination procedures for infants is welcome, since there is little evidence for food allergy as a factor in atopic dermatitis. Rightfully so, the use of topical immunomodulators such as tacrolimus is not advised for general practitioners because of uncertainty about the long-term safety. The guideline provides clear instructions for the use of topical steroids. More severe forms of atopic dermatitis can safely be treated by pulse schemes and a step-down approach. In conclusion, the revised practice guideline offers general practitioners a practical and evidence-based tool for the management of atopic dermatitis.     

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.     

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

The new guidelines on hearing loss from the Dutch College of General Practitioners are well stated and supported by clearly described evidence. Rightfully so, new screening methods for detecting hearing loss in young infants are included in the guidelines. However, these new techniques may generate many false-positive test results, notably in children with a low risk ofhearing impairment. The general practitioner should inform parents about these adverse effects of screening. Another important role for the general practitioner is in the detection of relevant hearing loss in the elderly, especially in those who show signs of depression and cognitive impairment.     

The practice guideline 'Peripheral vascular disease' (first revision) from the Dutch College of General Practitioners: a response from the perspective of general practice

The practice guideline 'Peripheral vascular disease' (PVD) from the Dutch College of General Practitioners will certainly be of benefit to the Dutch general practitioner. Its limited set of simple diagnostic steps can help the general practitioner to assess or exclude PVD in patients with intermittent claudication. The inclusion of a pretest-posttest probability scheme enhances a clear diagnostic process. This guideline differs from the previous one in one important aspect. This guideline deals not only with the specific management of peripheral arterial disease but also with the management of cardiovascular risk in general. In this way the guideline follows the recently changed international attitude reflected in the European Guidelines on cardiovascular disease prevention. Smoking cessation and exercise therapy continues to be the cornerstone as well as the stumbling block of management of most cases of PVD in general practice; a challenge for every general practitioner.     

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

The revised practice guideline by the Dutch College of General Practitioners (NHG) on vaginal discharge is intended to offer general practitioners a handle for management of vaginal complaints. Most general practitioners experience uncertainties in daily practice with respect to the diagnosis of vaginal discharge. In most cases history taking and physical examination fails to provide sufficient valuable information to arrive at a definite diagnosis. No further (microscopic) investigation is only permissible in a very obvious infection with Candida albicans. A recent onset of complaints of itching accompanied by white odourless discharge means a 70% chance of an infection with C. albicans. If the general practitioner also finds vulvar or vaginal inflammation and a nonhomogeneous fluor during examination the chance of an infection with C. albicans increases to 90%. In all other cases microscopic investigation is inevitable. This does not reflect an inadequacy of the NHG guideline but is a consequence of the limited diagnostic possibilities to arrive at a precise diagnosis.     

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.     

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

The first revision of the practice guideline 'Otitis externa' from the Dutch College of General Practitioners has been published. Data from a clinical trial in primary care clearly show that acid eardrops containing corticosteroids are superior to acid eardrops without corticosteroids. Other minor changes have been made. A KOH test is no longer necessary in general practice. Aluminium acetotartrate eardrops 1.2% are reserved for otitis externa with tympanic membrane perforation.     

The practice guideline 'pelvic inflammatory disease' (first revision) from the Dutch College of General Practitioners; a response from the perspective of general practice

In the revised guideline of the Dutch College of General Practitioners on pelvic inflammatory disease (PID), 5 criteria must be met to establish the diagnosis: (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 degrees C, and (e) no indications for other diseases, such as appendicitis or an extra-uterine pregnancy. Treatment is started when all criteria are met. In case ofuncertainty, the patient should be referred to a gynaecologist. In quite a few patients, however, the accumulated certainty obtained by a general practitioner from the 5 criteria still leaves room for doubt about the right moment for referral. Another potential weak point in this otherwise very practicable guideline is that the start of treatment in young women of childbearing age, in whom this disease is most prevalent, could well have been recommended at an earlier stage.     

The practice guideline 'Bacterial skin infections' (first revision) from the Dutch College of General Practitioners; a response from the perspective of general practice

The revised guideline 'Bacterial skin infections' from the Dutch College ofGeneral Practitioners offers a clear and extensive overview of the most prevalent superficial and deep bacterial infections in general practice. Given the lack of evidence, it is no longer recommended to keep children with impetigo out of school or daycare centres. Erysipelas and cellulitis are now considered variants of the same bacterial infection and require the same therapy. Due to its rising prevalence, methicillin-resistant Staphylococcus aureus should also be considered. In conclusion, the guideline is a practical and evidence-based tool for the diagnosis, education and treatment of bacterial skin infections.     

The practice guideline 'Pregnancy and puerperium' (first revision) from the Dutch College of General Practitioners; a response from the perspective of general practice medicine

The first revision of the Dutch College of General Practitioners' practice guideline about pregnancy and puerperium does not significantly differ from the first edition. The guideline is extensive, is well-worth reading and supports daily practice. There is a greater emphasis on the importance of cooperation and differentiation in primary care (midwifes and general practitioners). During the last decade many general practitioners stopped doing home deliveries and have therefore lost their experience in obstetric care and pathology. The guideline describes the general practitioner's tasks as a preconception counsellor, a professional expert on illnesses during pregnancy and after the delivery, and as the doctor of the newborn baby. It will hopefully stimulate a revived interest of and involvement in pregnancy and post-partum care among general practitioners.     

The practice guideline 'Hypertension' (third revision) from the Dutch College of General Practitioners; a response from the perspective of general practice

In the revised practice guideline on hypertension from the Dutch College of General Practitioners, some changes have been made in the areas of diagnosis and therapy in comparison to the previous edition. Finding people with hypertension is a major goal for the prevention of cardiovascular disease. A systolic blood pressure > 140 mmHg (> 160 mmHg in patients > 60 years) necessitates non-pharmaceutical advice and antihypertensive therapy with diuretics, beta-blockers, angiotensin-converting-enzyme (ACE) inhibitors or calcium antagonists, either as monotherapy or in combination. In view of the ever-increasing importance of ACE inhibitors in antihypertensive therapy, we expect that the next revision of the practice guideline will soon be necessary.     

The practice guideline 'Allergic and non-allergic rhinitis' (first revision) from the Dutch College of General Practitioners; a response from the perspective of general practice

The Dutch guideline 'Allergic and nonallergic rhinitis' of the Dutch College of General Practitioners has been revised. The use of intranasal corticosteroids (INCS) is now advocated in cases with persistent complaints and there is more evidence to prescribe intranasal antihistamines for intermittent allergic rhinitis. The effect of dust-proof bedding covers is questioned and only advocated in persons showing both allergic rhinitis and asthma. Attention is given to the relationship between allergic rhinitis and asthma. Although the efficacy of INCS on asthma outcome has not been assessed, the guideline suggests that INCS could improve asthma symptoms and perhaps could diminish the dose of inhalation corticosteroids for persons with concomitant asthma.     

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.     

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

The strength of the second revision of the practice guideline 'Acne' from the Dutch College of General Practitioners (NHG) lies mainly in bringing its therapy up to date. The guideline also points out psychosocial problems that can arise with acne, but discounts stress and diet as the possible cause. Schedules showing a medical plan of action and information on medications complete this clear and practical guideline.     

The practice guideline 'Influenza and influenza vaccination' (first revision) from the Dutch College of General Practitioners; a response from the perspective of general practice

The first revision of the guideline 'Influenza and influenza vaccination' from the Dutch College of General Practitioners illustrates that influenza has evolved from a supposedly harmless condition to a disease against which growing numbers of patients and healthcare professionals are vaccinated. Although recent studies support its effectiveness, it is still believed that vaccination may prevent serious health problems in the vulnerable patients, notably in homes for the elderly and nursing homes. In order to streamline diagnostic triage in cases of flu-like symptoms, general practitioners must keep abreast of the actual influenza figures, but also be aware that not all patients with flu-like symptoms have influenza. Pneumonia should always be present in the differential diagnosis of influenza.