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.     

The Dutch guideline 'Renal cell carcinoma'

The Dutch guideline 'Renal Cell Carcinoma' has been revised on the basis of new literature. With the assistance of the Netherlands Cancer Registry an assessment was made of the current care for patients with renal cell carcinoma. Renal cell carcinoma is a type of cancer for which knowledge of the genetic basis of the different histological subtypes has led to the development of new targeted therapies. By the introduction of these systemic therapies, histological subtyping of renal cell carcinoma has become more important. Although in the previous guideline cytological or histological diagnosis was recommended to determine the nature of the tumourous process in the kidney, in the revision it is advised to use histological needle biopsies to determine the histological subtype and therefore to provide evidence for the choice of systemic therapy. With modern diagnostic techniques, more patients with smaller tumours are identified. For these tumours, less invasive therapies are recommended in order to preserve as much renal tissue as possible.     

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

The first revision of the Dutch guidelines for the treatment of depressive disorders by general practitioners adapted the international psychiatric nomenclature for the diagnosis of depressive disorders. This enhances collaboration between general practitioners and psychiatrists. The use of selective serotonin reuptake inhibitors in this guideline is an advantage compared to the earlier version. The distinction between the indication for cognitive therapy and for antidepressant treatment is not very clear in this guideline. Overall the guideline represents a scientific and conservative stance in the treatment of depressed patients, which is commendable. The use of target plasma level concentrations with tricyclic antidepressants, better guidelines for the use of antidepressants or cognitive therapy, and the use of severity rating scales during treatment could further improve the next version of this guideline.     

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.     

Comparison of international guideline programs to evaluate and update the Dutch program for clinical guideline development in physical therapy

Background  

Clinical guidelines are considered important instruments to improve quality in health care. Since 1998 the Royal Dutch Society for Physical Therapy (KNGF) produced evidence-based clinical guidelines, based on a standardized program. New developments in the field of guideline research raised the need to evaluate and update the KNGF guideline program.     

Medically unexplained physical symptoms in medical practice: a psychiatric perspective

Clusters of medically unexplained physical symptoms have been referred to in the literature by many different labels, including somatization, symptom-based conditions, and functional somatic syndromes, among many others. The traditional medical perspective has been to classify and study these symptoms and functional syndromes separately. In psychiatry, current taxonomies (Diagnostic and Statistical Manual of Mental Disorder, 4th edition, and The International Statistical Classification of Diseases and Related Health Problems, 10th revision) classify these syndromes together under the rubric of somatoform disorders. In this article we approach medically unexplained physical symptoms from a psychiatric perspective and discuss the common features that unite multiple unexplained symptoms or functional somatic syndromes as a class. Included in this article is a discussion of nosological issues, clinical assessment, how these syndromes are viewed within the various medical specialties, and clinical management and treatment.     

The multidisciplinary practice guideline "The responsible use of biologicals"

A multidisciplinary working group has developed a practice guideline containing various recommendations on the responsible and efficient use of biologicals. These biologicals include both soluble immune-receptor proteins and monoclonal antibodies that are aimed at immune mediators, receptors or cells. They are produced by biotechnology. Biologicals are used to treat patients with immune-mediated inflammatory disorders (IMIDs) such as rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriatic arthritis, juvenile idiopathic arthritis (JIA), psoriasis, ulcerative colitis, Crohn's disease, uveitis and sarcoidosis. This article summarises the most important recommendations contained in the practice guideline. The practice guideline is intended for members of the medical profession in addition to patients, who are considering, or are already, using biologicals.     

亚健康状态的流行病学研究进展

  目的  探讨健康促进生活方式对中学教师亚健康疲劳影响。  方法  2013年4 — 5月采用横断面调查方法在广东省广州市采用简单随机抽样（随机数表法）随机抽取3个区的中学教师8 111名作为调查对象,在被调查者年度体检时进行现场调查。健康状况及疲劳的判定主要结合被调查者的体检报告及亚健康评定量表（SHMS V1.0）,生活方式的评估使用健康促进生活方式量表（HPLP-II）。  结果  共有1 586人发生疲劳,疲劳的现患率为19.55 %,其中,亚健康疲劳31.72 %（503人）,疾病疲劳65.89 %（1 045人）,远高于健康者疲劳2.39 %（38人）。回归分析发现健康促进生活方式对亚健康疲劳有明显影响（P < 0.05）,在校正一般人口学资料的模型中,相对于优秀的促进健康生活方式（最小暴露者）,差的生活方式（最高暴露者）发生亚健康疲劳的危险性高达70倍（OR = 69.63,95 % CI = 26.80～180.87）,一般的生活方式（较高暴露者）发生亚健康疲劳的危险性高达16倍（OR = 15.87,95 % CI = 8.43～29.89）,次优的生活方式发生亚健康疲劳的危险性为2倍（OR = 2.05,95 % CI = 1.07～3.93）;而且进一步的回归分析显示HPLP-II6个维度处于差的、一般的及次优的等级时,处于亚健康疲劳的危险度也增加（P < 0.05）,其中,差的、一般的压力管理、人际关系、心灵成长对亚健康疲劳发生的危险度较高。  结论  亚健康疲劳与不良生活方式影响因素密切相关。     

躯体形式障碍患者症状与心理社会因素关系

目的 探讨躯体形式障碍患者症状与心理社会因素的相关性,为心理治疗提供科学依据。方法 采用症状自评量表(SCL-90)、明尼苏达多相个性调查问卷(MMPI)、防御方式问卷(DSQ)对53名躯体形式障碍患者进行调查。结果 躯体形式障碍患者的症状与MMPI的诈分、疑病、心理变态、偏执、精神衰弱、精神分裂、轻躁症、社会内向、校正分及DSQ的不成熟防御机制、中间型防御机制有相关关系,与心理变态、偏执性、年龄、性别、文化程度有回归关系。结论 躯体形式障碍患者的躯体症状与其心理社会因素相关,必须注重其心理治疗。     

Medically unexplained symptoms in older adults: a combination of physical, psychiatric and psychological factors

3 women aged 75, 75 and 65 years, respectively, were referred to an outpatient clinic for medically unexplained symptoms (MUS). These cases illustrate the heterogeneity and complexity of MUS in elderly patients, which requires broad, multidisciplinary clinical examination by a geriatrician, psychiatrist and psychologist. The first patient presented with persistent pain in the lower back and legs. Examination revealed a spinal stenosis, which was treated surgically; symptoms subsequently resolved. The second patient had chronic abdominal pain and constipation in combination with depression. She was diagnosed with a severe depressive disorder. After adequate drug treatment, her mood improved and the somatic symptoms disappeared. The third patient complained of headache and feared that she may have a brain tumour. There was no somatic diagnosis. She underwent cognitive behavioural group therapy, which substantially improved her functioning. These cases illustrate the diversity and complexity of MUS in elderly patients and underscore the diagnostic appropriateness of the biopsychosocial paradigm. A specialised multidisciplinary examination ensures accurate diagnosis and cognitive behavioural therapy.     

Gulf War unexplained illnesses: persistence and unexplained nature of self-reported symptoms

Most published reports of health symptoms among Gulf War (GW) veterans have been based on self-reported questionnaire data. The presence of these symptoms at the time of a clinical evaluation and the unexplained nature of the symptoms have not been described. We report the findings of a sample of symptomatic veterans that were examined as part of a population-based case-control study of GW unexplained illnesses. Participants in the case-control study were selected from responders to a cross-sectional survey of a random sample of GW veterans residing in the northwestern United States. The initial survey questionnaire solicited information on the presence of fatigue and psychological/cognitive, gastrointestinal, musculoskeletal, and dermatological problems. The persistence of the symptoms and possible explanatory diagnoses were explored at the time of the clinical evaluation. Findings from the first 225 participants who completed clinical examinations indicate significant differences between self-reported symptoms on the survey questionnaire and those confirmed at the time of clinical exam. The agreement between symptoms reported both on the survey and at the time of examination varies across the symptom groups. While self-reported unexplained fatigue was confirmed at the time of clinical encounter in 79% of participants, self-reported gastrointestinal symptoms were confirmed at the clinical encounter in only 20% of participants. Differences between symptoms reported on the survey questionnaire and those confirmed at the time of clinical encounter were attributable to finding a clinical diagnosis for the symptom, resolution of symptom(s) between time of questionnaire and clinical exam, and inadvertent endorsement of the symptom on the questionnaire. These findings suggest that due to the possibility of outcome misclassification, inappropriate conclusions may be drawn about the association between exposures and unexplained illnesses in GW veterans from data derived solely from self-administered questionnaires.     

Caring for medically unexplained physical symptoms after toxic environmental exposures: effects of contested causation

Medically unexplained physical symptoms (MUPS) are persistent idiopathic symptoms that drive patients to seek medical care. MUPS syndromes include chronic fatigue syndrome, fibromyalgia syndrome, and multiple chemical sensitivities. When MUPS occur after an environmental exposure or injury, an adversarial social context that we call "contested causation" may ensue. Contested causation may occur publicly and involve media controversy, scientific disagreement, political debate, and legal struggles. This adversarial social context may diminish the effectiveness of the provider-patient relationship. Contested causation also may occur privately, when disagreement over the causes of MUPS takes place in the patient-provider context. These patient-provider disagreements over causation often occur because of the enigmatic nature of MUPS. We suggest that a context of contested causation may have serious negative effects on healthcare for individuals with MUPS. Context plays a larger role in MUPS care than it does for most medical care because of the uncertain nature of MUPS, the reliance of standard MUPS therapies on a potentially tenuous patient-provider partnership, and the clinical need to rely routinely on subjective MUPS assessments that often yield discordant patient and provider conclusions. Contested causation may erode patient-provider trust, test the provider's self-assurance and capacity to share power with the patient, and raise problematic issues of compensation, reparation, and blame. These issues may distract patients and providers from therapeutic goals. In occupational and military settings, the adverse impact of contested causation on the patient-provider partnership may diminish therapeutic effectiveness to a greater degree than it does in other medical settings. Contested causation therefore raises questions regarding generalizability of standard therapies for MUPS and related syndromes to these settings. Future research is needed to learn whether intuitively sensible and evidence-based MUPS therapies benefit occupational and military medical patients who are afforded care in the context of contested causation.     

The SQUASH was a more valid tool than the OBiN for categorizing adults according to the Dutch physical activity and the combined guideline

Objective

To examine whether the “Short QUestionnaire to ASsess Health-enhancing physical activity” (SQUASH) and the “Injuries and Physical Activity in the Netherlands” questionnaire (“Ongevallen en Bewegen in Nederland,” OBiN) were valid in assessing adherence to physical activity (PA) guidelines.

Study Design and Setting

Participants (N = 187) aged 20-69 years were categorized as “inactive,” “semiactive,” or “norm-active” according to the Dutch PA, the American College of Sports Medicine (ACSM), and the combined guideline (adhering to either or both of two other guidelines) by the questionnaires and a combined heart rate monitor and accelerometer (Actiheart). Percentage of exact agreement and maximum disagreement (difference of two categories) for the categorization between questionnaires and Actiheart was calculated.

Results

The SQUASH had a significant higher agreement than the OBiN for the Dutch PA (SQUASH: 78%, OBiN: 46%; P < 0.01) and combined guideline (SQUASH: 84%, OBiN: 55%; P < 0.01). Both questionnaires had a low agreement regarding the ACSM guideline (SQUASH: 37%, OBiN: 34%; P = 0.45). The SQUASH had a significant higher maximum disagreement than the OBiN for this guideline (SQUASH: 19.8%, OBiN 8%; P < 0.01).

Conclusion

The SQUASH was a more valid measure than the OBiN for categorizing adults according to the Dutch PA and the combined guideline. Both questionnaires failed to correctly categorize adults according to the ACSM guideline.     

Antidepressant therapy for unexplained symptoms and symptom syndromes

OBJECTIVE: To determine the efficacy of antidepressant therapy for unexplained symptoms or symptom syndromes. SEARCH STRATEGIES: We identified original studies through searching MEDLINE, EMBASE, PsycLIT, the Federal Research in Progress database, and The Cochrane Library. We also searched the bibliographies of primary and review articles for additional studies. SELECTION CRITERIA: We excluded trials of patients with neuropathic, oncologic, or degenerative joint pain. Independent duplicate review of 392 articles identified 94 relevant reports of randomized trials involving 6595 patients across 6 symptom syndromes. Independent duplicate assessment was made for inclusion and data abstraction. Meta-analysis was performed on extractable placebo-controlled data. MAIN RESULTS: Of 94 included trials, most studied either tricyclic antidepressants, antiserotonin antidepressants, selective serotonin reuptake inhibitors (SSRIs), or multiple agents for the treatment of the following syndromes: headache (50), fibromyalgia (18), functional gastrointestinal syndromes (13), idiopathic pain (11), tinnitus (2), and chronic fatigue (2). The quality of the studies was fair (mean score = 4.8 on a scale of 0 to 8). A majority of the studies (69%) demonstrated benefit for at least one outcome measure. Symptom improvement typically did not correlate with depression response in the few studies where it was assessed. Meta-analysis of all extractable data showed a substantial benefit from antidepressants: For the dichotomous outcome of improvement, the odds ratio was 3.4 (95% confidence interval [CI], 2.6 - 4.5), and for continuous outcomes, the standardized mean difference was 0.87 (95% CI, 0.59-1.14). The absolute percentage difference in improvement between the antidepressant and placebo arms was 32%, yielding a number needed to treat of 3 to improve one person's symptoms. Meta-regression indicated no differential effect across the classes of antidepressants; however, onbivariate tally tricyclic studies were associated with a greater likelihood of efficacy than SSRI studies (P = .02). CONCLUSIONS: Antidepressants can be effective for various physical symptoms and symptom syndromes. The relation of outcome to depression and the efficacy of SSRIs needs further study.     

The Dutch College of General Practitioners' practice guideline 'Parkinson's disease' in summary

Parkinson's disease is characterised by bradykinesia in combination with one or more of the following symptoms: rigidity, resting tremor and disorders of posture and balance. Refer a patient with suspected Parkinson's disease (or parkinsonism) for diagnosis and treatment preferably to a neurologist with expertise in movement disorders. The treatment of Parkinson's disease is symptomatic; to date, there is no treatment that slows disease progression. The treatment of patients with Parkinson's disease and its related disorders involves collaboration of the neurologist, Parkinson's disease nurse and general practitioner. In addition to recognizing the hypokinetic-rigid syndrome, the general practitioner has a role in diagnosing and treating associated symptoms and disorders, and in supporting and counseling the patient and their partner or caregiver.     

The somatising effect of clinical consultation: what patients and doctors say and do not say when patients present medically unexplained physical symptoms

Patients with symptoms that doctors cannot explain by physical disease are common in primary care. That they receive disproportionate amounts of physical intervention, which is largely ineffective and sometimes iatrogenic, is usually attributed to patients' belief that they are physically diseased, their denial of psychological difficulties, and their demand for physical intervention. The evidence for this view has mainly been doctors' subjective reports. By observing what patients and doctors say in consultation, we tested hypotheses arising from recent qualitative evidence. In particular, that physical intervention is proposed more often by general practitioners (GPs) than by patients, that most patients indicate psychosocial needs, and that GPs offer little effective explanation or empathy. Consultations of 420 consecutive patients identified by British GPs as presenting medically unexplained symptoms (MUS) were audio-recorded, transcribed and coded, utterance-by-utterance, using a specially developed coding scheme based on the previous qualitative analyses of these kinds of consultation. Physical intervention was, as predicted, proposed more often by GPs than patients. Also as predicted, almost all patients provided cues concerning psychosocial difficulties or their need for explanation. Although, contrary to prediction, most GPs did provide explanations other than physical disease, most also suggested physical disease. Few GPs empathised. The findings suggest that the explanation for the high level of physical intervention for MUS lies in GPs' responses rather than patients' demands, and we propose that explanations for 'somatisation' should be sought in doctor-patient interaction rather than in patients' psychopathology.     

The impact of the international guideline entitled Statistical Principles for Clinical Trials (ICH E9)

At the time of writing, the ICH E9 Note for Guidance entitled "Statistical principles for clinical trials" has been in force in Europe, Japan and the U.S.A. for almost a year. The purpose of this paper is to review the initial progress of E9 in terms of its degree of acceptance and also in terms of any early problems which have emerged. A different means of exploring these questions has been adopted in each of the three regions. From Europe there is a regulatory perspective on statistical issues which have been found to be incompletely covered within E9 and which have been important for specific regulatory decisions. From the U.S. there is a report of the results of a survey of U.S. pharmaceutical industry opinion concerning the effect of E9 on statistical practice in drug development. From Japan there is a discussion of the shortage of qualified statisticians in Japan and the difficulties that this causes when trying to implement E9. Some overall conclusions are drawn.     

Patient activism and the struggle for diagnosis: Gulf War illnesses and other medically unexplained physical symptoms in the US

We examine Gulf War illnesses--which include the fatigue, joint pain, dermatitis, headaches, memory loss, blurred vision, diarrhea, and other symptoms reported by Gulf War veterans--in relation to other medically unexplained physical symptoms such as multiple chemical sensitivity, chronic fatigue syndrome, and fibromyalgia. Our intent is to examine the diagnosis negotiations involved in these mysterious diseases, by showing the different forms of legitimacy involved in such interactions. Factors involved in diagnostic legitimacy are: diagnostic legitimacy in the medical community, lay acceptance of the diagnosis, uncertainty in looking for causes, and social mobilization. We conclude by noting that research may not be able to find any cause for these diseases/conditions; hence, it may be necessary to embrace medical uncertainty, and also to accept patient experience in order to facilitate diagnosis, treatment, and recovery process. Such a change can alter patients' expectations and taken-for-granted assumptions about medicine, and perhaps in turn reduce the frequency with which dissatisfied individuals form illness groups that mobilize to challenge what they see as an unresponsive medical system.     

The effectiveness of a training for patients with unexplained physical symptoms: protocol of a cognitive behavioral group training and randomized controlled trial

Background  

In primary care, up to 74% of physical symptoms is classified as unexplained. These symptoms can cause high levels of distress and healthcare utilization. Cognitive behavioral therapy has shown to be effective, but does not seem to be attractive to patients. An exception herein is a therapy based on the consequences model, which distinguishes itself by its labeling of psychosocial distress in terms of consequences rather than as causes of physical symptoms. In secondary care, 81% of the patients accepts this therapy, but in primary care the outcome is poor. We assume that positive outcome can also be reached in primary care, when the consequences model is modified and used bottom-up in an easily accessible group training, in which patients are relieved of being blamed for their symptoms. Our aim is to investigate the (cost-)effectiveness of this training.