RESUMEN
The previous guideline 'Migraine' has been replaced by the guideline 'Headache', which includes tension headache, migraine, substance-induced headache and cluster headache. For evaluation of the diagnosis and treatment of these types of headache, regular follow-up of these patients is necessary, preferably on the basis of a headache diary. In an individual patient, migraine and tension headache can occur interchangeably, even in the course of one attack. Ergotamine is no longer recommended for the treatment of migraine attacks in new patients. The pharmacotherapy of migraine must be adjusted to the medication already used by the patient and the severity of the attacks. The recommended treatment for substance-induced headache is to withdraw the responsible medicines completely; explanation, motivation, and support are very important.
Asunto(s)
Cefalea/diagnóstico , Cefalea/terapia , Médicos de Familia/normas , Pautas de la Práctica en Medicina , Diagnóstico Diferencial , Cefalea/clasificación , Cefalea/etiología , Humanos , Países Bajos , Sociedades MédicasRESUMEN
The practice guideline on STD consultations from the Dutch College of General Practitioners sets out guidelines for the diagnosis and treatment of Chlamydia-infection, gonorrhoea, syphilis, trichomoniasis, genital herpes condylomata acuminata, hepatitis B, HIV-infection and pubic lice. Testing for Chlamydia-infection is always indicated if an STD is suspected but the necessity of also testing for gonorrhoea, syphilis, hepatitis B or HIV-infection depends on the likely risk. For the diagnosis of Chlamydia in a symptomatic woman it advises taking material from the cervix and urethra. In an asymptomatic woman Chlamydia infection is excluded by means of a urine test. In men a urethral swab of the first part of the urinary stream can be used for diagnosis. The first choice of treatment for gonorrhoea is a single 1 g intramuscular dose ofcefotaxime. The practice guidelines also examine other aspects of treatment for STDs including counselling and telling partners.
Asunto(s)
Médicos de Familia/normas , Pautas de la Práctica en Medicina , Enfermedades de Transmisión Sexual/diagnóstico , Enfermedades de Transmisión Sexual/terapia , Trazado de Contacto , Humanos , Países Bajos , Derivación y Consulta , Factores de Riesgo , Enfermedades de Transmisión Sexual/tratamiento farmacológico , Enfermedades de Transmisión Sexual/prevención & control , Sociedades MédicasRESUMEN
The 1997 practice guideline from the Dutch College of General Practitioners concerning lower urinary-tract symptoms (LUTS) in middle-aged and elderly men has been revised and some points have been adapted. The underlying cause of LUTS in middle-aged and elderly men is an improperly functioning voiding mechanism of the bladder associated with ageing. Symptoms are not simply due to prostate enlargement. In uncomplicated LUTS the patient's perception of the level of inconvenience is very important in considering and choosing therapeutic options. Percussion of the bladder after micturition is no longer universally advised. In general, invasive treatment is more effective in relieving symptoms than medical treatment, although invasive treatment causes more adverse effects. LUTS and prostate cancer are different entities, and LUTS is not a risk factor for prostate cancer. The issue of prostate cancer is discussed in this practice guideline in order to clear up popular misconceptions and to enhance the practical implementation of this guideline.
Asunto(s)
Envejecimiento/fisiología , Medicina Familiar y Comunitaria/normas , Pautas de la Práctica en Medicina/normas , Trastornos Urinarios/terapia , Anciano , Humanos , Masculino , Persona de Mediana Edad , Países Bajos , Próstata/fisiología , Neoplasias de la Próstata/epidemiología , Sociedades Médicas , Trastornos Urinarios/etiología , Trastornos Urinarios/cirugíaRESUMEN
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.
Asunto(s)
Ansiolíticos/uso terapéutico , Trastornos de Ansiedad/terapia , Medicina Familiar y Comunitaria/normas , Pautas de la Práctica en Medicina/normas , Trastornos de Ansiedad/diagnóstico , Trastornos de Ansiedad/tratamiento farmacológico , Terapia Cognitivo-Conductual , Consejo , Humanos , Países Bajos , Educación del Paciente como Asunto , Factores de Riesgo , Sociedades MédicasRESUMEN
In most cases acute cough has an infectious, often viral, cause. When the coughing lasts longer than 3 weeks, the diagnosis has to be reconsidered. The effectiveness of cough medicines has not been proven. For the management of acute cough it is important to distinguish between non-serious and serious lower respiratory tract infections. A serious lower respiratory tract infection is: a lower respiratory tract infection with a higher risk of a complicated course: when pneumonia is suspected, in infants and the elderly, and in patients with relevant co-morbidity. The prescription of antibiotics for acute cough is not useful in the majority of the patients; antimicrobial therapy can be indicated, but only in the case of lower respiratory tract infections with a higher risk of a complicated course. Specific management has to be considered in the case of: whooping cough, bronchiolitis and croup. In the case of pneumonia, antimicrobial therapy is indicated; follow-up is necessary. In the case of moderate to severe croup, a single dose of corticosteroids is recommended.
Asunto(s)
Tos/diagnóstico , Medicina Familiar y Comunitaria , Infecciones del Sistema Respiratorio/diagnóstico , Enfermedad Aguda , Corticoesteroides/uso terapéutico , Antibacterianos/uso terapéutico , Infecciones Bacterianas/diagnóstico , Infecciones Bacterianas/terapia , Tos/terapia , Diagnóstico Diferencial , Humanos , Infecciones del Sistema Respiratorio/terapia , Factores de Riesgo , Virosis/diagnóstico , Virosis/terapiaRESUMEN
The Dutch College of General Practitioners' practice guideline concerning anaemia advises the general practitioner to carry out additional laboratory tests in patients with a decreased haemoglobin level (Hb) in order to establish the cause of the anaemia. In specified cases (premenopausal women with excessive vaginal bleeding and in some children with mild anaemia) these tests may initially be omitted. In these cases iron can be prescribed and, if a child has had an infectious disease within the previous month, to wait one month to see if levels return to normal. In older patients with iron-deficiency anaemia subsequent investigations should be performed in order to rule out gastro-intestinal neoplasm, even if the history and physical examination give no indication of this. In an anaemic patient at risk of thalassaemia trait, haemoglobin electrophoresis or chromatography should be performed if there is microcytosis and a serum ferritine level > 15 micrograms/l.
Asunto(s)
Anemia/diagnóstico , Médicos de Familia , Adulto , Factores de Edad , Anciano , Anemia/etiología , Anemia/terapia , Niño , Diagnóstico Diferencial , Femenino , Hemoglobinas/análisis , Humanos , Masculino , Países BajosRESUMEN
The routine examination of the neonate by the general practitioner directly after birth provides a first impression of the state and vitality of the newborn, gives base values that may be relevant for later occurring illnesses or problems, and is a first orientation on the presence of congenital malformations. Inspection of the newborn is the most important. Four possible malformations receive special attention: congenital malformations of the heart and eye, developmental hip dysplasia, and undescended testes. If the first examination was properly performed, a second routine examination by the general practitioner during the maternity visit has no proven added value. A specific physical examination should take place if indicated. It is recommended that all involved parties (health centre physicians, obstetricians, general practitioners, paediatricians and midwives) reach agreement as to the content and reporting of the first examination.
Asunto(s)
Tamizaje Neonatal/normas , Examen Físico , Médicos de Familia/normas , Humanos , Recién Nacido , Países BajosRESUMEN
The researchers wanted to obtain insight into the cooperation between physicians and nurses with regard to active euthanasia and physician-assisted suicide (EAS). In study I a stratified random sample of 203 clinical specialists, 152 general practitioners (GPs) and 50 nursing home physicians (NHPs) participated. In study II a random sample of 521 GPs was drawn from the province of North Holland and a random sample of 521 GPs was drawn from the rest of the Netherlands. For study III all NHPs were approached. Data were collected by means of an interview in study I. In studies II and III an anonymous, postal questionnaire was used. Approximately half of the GPs did not consult with nurses about a patient's request for EAS, the intention to administer EAS, and the actual administration. In 5% of cases, the NHPs and the specialists did not consult with nurses concerning these aspects. The GPs and NHPs indicated in 4% and 3% of the cases, respectively, that nurses administered the lethal drug(s) to the patients; the corresponding figure for the specialists was 21%. Almost all GPs and NHPs and about three-quarters of the specialists thought that nurses should never be allowed to administer EAS.
Asunto(s)
Eutanasia/estadística & datos numéricos , Perfil Laboral , Atención de Enfermería/métodos , Relaciones Médico-Enfermero , Suicidio Asistido/estadística & datos numéricos , Conducta Cooperativa , Medicina Familiar y Comunitaria , Humanos , Medicina , Países Bajos , Casas de Salud , Estudios Retrospectivos , Especialización , Encuestas y CuestionariosRESUMEN
BACKGROUND: Decisions to withhold or withdraw treatment (nontreatment decisions) become increasingly important because they have to be made more frequently and more explicitly. This nationwide study provides information on the occurrence and background of these nontreatment decisions. METHODS: Three studies were undertaken: interviews with 405 physicians, 5197 answered questionnaires concerning deceased persons, and information about 2257 deaths collected by a prospective study. RESULTS: Of all deaths, 30% appeared to be sudden and unexpected. In 39% of all nonsudden deaths, a nontreatment decision was made. This percentage varied by specialty (28% to 55%). Nontreatment decisions were made more often in older female patients. The decisions were made at the explicit request of the patient (19%), after discussion with the patient or after a previous wish (22%), or without any involvement of the patient (59%). Of this last group, 87% of patients were not competent at the time of the decision. In 24% of cases of nontreatment, life was shortened by at least a week. Of all physicians interviewed, 56% had changed their attitude since the beginning of their practice, most of them toward more nontreatment decisions at the end of life. CONCLUSIONS: Nontreatment decisions are made frequently in medical practice. Most often the physician has to weigh medical and nonmedical burdens and benefits. For this to be done properly, the patient should be involved whenever possible. Other requirements are optimal palliative treatment, better prognostic knowledge, consultation of other specialists, and the absence of defensive motives.
Asunto(s)
Toma de Decisiones , Derecho a Morir , Terapéutica , Privación de Tratamiento , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Certificado de Defunción , Investigación Empírica , Femenino , Servicios de Atención de Salud a Domicilio , Humanos , Intención , Masculino , Persona de Mediana Edad , Países Bajos , Paternalismo , Estudios Prospectivos , Negativa al Tratamiento , Encuestas y Cuestionarios , Negativa del Paciente al TratamientoRESUMEN
OBJECTIVE: To gain insight into decisions made in general practice about the end of life. DESIGN: Study I: interviews with 405 physicians. Study II: analysis of death certificates with data obtained on 5197 cases in which decisions about the end of life may have been made. Study III: prospective study with doctors from study I: questionnaires used to collect information about 2257 deaths. The information was representative for all deaths in the Netherlands. RESULTS: Over two fifths of all patients in the Netherlands die at home. General practitioners took fewer decisions about the end of life than hospital doctors and doctors in nursing homes (34%, 40%, and 56% of all dying patients, respectively). Specifically, decisions to withhold or withdraw treatment to prolong life were taken less often. Euthanasia or assisted suicide, however, was performed in 3.2% of all deaths in general practice compared with 1.4% in hospital practice. In over half of the cases concerning pain relief or non-treatment general practitioners did not discuss the decision with the patient, mostly because of incapacity of the patient, but in 20% of cases for "paternalistic" reasons. Older general practitioners discussed such decisions less often with their patients. Colleagues were consulted more often if the general practitioner worked in group practice. CONCLUSION: Differences in work situation between general practitioners and hospital doctors and differences between the group of general practitioners contribute to differences in the number and type of decisions about the end of life as well as in the decision making process.
Asunto(s)
Eutanasia Activa , Medicina Familiar y Comunitaria/estadística & datos numéricos , Servicios de Atención de Salud a Domicilio , Hospitalización/estadística & datos numéricos , Negativa al Tratamiento/estadística & datos numéricos , Cuidado Terminal/estadística & datos numéricos , Anciano , Causas de Muerte , Certificado de Defunción , Toma de Decisiones , Eutanasia Activa Voluntaria , Eutanasia Pasiva , Femenino , Humanos , Lactante , Recién Nacido , Intención , Masculino , Persona de Mediana Edad , Países Bajos , Paternalismo , Estudios Prospectivos , Confianza , Privación de TratamientoRESUMEN
The use of do not resuscitate (DNR) orders in Dutch hospitals was studied as part of a nationwide study on medical decisions concerning the end of life. DNR decisions are made in 6 per cent of all admissions, and 61 per cent of all in-hospital deaths were preceded by a DNR decision. We found that in only 14 per cent of the cases had the patients been involved in the DNR decision (32 per cent of competent patients). The concept of futility is analysed as these findings are discussed. We conclude that determining the effectiveness of resuscitation is a medical judgement whereas determining the proportionality (burden/benefit ratio) of it requires a discussion between doctor and patient (or his or her surrogates). Since the respondents in the cases without patient involvement gave many reasons for their decision that went beyond determining effectiveness, we conclude that more patient involvement would have been desirable.
Asunto(s)
Hospitales/estadística & datos numéricos , Órdenes de Resucitación , Certificado de Defunción , Familia , Hospitales/normas , Internacionalidad , Medicina/estadística & datos numéricos , Competencia Mental , Países Bajos , Paternalismo , Participación del Paciente , Estudios Prospectivos , Medición de Riesgo , Valores Sociales , Especialización , Encuestas y CuestionariosAsunto(s)
Actitud del Personal de Salud , Toma de Decisiones , Eutanasia Activa Voluntaria , Eutanasia Activa , Eutanasia/legislación & jurisprudencia , Médicos/psicología , Cuidado Terminal/legislación & jurisprudencia , Comités Consultivos , Eutanasia/tendencias , Predicción , Regulación Gubernamental , Humanos , Países Bajos , Médicos/legislación & jurisprudencia , Estudios Prospectivos , Estrés Psicológico , Encuestas y Cuestionarios , Cuidado Terminal/tendencias , Argumento RefutableAsunto(s)
Eutanasia Activa , Eutanasia , Participación del Paciente , Toma de Decisiones , Humanos , Países Bajos , Estrés PsicológicoRESUMEN
In the Dutch nationwide study on medical decisions concerning the end of life (MDEL) life-terminating acts without the explicit request of the patient (LAWER) were noted in 0.8% of all deaths. We present here quantitative information and a discussion of the main issues raised by LAWER. In 59% of LAWER the physician had some information about the patient's wish; in 41% discussion on the decision would no longer have been possible. In LAWER patients tend to be younger and more likely to be male and to have cancer than in non-acute deaths generally. The physician (specialist or general practitioner) knew the patient on average 2.4 years and 7.2 years, respectively. Life was shortened by between some hours and a week at most in 86%. In 83% the decision has been discussed with relatives and in 70% with a colleague. In nearly all cases, according to the physician, the patient was suffering unbearably, there was no chance of improvement, and palliative possibilities were exhausted. MDEL probably will increase in number in future but interviews with Dutch physicians suggest a possible fall in LAWER, even though there will always be some situations in which a well-considered LAWER decision may have to be made.
Asunto(s)
Toma de Decisiones , Eutanasia Activa , Eutanasia/estadística & datos numéricos , Participación del Paciente , Pautas de la Práctica en Medicina/estadística & datos numéricos , Adolescente , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Certificado de Defunción , Femenino , Humanos , Lactante , Medicina/clasificación , Medicina/estadística & datos numéricos , Competencia Mental , Persona de Mediana Edad , Países Bajos , Dolor Intratable/prevención & control , Participación del Paciente/estadística & datos numéricos , Relaciones Médico-Paciente , Estudios Prospectivos , Factores Sexuales , Especialización , Estrés Psicológico , Encuestas y Cuestionarios , Factores de TiempoAsunto(s)
Toma de Decisiones , Eutanasia/estadística & datos numéricos , Médicos/estadística & datos numéricos , Suicidio Asistido/estadística & datos numéricos , Cuidado Terminal/estadística & datos numéricos , Adulto , Anciano , Actitud del Personal de Salud , Preescolar , Recolección de Datos , Certificado de Defunción , Femenino , Humanos , Recién Nacido , Masculino , Persona de Mediana Edad , Morfina/administración & dosificación , Países Bajos/epidemiología , Cuidados Paliativos/estadística & datos numéricos , Participación del Paciente/estadística & datos numéricos , Estudios Prospectivos , Negativa al Tratamiento/estadística & datos numéricos , Estudios Retrospectivos , Negativa del Paciente al TratamientoRESUMEN
This article presents the first results of the Dutch nationwide study on euthanasia and other medical decisions concerning the end of life (MDEL). The study was done at the request of the Dutch government in preparation for a discussion about legislation on euthanasia. Three studies were undertaken: detailed interviews with 405 physicians, the mailing of questionnaires to the physicians of a sample of 7000 deceased persons, and the collecting of information about 2250 deaths by a prospective survey among the respondents to the interviews. The alleviation of pain and symptoms with such high dosages of opioids that the patient's life might be shortened was the most important MDEL in 17.5% of all deaths. In another 17.5% a non-treatment decision was the most important MDEL. Euthanasia by administering lethal drugs at the patient's request seems to have been done in 1.8% of all deaths. Since MDEL were taken in 38% of all deaths (and in 54% of all non-acute deaths) we conclude that these decisions are common medical practice and should get more attention in research, teaching, and public debate.