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 guideline 'Osteoporosis' of the Dutch College of General Practitioners. Dutch College of General Practitioners]

The Dutch College of General Practitioners issued a standard 'Osteoporosis' with guidelines for prevention, diagnosis and treatment in patients who have a (probably) osteoporotic fracture, who are taking at least 7.5 mg corticosteroids per day for at least six months or who have questions about osteoporosis. The core of the management is information about lifestyle (stimulation of physical activity) and nutrition. Prevention of falling is to be stimulated; sedatives, excessive drinking and smoking are to be discouraged. Persons who cannot achieve a calcium intake of 500 mg/day, patients with osteoporotic fractures and takers of biphosphonates or corticosteroids whose calcium intake is insufficient are eligible for calcium suppletion. In patients with (probably) osteoporotic fractures and those taking 7.5 mg corticosteroids per day for longer than six months preventive treatment may be considered with alendronic acid for a maximum of 3 years, if several vertebral fractures are visible roentgenologically, the T score is < -2.5 (if age < 70 years) or the Z score < -1.0 (> 70 years).     

The 'Osteoporosis' guideline of the Dutch College of General Practitioners; response from family practice]

The guideline gives a well considered view of the management of osteoporosis. According to the characteristics of general practice the guideline emphasises good information to patients about lifestyle and nutrition. There is a strong advice against screening for osteoporosis. Case-finding of high risk patients in general practice meets a reticent attitude. The guideline indicates precisely the conditions to consider interventions by drugs. The decision to start drug therapy can only be made after adequate information in consultation with the patient. The management of osteoporosis needs much more reserve than most physicians and patients (want to) know.     

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 'CVA' from the Dutch College of General Practitioners

The practice guideline 'CVA' from the Dutch College of General Practitioners provides guidelines for the management of stroke patients. The guideline is in agreement with the changing insights about the benefits of stroke-units and thrombolysis. The most important recommendations are the following. In the acute phase, most patients with a cerebrovascular accident should be referred for admission to a stroke-unit. Exceptions are patients with only slight neurological disability and patients with severe comorbidity. Patients with a CVA that started less than three hours ago should be referred for emergency thrombolytic therapy in regions where this possibility exists. In situations in which the general practitioner considers a home visit to involve an unacceptable loss of time, he may decide to refer on the basis of the results of the 'face-arm-speech-time' (FAST) test, which can be administered by telephone. For patients that remain at home, the general practitioner sees to the early start of a rehabilitation programme, and takes the initiative if necessary. The general practitioner can support stroke patients with permanent neurological deficits by considering them to be chronically ill patients requiring regular check-ups.     

Summary of the practice guideline 'Headache' from the Dutch College of General Practitioners

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.     

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.     

Summary of the practice guideline 'atrial fibrillation' from the Dutch College of General Practitioners

The practice guideline 'Atrial fibrillation' from the Dutch College of General Practitioners provides the general practitioner with guidelines for the diagnosis and management of patients with atrial fibrillation. Atrial fibrillation can be detected by observation of the cardiac rhythm during every measurement of the blood pressure. The diagnosis 'atrial fibrillation' must be made on the basis of an ECG. Atrial fibrillation must not be looked upon as an isolated phenomenon: possible comorbidity (cerebral infarction ('transient ischaemic attack'; TIA), hypertension, diabetes mellitus, heart failure, coronary heart disease, hyperthyroidism) should be taken into consideration in the evaluation. Particular attention should be given to determining whether heart failure is also present. An important goal of treatment is the prevention of thromboembolic complications. Cardioversion is not generally recommended. The symptoms may be an indication that an attempt should be made to restore sinus rhythm. This constitutes one of the indications for referral for specialised treatment.     

Summary of the practice guideline 'Refraction errors' from the Dutch College of General Practitioners

The practice guideline 'Refraction errors' from the Dutch College of General Practitioners describes the examinations that need to be carried out in patients complaining about a gradual loss of vision. A measurement of vision by means of a Snellen chart is insufficient to determine if the condition is caused by a refraction error or if other pathology of the eye such as cataract, glaucoma or retinopathy is involved. It is therefore recommended that the vision should also be measured with a simple device containing spherical lenses of +0.5 and -0.5 dioptre, so-called diagnostic refraction. Improvement of vision with the negative lens indicates myopia. Improvement or at least a stable vision with the positive lens makes hyperopia very likely. Diagnostic refraction, which can be used in patients of six years and older, enables the general practitioner to distinguish between patients needing glasses or contact lenses, and patients requiring referral to an ophthalmologist.     

Summary of the practice guideline 'Smoking cessation' from the Dutch College of General Practitioners

In general practice important health gain is obtainable by encouraging patients to stop smoking with support from the general practitioner. The practice guideline 'Smoking cessation' differentiates between smokers who are motivated to stop smoking, smokers who are considering smoking cessation, and smokers who are unmotivated to stop smoking. It is important to offer smokers, who are motivated to stop, intensive support at the right moment. Medicinal support in the way of nicotine replacement therapy, nortriptyline or bupropion is, ifpossible, recommended in motivated smokers who smoke at least 10 cigarettes daily.     

The 'Osteoporosis' guideline of the Dutch College of General Practitioners compared with the report by the Health Council]

Within one year the report 'Prevention of fractures related to osteoporosis' from the Dutch Health Council and the standard 'Osteoporosis' from the Dutch College of General Practitioners were published. At first sight the documents appear to diverge in several respects. The main discrepancy is that the standard shows far less optimism about the effects of drug therapy, by consequence of which only some well defined high risk groups should be treated. The standard therefore applies stricter criteria for case finding than the Health Council considers necessary. Although both documents base their opinions on similar studies and publications, they lead to different conclusions. Given the high prevalence of osteoporosis in the elderly part of the Dutch population, case finding seems to be a rather ineffective strategy for people at risk. Apparently, the Health Council at heart does not expect much benefit from drug interventions either. This forms an important indication that the remaining disagreements will be settled in the near future.     

Summary of the practice guideline 'The STD consultation' from the Dutch College of General Practitioners

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.     

Summary of the practice guideline 'The Prevention Visit' from the Dutch College of General Practitioners

The aim of the practice guideline 'The Prevention Visit' is the prevention of cardiovascular diseases, type 2 diabetes and chronic kidney injury in adults not previously diagnosed with hypertension, hypercholesterolaemia, or the above-mentioned cardiometabolic disorders. This is done by actively offering risk assessment combined with relevant treatment and advice (if indicated), integrated into primary health care. A self-report questionnaire is used to identify persons at high risk of developing cardiometabolic disease. Individuals with a risk score above the established threshold are advised to visit their general practitioner for measurement of height, weight, waist circumference, blood pressure, fasting glucose, cholesterol, and HDL cholesterol. At a subsequent practice visit, a risk assessment is performed according to the Dutch College of General Practitioners' practice guideline 'Cardiovascular Risk Management', at which time the patient's lifestyle is evaluated. If indicated, the general practitioner will initiate support and treatment according to relevant practice guidelines established by the Dutch College of General Practitioners.     

Summary of the practice guideline 'Pregnancy and puerperium' from the Dutch College of General Practitioners

During the first trimester of pregnancy, obstetric care concentrates particularly on assessment of gestational age (by history taking or if menstrual history is unclear, ultrasonography) and on the assessment of obstetric or medical risk factors necessitating a referral for specialist care. Tracing hereditary conditions in relatives is important as this is a reason for antenatal screening for congenital abnormalities. In comparison to the previous guideline, blood testing in the first trimester has been extended to include screening for irregular erythrocyte antibodies and the possibility of screening for HIV. Pregnant women with a history of thyroid problems may also be tested for serum concentrations of thyroid stimulating hormone (TSH), free T4 and, on indication, the TSH-receptor antibody levels. Since haemodilution is physiologically normal during the second half of pregnancy, at a gestational age of 18 weeks and above, only a haemoglobin-level of 6.5 mmol/l or less justifies the diagnosis of anaemia, and should treatment be commenced. If a newborn does not show any abnormalities immediately after delivery, the physical examination now routinely carried out at a few days post-partum rarely produces any additional findings and can safely be omitted.