Longer Duration Of Complaints Research Articles

Surgical outcomes of trigonal intraventricular meningiomas: a single-centre study.

Trigonal meningiomas are rare intraventricular tumours that present a surgical challenge. There is no consensus on the optimal surgical approach to these lesions, though the transtemporal and transparietal approaches are most frequently employed. We aimed to examine the approach-related morbidity and surgical nuances in treating trigonal meningiomas. This retrospective review assimilated data from 64 trigonal meningiomas operated over 15 years. Details of clinicoradiological presentation, surgical approach and intraoperative impression, pathology and incidence of various postoperative deficits were recorded. In our study, Trigonal meningiomas most frequently presented with headache and visual deterioration. The median volume of tumours was 63.6cc. Thirty-one meningiomas each (48.4%) were WHO Grade 1 and WHO Grade 2, while 2 were WHO Grade 3. The most frequent approach employed was transtemporal (38 patients, 59.4%), followed by transparietal (22 patients, 34.4%). After surgery features of raised ICP and altered mental status resolved in all patients, while contralateral limb weakness resolved in 80%, aphasia in 60%, seizures in 70%, and vision loss in 46.2%. Eighteen patients (28.13%) developed transient postoperative neurological deficits, with one patient (1.5%) developing permanent morbidity. Surgery for IVMs results in rapid improvement of neurological status, though visual outcomes are poorer in patients with low vision prior to surgery, longer duration of complaints and optic atrophy. The new postoperative deficits in some patients tend to improve on follow up. Transtemporal and transparietal approaches may be employed, based on multiple factors like tumour extension, loculation of temporal horn, size of lesion with no significant difference in their safety profile.

Factors Affecting Prognosis in the Course of Pediatric Celiac Disease.

Introduction Celiac disease (CD) is a rather frequent chronic autoimmune disease that causes impaired growth in children. The present study aims to evaluate patients' condition after diagnosis cross-sectionally and determine the factors affecting prognosis. Methods Control visits were performed at the end of the 13-month intervention period. The study was designed as a single-center retrospective study and included patients diagnosed with CD. The study cohort consisted of 211 patients aged 1 to 18 years. Statistical parameters include Helicobacter positivity, Marsh classification; economic status; and body mass index (BMI) z-score, weight z-score, and height z-score to observe the difference between admission and follow-up. Results Treatment adherence is one of the most critical factors influencing improvement in developmental parameters during control visits (p<0.033). It was observed that the weight z-scores at the control visit deteriorated significantly with a longer duration of complaints (p=0.033). Better improvement of control visit BMI z-scores among patients with complaints compared to asymptomatic patients (p=0.036) indicate the importance of early diagnosis in asymptomatic cases. Developmental parameters of patients with CD without growth retardation (GR) show faster improvement compared to patients with GR (p<0.001). Families with good socioeconomic status can easily adapt to the diet by reaching a greater variety of gluten-free products, so anthropometric measurements are observed to be significantly higher at the control visit (p<0.002). Conclusions Treatment adherence is the most critical factor for improvement in CD treatment, as in all treatments. In addition, the investigation of suspected, additional disease symptoms during the follow-up of a CD patient is also of great importance for early diagnosis. The importance of early diagnosis has been emphasized in terms of anthropometric improvement in asymptomatic CD cases.

Diverticular Disease of the Vermiform Appendix - Is it a Distinctive Clinico- Pathological Entity?

Background: Diverticular disease of the appendix [DDOA] is a rare occurrence. Although acquired in nature, its impact on the disease process of appendicitis is not well-defined. The purpose of the current study is to include a comprehensive clinico-pathological definition of the disease through a retrospective single-center cohort analysis with a prospective pathological re-evaluation. Methods: A retrospective analysis of post-appendectomy patients over a period of 16 years [2000-2015] was carried out. Patients with DDOA were identified and compared to a control group of patients with acute appendicitis. Histology was re-evaluated prospectively by a senior pathologist. Primary measures of the outcome included clinical and surgical differences. Pathological macroscopic differences between the two groups and a comprehensive description of the DDOA itself were performed. Results: 6846 post appendectomy patients were operated on during the study period, and 127 [1.9%] were diagnosed with DDOA. The DDOA group showed significantly higher age, longer duration of complaints, and a different clinical presentation. Operative time was significantly longer in the study group and had higher rates of severe postoperative complications such as postoperative bleeding, need for ICU recovery, and need for postoperative mechanical ventilation. All diverticula were pseudo-diverticula and were significantly shorter and wider. Multivariate analysis showed that age, length, and width of the appendix were independently associated with DDOA. Conclusions: The results of this study suggest that DDOA is an independent clinical entity, showing differences in etiology, clinical presentation, and postoperative outcome. Prospective studies are needed to assess whether the preoperative diagnosis is feasible and will change conventional surgical management.

Prognostic Factors in Open Triangular Fibrocartilage Complex (TFCC) Repair

PurposePatients with triangular fibrocartilage complex (TFCC) injury report ulnar-sided wrist pain and impaired function. Open TFCC repair aims to improve the condition of these patients. Patients have shown reduction in pain and improvement in function at 12 months after surgery; however, results are highly variable. The purpose of this study was to relate patient (eg, age and sex), disease (eg, trauma history and arthroscopic findings), and surgery factors (type of bone anchor) associated with pain and functional outcomes at 12 months after surgery.MethodsThis study included patients who underwent an open TFCC repair between December 2011 and December 2018 in various Xpert Clinics in the Netherlands. All patients were asked to complete Patient-Rated Wrist Evaluation (PRWE) questionnaires at baseline as well as at 12 months after surgery. Patient, disease, and surgery factors were extracted from digital patient records. All factors were analyzed by performing a multivariable hierarchical linear regression.ResultsWe included 274 patients who had received open TFCC repair and completed PRWE questionnaires. Every extra month of symptoms before surgery was correlated with an increase of 0.14 points on the PRWE total score at 12 months after surgery. In addition, an increase of 0.28 points in the PRWE total score at 12 months was seen per extra point of PRWE total score at baseline.ConclusionsIncreased preoperative pain, less preoperative function, and a longer duration of complaints are factors that were associated with more pain and less function at 12 months after open surgery for TFCC. This study arms surgeons with data to predict outcomes for patients undergoing open TFCC repair.Type of study/level of evidencePrognostic II.

Evaluation of Bone and Joint Involvement in Patients Followed with the Diagnosis of Brucellosis

Aim: Brucellosis is an important problem all over the world. The most common form is bone-joint involvement. In this study, we planned to reveal our experiences by examining the epidemiological, clinical, laboratory and radiological features of brucellosis cases with and without bone-joint involvement. Material and Methods: This retrospective clinical study includes the data of 443 patients who were followed up with the diagnosis of brucellosis between December 2014 and August 2019. The epidemiological, clinical, laboratory and radiological findings of the patients were obtained from the patient files and hospital database. Patients were divided into two groups as with and without bone-joint involvement and their data were compared statistically. Results: A total of 443 patients who were followed up with a diagnosis of brucellosis were included in the study. 92 (20.8%) of these patients had bone-joint involvement of brucellosis (sacroileitis, spondylodiscitis, arthritis, bursitis, synovitis). Magnetic resonance imaging method was used for diagnosis in patients with bone-joint involvement. Patients with bone-joint involvement had longer duration of complaints, and acute phase reactants and agglutination titers were higher. Conclusion: Bone-joint involvement in brucellosis is very important as it may cause inadequate treatment and may end with sequelae. Radiological imaging is important in the diagnosis of bone-joint involvement, but unnecessary requests should also be avoided. Symptom duration, acute phase reactants, agglutination titer may be guiding for this.

Comparison of Ocular Complaints and Visual Acuity Among Dry-Yam Grinders and Nongrinders in Two Selected Markets in Ibadan

Background: Dry-yam grinding like any other grinding process is usually associated with a lot of dust released into the atmosphere. Aims: This study examined and compared the eye complaints of dry-yam grinders and nongrinders, and evaluates the differences in their visual acuity (VA) test scores. This was with a view of determining influence of yam powder on the eye health of the grinders. Settings and Design: The study was conducted among grinders and nongrinders in two major markets in Ibadan. The study design was ex post facto. Materials and Methods: Participants were recruited using purposive sampling technique. Data were collected using interviewer-administered questionnaire and Snellen chart. Statistical Analysis Used: Frequency, mean, independent sample t-test, and Pearson’s moment correlation were use for statistical analyses. Results: Among 252 grinders and nongrinders who participated in the study, eye complaints such as foreign body in the eye (59.5% vs 29.0%) and headache (57.9% vs 37.3%) were more prevalent among grinders compared to nongrinders. More grinders had severe eye complaints (12.7% vs 3.2%). Mean eye complaints among the grinders were 6.92 ± 4.83 compared to 3.76 ± 4.37 among nongrinders. Dry-yam grinders exposed to yam powder had significantly more eye complaints and longer duration of complaints (P = 0.01). There was a weak positive linear correlation (0.167) between the duration of exposure to yam powder and severity of eye complaints. Grinders were observed to have a significantly lower VA on both the eyes (P = 0.01). Conclusion: Dry-yam grinders have more eye complaints than nongrinders. Grinders are encouraged to conform to safety dictates, such as using appropriate personal protective equipment and go for prompt eye assessment so that possible eye morbidity can be diagnosed and treated.

Clinical Prediction Models for Patients With Nontraumatic Knee Pain in Primary Care: A Systematic Review and Internal Validation Study.

Study Design Systematic review and validation study. Background Many prognostic models of knee pain outcomes have been developed for use in primary care. Variability among published studies with regard to patient population, outcome measures, and relevant prognostic factors hampers the generalizability and implementation of these models. Objectives To summarize existing prognostic models in patients with knee pain in a primary care setting and to develop and internally validate new summary prognostic models. Methods After a sensitive search strategy, 2 reviewers independently selected prognostic models for patients with nontraumatic knee pain and assessed the methodological quality of the included studies. All predictors of the included studies were evaluated, summarized, and classified. The predictors assessed in multiple studies of sufficient quality are presented in this review. Using data from the Musculoskeletal System Study (BAS) cohort of patients with a new episode of knee pain, recruited consecutively by Dutch general medical practitioners (n = 372), we used predictors with a strong level of evidence to develop new prognostic models for each outcome measure and internally validated these models. Results Sixteen studies were eligible for inclusion. We considered 11 studies to be of sufficient quality. None of these studies validated their models. Five predictors with strong evidence were related to function and 6 to recovery, and were used to compose 2 prognostic models for patients with knee pain at 1 year. Running these new models in another data set showed explained variances (R2) of 0.36 (function) and 0.33 (recovery). The area under the curve of the recovery model was 0.79. After internal validation, the adjusted R2 values of the models were 0.30 (function) and 0.20 (recovery), and the area under the curve was 0.73. Conclusion We developed 2 valid prognostic models for function and recovery for patients with nontraumatic knee pain, based on predictors with strong evidence. A longer duration of complaints predicted poorer function but did not adequately predict chance of recovery. Level of Evidence Prognosis, levels 1a and 1b. J Orthop Sports Phys Ther 2017;47(8):518-529. Epub 16 Jun 2017. doi:10.2519/jospt.2017.7142.

Treatment response and central pain processing in Anterior Cutaneous Nerve Entrapment Syndrome: An explorative study

Background10–30% of chronic abdominal pain originates in the abdominal wall. A common cause for chronic abdominal wall pain is the Anterior Cutaneous Nerve Entrapment Syndrome (ACNES), in which an intercostal nerve branch is entrapped in the abdominal rectus sheath. Treatment consists of local anaesthetics and neurectomy, and is ineffective in 25% of cases for yet unknown reasons.In some conditions, chronic pain is the result of altered pain processing. This so-called sensitization can manifest as segmental or even generalized hyperalgesia, and is generally difficult to treat. ObjectiveThe aim of this study was to assess pain processing in ACNES patients responsive and refractory to treatment by using Quantitative Sensory Testing, in order to explore whether signs of altered central pain processing are present in ACNES and are a possible explanation for poor treatment outcomes. Methods50 patients treated for ACNES with locally orientated treatment were included. They were allocated to a responsive or refractory group based on their response to treatment. Patients showing an improvement of the Visual Analogue Scale (VAS) pain score combined with a current absolute VAS of <40mm were scored as responsive.Sensation and pain thresholds to pressure and electric skin stimulation were determined in the paravertebral bilateral ACNES dermatomes and at four control areas on the non-dominant side of the body, i.e. the musculus trapezius pars medialis, musculus rectus femoris, musculus abductor hallucis and the thenar. The ACNES dermatomes were chosen to signal segmental hyperalgesia and the sum of the control areas together as a reflection of generalized hyperalgesia. Lower thresholds were interpreted as signs of sensitized pain processing. To test for alterations in endogenous pain inhibition, a conditioned pain modulation (CPM) response to a cold pressor task was determined. Also, patients filled in three pain-related questionnaires, to evaluate possible influence of psychological characteristics on the experienced pain. ResultsPatients refractory to treatment showed significantly lower pressure pain thresholds in the ACNES dermatomes and for the sum of as well as in two individual control areas. No differences were found between groups for electric thresholds or CPM response. Duration of complaints before diagnosis and treatment was significantly longer in the refractory compared to the responsive group, and refractory patients scored higher on the pain-related psychological surveys. Conclusion and ImplicationsIn this hypothesis-generating exploratory study, ACNES patients refractory to treatment showed more signs of sensitized segmental and central pain processing. A longer duration of complaints before diagnosis and treatment may be related to these alterations in pain processing, and both findings could be associated with less effective locally orientated treatment. In order to validate these hypotheses further research is needed. Registration numberNCT01920880 (Clinical Trials Register; http://www.clinicaltrials.gov).

A Multivariable Prediction Model for the Chronification of Non-traumatic Shoulder Pain: A Systematic Review

Shoulder pain is the third most common musculoskeletal complaint and many patients have an unfavorable outcome with long-term disability. Only 50% of all new episodes of shoulder pain show complete recovery within 6 months. Little is known about factors that contribute to chronicity of shoulder pain, although such information is needed for the management of patients with acute and sub-acute shoulder pain. To systematically review the literature for prognostic factors which are potential predictors for either recovery or chronification in patients with acute and sub-acute non-traumatic shoulder pain. Systematic review. This systematic review examined all studies involving the prognosis of shoulder pain patients. This systematic review was reported following the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Two reviewers independently scored the methodological quality of the selected studies. Due to heterogeneity of studies, a best-evidence synthesis of the available prognostic factors was provided. Nine studies met our inclusion criteria and were included in this systematic review. There is strong evidence that high scores on the Shoulder Pain and Disability Index (SPADI), high scores on shoulder pain severity, and a long duration of complaints are factors that contribute to the chronification of shoulder pain. Moderate evidence was found supportive for other prognostic factors that enhance chronification, like being male, being over 55 years of age, having poor general health, having a gradual onset of complaints, a large amount of sick leave, the perception of high job demand, the perception of low social support, and the amount of visits to a health care professional. Also moderate evidence exists regarding factors that contributed to a reduced possibility of chronification: an active treatment policy and not taking medication on regular basis. The large variability in definitions of shoulder pain, and patient selection bias. In addition, there is a paucity of strong longitudinal prospective studies. This systematic review found evidence that high scores on the SPADI questionnaire, more shoulder pain, and a longer duration of complaints are associated with chronification of shoulder pain. In order to reduce chronification, clinicians can use the International Classification of Functioning based model presented here that could aid their decision-making.

Final diagnosis of children and adolescents with musculoskeletal complaints

Musculoskeletal complaints (MSCs) are one of the leading causes of outpatient admissions. However, analytical and epidemiological data are limited. The aim of this study is to identify the etiology of MSCs (excluding acute traumatic conditions) in children and adolescents, and to identify clues for the differential diagnosis. Children and adolescents presenting with musculoskeletal pain, swelling or limitation of movement were enrolled in a prospective design. Demographic, clinical and laboratory features were recorded. Four hundred and twenty-two children (48.2% female) with a mean age of 7.90±3.95 years were enrolled. Etiology was identified in 97.2% of the cases: non-inflammatory and mechanical conditions (NIMC; 42.2%), rheumatic diseases (RD; 31%), infection-related disorders (IRD; 21.6%) and malignancy (M; 2.4%). NIMC was characterized by longer duration of complaints, a higher rate of non-articular complaints, a lower rate of joint involvement and limping and lower levels of leukocytes, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). The prevalence of RD was higher in the age group of >12 years; younger age was associated with higher prevalence of IRD. Small-joint involvement was highest in the RD group. Median ESR in RD and M groups was higher; compared to the other groups; the frequency of patients with ESR ≥ 60 mm/hr was higher in the M group; compared to the RD group. In the RD group familial Mediterranean fever (9.7%), juvenile idiopathic arthritis (8.3%) and Henoch-Schönlein purpura (5.7%) were the leading causes of MSCs. RD accounted for one-third of the etiologies for MSCs. Age, duration of complaints, pattern of joint involvement and acute phase reactants are practical tools that may guide the pediatrician for diagnosis.

C-reactive protein and white blood cell count as triage test between urgent and nonurgent conditions in 2961 patients with acute abdominal pain.

The purpose of this article is to assess the diagnostic accuracy of C-reactive protein (CRP) and white blood cell (WBC) count to discriminate between urgent and nonurgent conditions in patients with acute abdominal pain at the emergency department, thereby guiding the selection of patients for immediate diagnostic imaging.Data from 3 large published prospective cohort studies of patients with acute abdominal pain were combined in an individual patient data meta-analysis. CRP levels and WBC counts were compared between patients with urgent and nonurgent final diagnoses. Parameters of diagnostic accuracy were calculated for clinically applicable cutoff values of CRP levels and WBC count, and for combinations.A total of 2961 patients were included of which 1352 patients (45.6%) had an urgent final diagnosis. The median WBC count and CRP levels were significantly higher in the urgent group than in the nonurgent group (12.8 ×109/L; interquartile range [IQR] 9.9–16) versus (9.3 ×109/L; IQR 7.2–12.1) and (46 mg/L; IQR 12–100 versus 10 mg/L; IQR 7–26) (P < 0.001).The highest positive predictive value (PPV) (85.5%) and lowest false positives (14.5%) were reached when cutoff values of CRP level >50 mg/L and WBC count >15 ×109/L were combined; however, 85.3% of urgent cases was missed.A high CRP level (>50 mg/L) combined with a high WBC count (>15 ×109/L) leads to the highest PPV. However, this applies only to a small subgroup of patients (8.7%). Overall, CRP levels and WBC count are insufficient markers to be used as a triage test in the selection for diagnostic imaging, even with a longer duration of complaints (>48 hours).

Can we predict which patients with patellofemoral pain are more likely to benefit from exercise therapy? A secondary exploratory analysis of a randomized controlled trial.

Secondary exploratory analysis of a randomized controlled trial comparing supervised exercise therapy to usual care in patients with patellofemoral pain (PFP). To explore which patients with PFP are more likely to benefit from exercise therapy. Patellofemoral pain is a common condition for which exercise therapy is effective in reducing pain and improving function. However, not all patients benefit from exercise therapy. The present study explored patient characteristics that might interact with treatment effects of PFP in 131 patients treated with usual care or exercise therapy. These characteristics were tested for interaction with treatment in a regression analysis. The primary outcomes were function and pain on activity at a 3-month follow-up. None of the tested variables had a significant interaction with treatment. A positive trend was seen for females with PFP: they were more likely to report higher function scores with exercise therapy than with usual care compared to males with PFP (β = 12.1; 95% confidence interval: 0.23, 24.0; P = .05). A positive trend was seen for patients with a longer duration of complaints (greater than 6 months); they were more likely to report higher function scores and to have less pain on activity with exercise therapy than with usual care compared to those with a shorter duration of complaints (β = 12.3; 95% confidence interval: -0.08, 24.7; P = .05 and β = -1.74; 95% confidence interval: -3.90, 0.43; P = .12, respectively). Two factors, sex and duration of complaints, may have a predictive value for response to exercise therapy at 3-month follow-up. Due to the exploratory design of the study, future research should confirm this tendency.

DIFFERENCES IN SPATIAL AND TEMPORAL ORDER MEMORY IN VARIOUS NEURODEGENERATIVE DEMENTIAS

memory (MOD-MEM) included 43% of patients. On visual inspection these patients had more severe MTA and were more often APOE e4 positive. Memory-spared clusters mild-executive (MILD-EXE), mild-visuoperception-language (MILD-VILA) and moderate-visuospatial (MOD-VISP) included 30% of patients. Using MILD-MEM as reference cluster, younger age was associated with higher likelihood for membership of MOD-VISP (Odds Ratio [OR] 6.21, 95% confidence interval [CI] 3.56-10.83) and MILD-EXE (OR 2.06, CI 1.32-3.23). Membership of MOD-VISP was more likely when APOE e4 was absent (OR 1.82, CI 1.04-3.20) and PA and GCAwere more severe (resp. OR 2.17, CI 1.15-4.10 and OR 2.64, CI 1.44-4.84). On visual inspection, MTA was less severe in memory-spared clusters than in other clusters. Finally, mild-diffuse (MILD-DIFF), moderate-language (MOD-LAN) and severe-diffuse (SEV-DIFF) were characterized by a memory-indifferent profile and included 28% of patients. Using MILD-MEM as reference, membership of SEV-DIFF was more likely when patients were younger (OR 2.77, CI 1.65-4.63), had longer duration of complaints (OR 2.18, CI 1.04-4.57) and had more severe PA and GCA (resp. OR 2.10, CI 1.07-3.76 and OR 2.28, CI 1.29-4.03). Conclusions: We demonstrated that LCA is an eligible method to identify cognitive subtypes in AD dementia using an extensive neuropsychological test battery. The cluster characteristics we found corresponded with earlier findings regarding the association between neurobiological characteristics and cognition.

Multidisciplinary rehabilitation for chronic widespread musculoskeletal pain: results from daily practice.

Evidence for the efficacy of a multi-component approach for chronic widespread musculoskeletal pain (CWP) has been reported, although the effects are overall moderate and this approach has rarely been investigated in real life. The aim of the study was to describe the effects of a 15-week multidisciplinary pain rehabilitation programme on pain, activities and participation in patients with CWP. The current retrospective study used data which were routinely gathered on all consecutive patients with CWP referred to a rehabilitation programme over a 21-month period. The 15-week multidisciplinary rehabilitation programme consisted of cognitive behavioural therapy and exercise, as well as individual and group sessions with additional treatment modalities. Assessments included the Pain Disability Index (PDI), the Pain Catastrophizing Scale (PCS), the Multidimensional Pain Inventory (MPI), numerical scales for pain and fatigue, the Canadian Occupational Performance Measure (COPM), the one-minute stair-climb test and the RAND-36. Paired t-tests and Wilcoxon signed-rank tests were carried out to analyse changes over time. A total of 165 patients were included [mean age 44.1 (standard deviation 12.9) years], 143 (87%) women). Discharge data were available for 154 patients (93%). All outcomes showed statistically significant improvements between admission and discharge (p<0.05), with the largest effect sizes (>1.0) observed for the COPM. A longer duration of complaints was associated with less improvement in the PDI. In daily rehabilitation practice, a 15-week multidisciplinary treatment programme for patients with CWP showed statistically significant improvements in pain, activities and participation over time. Future studies are needed further to substantiate the long-term cost-effectiveness, and to identify the patients who benefit the most.

FRI0466 Back pain and peripheral joint complaints in inflammatory bowel disease patients

BackgroundArthropathies are the most common extraintestinal manifestation in patients with inflammatory bowel disease (IBD).ObjectivesTo characterize joint complaints in IBD patients and classify these complaints according to spondyloarthritis (SpA) criteria sets.MethodsIn...

Patients with shoulder syndromes in general and physiotherapy practice: an observational study.

BackgroundShoulder complaints are commonly seen in general practice and physiotherapy practice. The only complaints for which general practitioners (GPs) refer more patients to the physiotherapist are back and neck pain. However, a substantial group have persistent symptoms. The first goal of this study is to document current health care use and the treatment process for patients with shoulder syndromes in both general practice and physiotherapy practice. The second goal is to detect whether there are differences between patients with shoulder syndromes who are treated by their GP, those who are treated by both GP and physiotherapist and those who access physiotherapy directly.MethodsObservational study using data from the Netherlands Information Network of General Practice and the National Information Service for Allied Health Care. These registration networks collect healthcare-related information on patient contacts including diagnoses, prescriptions, referrals, treatment and evaluation on an ongoing basis.ResultsMany patients develop symptoms gradually and 35% of patients with shoulder syndromes waited more than three months before visiting a physiotherapist. In 64% of all patients, treatment goals are fully reached at the end of physiotherapy treatment. In general practice, around one third of the patients return after the referral for physiotherapy. Patients with shoulder syndromes who are referred for physiotherapy have more consultations with their GP and are prescribed less medication than patients without a referral. Often, this referral is made at the first consultation. In physiotherapy practice, referred patients differ from self-referrals. Self-referrals are younger, they more often have recurrent complaints and their complaints are more often related to sports and leisure activities.ConclusionsThere is a fairly large group of patients with persistent symptoms. Early referral by a GP is not advised under current guidelines. However, in many patients, symptoms develop gradually and a wait-and-see policy means more valuable time may pass before physiotherapy intervention takes place. Meanwhile a long duration of complaints is a predictor for poor outcome. Therefore, future research into early referral is required. As physiotherapists, we should develop a way of educating patients to avoid lengthy waiting periods before seeking help. To prevent high costs, physiotherapists could consider a classification of pain and limitations and wait-and-see policy as used by GPs. With early detection, a once-off consultation might be sufficient.

Management Decisions in Nontraumatic Complaints of Arm, Neck, and Shoulder in General Practice

OBJECTIVE We wanted to evaluate associations between diagnosis and characteristics of the patient, complaint, and general practitioner (GP), as well as 6 common management decisions, in patients with nontraumatic arm, neck, and shoulder complaints at the time of the first consultation with their physician. We undertook an observational cohort study set in 21 Dutch general practices, including 682 patients with nontraumatic complaints of arm, neck, and shoulder. The outcome measure was application (yes/no) of a specific management option: watchful waiting, additional diagnostic tests, prescription of medication, corticosteroid injection, referral for physiotherapy, and referral for medical specialist care. Separate multilevel analyses showed that overall, the diagnostic category, having long duration of complaints, and reporting many functional limitations were most frequently associated with the choice of a management option. For watchful waiting, only complaint variables played a role (long duration of complaints, high complaint severity, many functional limitations, recurrent complaint). All these variables were negatively associated with watchful waiting. When opting for 1 of the 5 other management options, several physician characteristics played a role as well. Less clinical experience was associated with additional diagnostic tests and referral to a medical specialist. GPs working in a solo practice more frequently referred to a medical specialist. GPs working in a rural area more frequently referred for physiotherapy. Female GPs prescribed medication less frequently. Physicians with special interest in musculoskeletal complaints gave corticosteroid injections more frequently. Diagnostic category, long duration of complaints, and high functional limitations were key variables in management decisions with these complaints. In addition, several physician characteristics played a role as well.

Das Management der Milchgangsfistel: eine Evaluation 13-jähriger Erfahrung mit Fistelexstirpation und primärem Wundverschluss

Fragestellung: Die Milchgangsfistel ist eine eher seltene und unvollständig verstandene Erkrankung der Mamma. Die Belastung für die betroffenen Frauen kann allerdings erheblich sein. Sie leiden unter Schmerzen, rezidivierenden Infektionen und schlechten kosmetischen Ergebnissen. Die adäquate chirurgische Herangehensweise ist nicht abschließend geklärt. In diesem Artikel wollen wir einen Überblick über die aktuell verfügbare Literatur geben und unsere Erfahrungen aus 13 Jahren operativer Behandlung der Milchgangsfistel darstellen. Methode: Es erfolgte die retrospektive Analyse der Krankengeschichten von Patientinnen, die zwischen 1993 und 2007 in unserem Zentrum behandelt wurden. Sie wurden mittels Telefoninterview anhand eines Fragebogens befragt. Die Gesamtzahl der betroffenen Frauen im Zeitraum von 7/1993 bis 10/2007 betrug 110, beim Follow-up wurden 78 Patientinnen erreicht. Ergebnisse: Der Mittelwert des Follow-up betrug 31 Monate (Range 4 – 175 Monaten). Das Durchschnittsalter der Patientinnen zum Zeitpunkt der Vorstellung betrug 40,5 Jahre (Range 20 – 65 Jahren). Die Beschwerdedauer vor der Operation ergab einen Mittelwert von 39 Monaten (Range 0 – 27 Jahre). Die Rezidivrate betrug 12 %. 46 % der Frauen waren voroperiert. Die Beeinträchtigung durch Schmerzen war erheblich: auf einer visuellen Analogskala von 0 bis 10 gaben die Patientinnen im Mittel 6,6 an. Schlussfolgerung: Der lange Zeitraum bis zur definitiven operativen Versorgung verdeutlicht, wie wenig bekannt das Management der Milchgangsfistel ist. Bei den betroffenen Frauen besteht ein erheblicher Leidensdruck, der durch deutliche Schmerzen gesteigert wird. Die Operationstechnik der Fistelexstirpation mit primärem Wundverschluss unter antibiotischer Abdeckung bringt sehr gute Resultate und die Behandlung sollte in spezialisierten Zentren erfolgen.

Impact of motor vehicle accidents on neck pain and disability in general practice

High levels of continuous neck pain after a motor vehicle accident (MVA) are reported in cross-sectional studies. Knowledge of this association in general practice is limited. To compare the differences in perceived pain and disability in patients with acute neck pain due to an MVA versus other self-reported causes. The secondary aim was to identify prognostic factors for continuous neck pain. Prospective cohort study with 1-year follow-up. General practices in Rotterdam and its suburban region. Patients with non-specific acute neck pain were invited to participate. Questionnaires were collected at baseline and after 6, 12, 26, and 52 weeks. The numerical pain-rating scale (NRS) and the neck disability index (NDI) were measured. Regression analysis was used to identify prognostic factors for continuous neck pain. A total of 187 patients were included. The MVA subgroup (n = 42) was significantly younger (P = 0.007), reported more sick leave (P = 0.037), higher levels of headache (P<0.001) and higher NDI scores at baseline (P = 0.018) but lower scores for previous neck pain (P = 0.015) compared to the remaining cohort. At follow-up the MVA subgroup had higher scores for continuous neck pain (63% versus 40%) and at the NDI (11.0 versus 7.1). After multivariate analysis 'pain in the upper part of the neck' (odds ratio [OR] = 1.6), 'duration of complaints at baseline longer than 2 weeks' (OR = 5.3), and an 'MVA' (OR = 5.3) were significantly correlated with outcome. Individuals exposed to MVAs constitute a relevant subgroup of patients with neck pain. An MVA and a longer duration of complaints are prognostic factors for continuous neck pain.

Social and psychological factors influenced the course of arm, neck and shoulder complaints

Objective To investigate the clinical course and prognostic factors of complaints of arm, neck, and shoulder. Study Design and Setting A prospective cohort study in physical therapy practice. Participating physiotherapists recruited new consulters with musculoskeletal complaints of the neck and/or upper extremities. Participants filled in questionnaires at baseline, 3 months, and 6 months. The main outcome measure was the persistence of complaints over 6-month follow-up. Possible predictors like social and psychological factors, physical factors, and complaint specific factors were tested in univariate and multivariate logistic regression analyses for repeated measurements. Results Of the 624 participants at baseline 543 (87%) returned at least one follow-up questionnaire. At 6-month follow-up, 40% had persisting pain and discomfort. Somatization, kinesiophobia, catastrophizing, and a long duration of complaints at baseline were significantly related to the persistence of complaints over 6 months in the total population. In those with paid work (77%), catastrophizing, low decision authority at work, and a long duration of complaints at baseline were significantly related to the persistence of complaints over 6 months. Conclusion 40% of the participants had persisting pain and discomfort after 6 months and mainly social and psychological factors played a role in this course.