家庭医师有严肃看待腹痛吗?


  【24drs.com】根据发表于7/8月号家庭医学志(Annals of Family Medicine)的一篇研究,孩童主诉非特异性腹痛(NSAP)很少会让家庭医师进行额外的检查或转诊,一般仅开立药物解决症状,但是缺乏效益佐证。
  
  NSAP定义为医师认为没有器官病理引起之疼痛,是造成孩童缺课和影响健康的常见主诉,这是一种复杂且需费时处理的问题。
  
  可能有生理上的共病症或其它非特异性腹部症状,这些症状也可能持续一段时间,不过,一般认为家庭医师将NSAP视为良性,家长和孩童需要的只是多一点信心。
  
  为了更了解专科医师和家庭医师有关NSAP之歧见,荷兰鹿特丹Erasmus MC大学医学中心一般执业系的Marieke J. Gieteling医师等人评估了这类状况的一般照护观点,迄今多数的NSAP研究是由专科医师所进行,此外,Gieteling等人使用「Second Dutch National Survey of General Practice (2001)」的资料计算发生率,并检视于一线照护机构治疗NSAP孩童的相关因素,该篇研究聚焦在患有NSAP的4至17岁孩童。
  
  每1000人年之NSAP发生率为25.0 (95%信心区间[CI]为23.7 - 26.3),新诊断NSAP的孩童中,92.7% 就诊1或2次,和NSAP独立相关的各项因素为:女性(胜算比[OR]为1.4;95% CI为1.3 - 1.5)、非胃肠-非特异型胃部症状(OR为1.3;95% CI为1.1 - 1.5)、就诊次数较多(OR为1.04;95% CI为1.03 - 1.05)。
  
  作者们计算了平均值,所有就诊次数中,家庭医师开立药物处方的比率有45.3%;不过,处方的药物(缓泻剂和解痉孪剂最为常见)仅21.3%有NSAP诊断,这比率显著偏低(P < .001),NSAP诊断之病患有3%转诊给专科医师,有1%接受进一步检查。
  
  研究者指出,NSAP病患仅就诊1次或2次是相当令人惊讶的,因为专科医师报告指出,NSAP倾向是慢性的,很难给家长和孩童保证,可能是家庭医师藉由确认没有潜在异常且教育他们因应这些问题的方法而成功处置NSAP。
  
  不过,不清楚未再回诊病患是否继续有疼痛且加以忍受、或是以替代疗法治疗。
  
  研究者呼吁进行后续研究,探讨家庭医学科的NSAP预后,以及家庭医师处置后的效果。
  
  资料来源:http://www.24drs.com/professional/list/content.asp?x_logon=W&x_idno=6571&x_classno=0
  
  

Do Family Physicians Take Abdominal Pain Seriously?

By Jim Kling
Medscape Medical News

July 13, 2011 — Complaints of nonspecific abdominal pain (NSAP) in children rarely prompt additional testing or referrals from family physicians, who commonly prescribe medications for the conditions despite a lack of evidence of their effectiveness, according to a study published in the July/August issue of the Annals of Family Medicine.

NSAP, defined as pain for which the physician believes there is no organic pathologic cause, is a common complaint that can lead to school absences and affect a child's well-being. It is often a complex and time-consuming problem for specialists.

There may be psychological comorbidity or other nonspecific somatic symptoms, and the symptoms can be long-lasting. However, there is a general belief that family physicians consider NSAP to be benign and that parents and children are in need of little more than reassurance.

To better understand the discrepant view between specialists and family physicians regarding NSAP, Marieke J. Gieteling, MD, from the Department of General Practice, Erasmus MC–University Medical Center, Rotterdam, the Netherlands, and colleagues set out to evaluate the primary care view of this condition. Most studies to date on NSAP have been conducted on patients under the care of specialists. Instead, Dr. Gieteling and colleagues used data from the Second Dutch National Survey of General Practice (2001) to calculate incidence and to identify factors associated with childhood NSAP treated in primary care settings. The study focused on children between the ages of 4 and 17 years who had NSAP.

NSAP incidence was 25.0 (95% confidence interval [CI], 23.7 - 26.3) per 1000 person years. Of children with newly diagnosed NSAP, 92.7% saw their physician once or twice. Several factors were independently associated with NSAP: female sex (odds ratio [OR], 1.4; 95% CI, 1.3 - 1.5), nongastrointestinal-nonspecific somatic symptoms (OR, 1.3; 95% CI, 1.1 - 1.5), and a higher frequency of healthcare visits (OR, 1.04; 95% CI, 1.03 - 1.05).

The authors determined that on average, family physicians prescribe medication in 45.3% of all healthcare visits; yet, they prescribed medication (laxatives and antispasmodics being the most common) in only 21.3% of visits in which NSAP was diagnosed, which was a significantly lower rate (P < .001). Three percent of patients with an NSAP diagnosis received referrals to a specialist, and 1% received further testing.

The researchers note that it is quite surprising that patients only visit once or twice for NSAP, because specialists report that NSAP tends to be chronic, and parents and children can be difficult to reassure. It is possible that family physicians are successfully managing NSAP by reassuring parents that there is no underlying disorder and teaching them methods to cope with the problem.

However, it is unknown whether patients who did not revisit the physician continued to experience pain and simply endured it, or were treated with alternative medicine.

The researchers call for further studies into the prognosis of NSAP in family practice settings and the effectiveness of family physician management.

The authors have disclosed no relevant financial relationships.

Ann Fam Med. 2011;9:337-343.

    
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