家庭醫師有嚴肅看待腹痛嗎?


  【24drs.com】根據發表於7/8月號家庭醫學誌(Annals of Family Medicine)的一篇研究,孩童主訴非特異性腹痛(NSAP)很少會讓家庭醫師進行額外的檢查或轉診,一般僅開立藥物解決症狀,但是缺乏效益佐證。
  
  NSAP定義為醫師認為沒有器官病理引起之疼痛,是造成孩童缺課和影響健康的常見主訴,這是一種複雜且需費時處理的問題。
  
  可能有生理上的共病症或其他非特異性腹部症狀,這些症狀也可能持續一段時間,不過,一般認為家庭醫師將NSAP視為良性,家長和孩童需要的只是多一點信心。
  
  為了更暸解專科醫師和家庭醫師有關NSAP之歧見,荷蘭鹿特丹Erasmus MC大學醫學中心一般執業系的Marieke J. Gieteling醫師等人評估了這類狀況的一般照護觀點,迄今多數的NSAP研究是由專科醫師所進行,此外,Gieteling等人使用「Second Dutch National Survey of General Practice (2001)」的資料計算發生率,並檢視於一線照護機構治療NSAP孩童的相關因素,該篇研究聚焦在患有NSAP的4至17歲孩童。
  
  每1000人年之NSAP發生率為25.0 (95%信心區間[CI]為23.7 - 26.3),新診斷NSAP的孩童中,92.7% 就診1或2次,和NSAP獨立相關的各項因素為:女性(勝算比[OR]為1.4;95% CI為1.3 - 1.5)、非胃腸-非特異型胃部症狀(OR為1.3;95% CI為1.1 - 1.5)、就診次數較多(OR為1.04;95% CI為1.03 - 1.05)。
  
  作者們計算了平均值,所有就診次數中,家庭醫師開立藥物處方的比率有45.3%;不過,處方的藥物(緩瀉劑和解痙孿劑最為常見)僅21.3%有NSAP診斷,這比率顯著偏低(P < .001),NSAP診斷之病患有3%轉診給專科醫師,有1%接受進一步檢查。
  
  研究者指出,NSAP病患僅就診1次或2次是相當令人驚訝的,因為專科醫師報告指出,NSAP傾向是慢性的,很難給家長和孩童保證,可能是家庭醫師藉由確認沒有潛在異常且教育他們因應這些問題的方法而成功處置NSAP。
  
  不過,不清楚未再回診病患是否繼續有疼痛且加以忍受、或是以替代療法治療。
  
  研究者呼籲進行後續研究,探討家庭醫學科的NSAP預後,以及家庭醫師處置後的效果。
  
  資料來源: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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