Triptan overuse in the Dutch general population: a nationwide pharmaco-epidemiology database analysis in 6.7 million people.

INTRODUCTION: A population-based observational study was used to assess the prevalence, demographics, risk factors, and costs of triptan overuse, defined as more than 30 (International Headache Society criteria) or 54 (stringent criteria) defined daily doses per 3 months. METHODS: Analysis of the Dutch Health Care Insurance Board Database for 2005, which included prescriptions for 6.7 million people (46% of the total Dutch population). RESULTS: Triptans were used by 85,172 (1.3%) people; of these, 8,844 (10.4%; 95% CI 10.2-10.6) were overusers by International Headache Society and 2,787 (3.3%; 95% CI 3.2-3.4) were overusers by stringent criteria. The triptan-specific odds ratios for the rate of International Headache Society overuse compared with sumatriptan were: 0.26 (95% CI 0.19-0.36) for frovatriptan; 0.34 (95% CI 0.32-0.37) for rizatriptan; 0.76 95% CI 0.68-0.85) for naratriptan; 0.86 (95% CI 0.72-1.02) for eletriptan; 0.97 (95% CI 0.88-1.06) for zolmitriptan; and 1.49 (95% CI 1.31-1.72) for almotriptan. Costs for overuse were 29.7 million euros; for the International Headache Society criteria this was 46% of total costs and for stringent criteria it was 23%. DISCUSSION: In the Dutch general population, 1.3% used a triptan in 2005, of which 10.3% were overusers and accounted for half of the total costs of triptans. Users of frovatriptan, rizatriptan and naratriptan had a lower level of overuse.

Psychological determinants of the intention to educate patients about benzodiazepines.

OBJECTIVE: General practitioners and pharmacists do not properly educate their patients about the disadvantages of benzodiazepines. In order to increase and improve education, this study will investigate which psychological factors (i.e., beliefs, outcome expectation, social norm and self-efficacy) predict the intention to educate. METHODS: A cross-sectional survey study was conducted in which 339 general practitioners and 149 pharmacists in the Netherlands completed a questionnaire. RESULTS: The Results show that the above-mentioned factors play an important role in forming intentions to educate. However, differences exist between general practitioners and pharmacists. CONCLUSION: General practitioners and pharmacists intend to educate in cases where they think that benzodiazepines have well-defined disadvantages, when the education they undertake leads to success, when they feel pressure to educate from their surroundings and when they are capable of educating. Implications for practice These findings contribute to a better understanding of patient education and are of great value in developing new interventions to improve education.

Can history and exam alone reliably predict pneumonia?

BACKGROUND: Prediction rules based on clinical information have been developed to support the diagnosis of pneumonia and help limit the use of expensive diagnostic tests. However, these prediction rules need to be validated in the primary care setting. METHODS: Adults who met our definition of lower respiratory tract infection (LRTI) were recruited for a prospective study on the causes of LRTI, between November 15, 1998 and June 1, 2001 in the Leiden region of The Netherlands. Clinical information was collected and chest radiography was performed. A literature search was also done to find prediction rules for pneumonia. RESULTS: 129 patients--26 with pneumonia and 103 without--were included, and 6 prediction rules were applied. Only the model with the addition of a test for C-reactive protein had a significant area under the curve of 0.69 (95% confidence interval [CI], 0.58-0.80), with a positive predictive value of 47% (95% CI, 23-71) and a negative predictive value of 84% (95% CI, 77-91). The pretest probabilities for the presence and absence of pneumonia were 20% and 80%, respectively. CONCLUSIONS: Models based only on clinical information do not reliably predict the presence of pneumonia. The addition of an elevated C-reactive protein level seems of little value.

Chronic frequent headache in the general population: prevalence and associated factors.

We studied the prevalence and short-term natural course of chronic frequent headache (CFH) in the general population and identified risk factors. In the Netherlands everyone is registered at a single general practice. We sent questionnaires to all persons (n = 21 440) aged 25-55 years, registered at 16 general practices. We compared the characteristics of 177 participants with CFH (>14 headache days/month for >3 months) with 141 participants with infrequent headache (1-4 days/month) and 526 without headache (<1 day/month). The prevalence of CFH was 3.7% [95% confidence interval (CI) 3.4, 4.0]. In 5 months, 12% showed a clinically relevant decrease to <7 days/month. In both headache groups 70% were women vs. 41% in the group without headache. Compared with the group with infrequent headache, the CFH group had more subjects with low educational level [35% vs. 11%; odds ratio (OR) 4.3, 95% CI 2.3, 7.8], medication overuse (62% vs. 3%; OR 38.4, 95% CI 13.8, 106.9), sleeping problems (44% vs. 8%; OR 8.1, 95% CI 3.6, 18.1), a history of head/neck trauma (36% vs. 14%; OR 4.0, 95% CI 2.2, 7.1), high scores on the General Health Questionnaire (62% vs. 34%; OR 2.7, 95% CI 1.3, 3.6) and more smokers (45% vs. 19%; OR 3.1, 95% CI 1.9, 5.3). We conclude that headache frequency fluctuates. CFH is common and associated with overuse of analgesics, psychopathology, smoking, sleeping problems, a history of head/neck trauma and low educational level. Female sex is a risk factor for headache, not for chronification of headache.

Chronic frequent headache in the general population: comorbidity and quality of life.

We studied the nature and extent of comorbidity of chronic frequent headache (CFH) in the general population and the influence of CFH and comorbidity on quality of life. Subjects with CFH (headache on >14 days/month) were identified in a general health survey. We sent a second questionnaire including questions on comorbidity and quality of life to subjects with CFH and subjects with infrequent headache (IH) (1-4 days/month). We recoded comorbidity by using the Cumulative Illness Rating Scale (CIRS) and measured quality of life with the RAND-36, a Dutch version of Short Form-36. CFH subjects (n = 176) had higher comorbidity scores than the IH subjects (n = 141). Mean CIRS scores were 2.94 for CFH and 1.55 for IH [mean difference 1.40, 95% confidence interval (CI) 0.91, 1.89]. The mean number of categories selected was 1.92 in CFH and 1.10 in IH (mean difference 0.82, 95% CI 0.54, 1.11). Fifty percent of CFH subjects had a comorbidity severity level of at least 2, indicating disorders requiring daily medication, compared with 28% of IH subjects (mean difference 22%, 95% CI 12, 33). CFH subjects had more musculoskeletal, gastrointestinal, psychiatric and endocrine/breast pathology than IH subjects. Quality of life in CFH subjects was lower than that of IH subjects in all domains of the RAND-36. Both headache frequency and CIRS score had a negative influence on all domains. We conclude that patients with CFH have more comorbid disorders than patients with infrequent headaches. Many CFH patients have a comorbid chronic condition requiring daily medication. Both high headache frequency and comorbidity contribute to the low quality of life in these patients.

[Condylomata acuminata: a rare symptom of ubiquitous human papilloma virus and not a sign of risky sex behavior]. / Condylomata acuminata: een zeldzaam symptoom van ubiquitair humaan papillomavirus en geen teken van riskant seksueel gedrag.

In general, condylomata acuminata can be diagnosed and treated by the general practitioner. Condylomata are caused by certain types of human papillomavirus (HPV). According to their carcinogenicity HPVs are classified as high risk and low risk HPV. The benign condylomata are an infrequent sign of an infection with low risk HPV, while cervical cancer is a rare and late complication of an infection with high risk HPV. Because high and low risk HPV are different viruses, the risk of cervical cancer is not increased by condylomata. Anogenital HPVs are predominantly transmitted sexually. It is useful to discriminate between sexually transmitted diseases (STDs) that are ubiquitous, like infections with HPV or herpes simplex virus (HSV), and rare STDs like syphilis, gonorrhoea and HIV infection: infections with HPV and HSV are also common with unriskful sexual behaviour, while syphilis, gonorrhoea and HIV infection are almost exclusively associated with riskful sexual behaviour. It has been shown that double infections with HPV and Chlamydia trachomatis are not more frequent than may be expected by chance. The literature indicates that the presence of condylomata acuminata by itself is no reason to screen patients for other STDs.

Once-daily budesonide in mild asthma.

Inhaled steroid therapy is the most important treatment in the management of chronic asthma and currently twice-daily administration is recommended in mild to moderate asthma. Compliance is often a problem in asymptomatic patients and may lead to reduced disease control. Our aim was to investigate whether budesonide 0.2 mg once daily administered via the Turbuhaler is as effective as 0.1 mg twice daily. A randomized, double-blind, parallel group study was carried out in which 76 adult patients with mild to moderate asthma (FEV1 86% of predicted) were allocated to budesonide once or twice daily. After a run-in period of 2 weeks on present inhaled steroid treatment (0.2-0.5 mg day-1) there was an 8 week treatment period, followed by a washout period in which patients received no steroid for 4 weeks unless a drop in morning peak flow of at least 20% occurred or the use of beta 2-agonists increased by 50%. Both treatment groups improved minimally in peak flow (1.7 and 4.31 min-1 in the once-daily and twice-daily groups respectively) but the differences between the two groups were not significant. Testing the reverse hypothesis revealed clinical equivalence. The 90% confidence interval of the difference in the change of peak flow from run-in was between +30 and -30 l min-1, the limits deemed to be clinically relevant. There were no differences in symptom scores, beta 2-agonist use or spirometry measurements between the two groups. In the washout period there was a significant deterioration in peak flow and symptoms. This study shows that 0.2 mg budesonide given once a day is as affective as 0.1 mg given twice daily in patients with mild to moderate asthma.

Wrist actigraphic assessment of sleep in 116 community based subjects suspected of obstructive sleep apnoea syndrome.

BACKGROUND: The combined use of wrist actigraphic assessment and self assessment of sleep in the screening of obstructive sleep apnoea syndrome was evaluated in a community based sample. METHODS: One hundred and sixteen community based subjects clinically suspected of having obstructive sleep apnoea (syndrome) were evaluated by means of simultaneous ambulatory recording of respiration (oronasal flow thermistry), motor activity (wrist actigraphy), and subjective sleep (sleep log) during one night of sleep. RESULTS: The subjects were distributed according to their apnoea index (AI); AI < 1 (non-apnoeic snorers) 44%; AI 1- < 5 39%; and AI > or = 5 17%. High apnoea index values were associated with self reported disturbed sleep initiation and more fragmented and increased levels of motor activity and decreased duration of immobility periods, particularly in those with an apnoea index of > or = 5. Across subjects the duration of immobility periods was the only predictor of the apnoea index, explaining 11% of its variance. Use of the multiple regression equation to discriminate retrospectively between those with an apnoea index of < 1 and > or = 5 resulted in sensitivity and specificity values of 75% and 43%, and 5% and 100%, respectively. CONCLUSIONS: The combined use of a sleep log and actigraphic assessment of sleep failed to identify reliably those subjects who suffered from obstructive sleep apnoea (syndrome) in a sample of community based subjects reporting habitual snoring combined with excessive daytime sleepiness and/or nocturnal respiratory arrests.