[Practice guideline 'Medical treatment of COPD']. / Richtlijn 'Medicamenteuze behandeling van COPD'.

The practice guideline 'Medical treatment of COPD' completes the practice guideline for diagnostics and non-medicinal treatment. Patients with stable chronic obstructive pulmonary disease (COPD) and minor complaints can be treated with short-acting beta-2-adrenoceptor agonists or anticholinergics or a combination of these. In cases of insufficient clinical control of the condition or if patients use their medication for maintenance, a long-acting bronchodilator is the drug of choice. In patients with severe or very severe COPD (stage III-IV of the criteria of the Global Initiative for Obstructive Lung Disease (GOLD) or with cardiac comorbidity, there is a slight preference for the long-acting anticholinergic tiotropium. Inhaled corticosteroids (ICS) reduce the exacerbation frequency in patients with moderate to severe or very severe COPD (GOLD stage II-IV) and recurrent exacerbations. A combination of ICS with long-acting beta-2-adrenoceptor agonists (LABA) is prescribed in patients with GOLD stage III-IV with at least 2 exacerbations in the past year, a deterioration of the quality of life and with symptoms, if treatment with a LABA alone or an ICS alone results in insufficient improvement. Anticholinergics and beta-2-adrenoceptor agonists have a similar effect on bronchodilation in patients with an acute exacerbation of COPD. If improvement is inadequate, patients with an exacerbation should be treated with prednisolone 30 mg for a period of 7 to 14 days. In outpatients and clinical patients with an exacerbation ofCOPD, an antibiotic is added to prednisolone in very poor lung function (forced expiratory volume in 1 second (FEV1) < 30%) or another risk factor of a severe disease course, such as a respiratory rate > or = 30/min, a systolic blood pressure < 90 mmHg, and disorientation in time, place or person.

[Summary of the practice guideline 'Asthma in children' (second revision) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'astma bij kinderen' (tweede herziening) van het Nederlands Huisartsen Genootschap.

A number of important changes have been made in the second revision of the guideline 'Asthma in children' from the Dutch College of General Practitioners. In children under the age of 6 years, the symptoms stuffiness and recurrent cough are no longer considered part of the symptomatic diagnosis of asthma. Wheezing has become the key symptom of asthma. In children aged 6 years or more, spirometry is the optimal method for both diagnosis and monitoring. This method is preferred over peak flow measurement. Inhalation allergies should be investigated in children under the age of 6 years because the presence of an inhalation allergy may influence the management approach. Starting asthma medication in children under the age of 6 years should always be considered a therapeutic trial, and its effect should always be evaluated. The prescription of allergen-resistant mattresses and bed coverings is only effective when it is one component of a set of allergen reduction measures. At this time, the Dutch Health Council recommends influenza vaccination in children with asthma.

[Summary of the practice guideline 'Headache' from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Hoofdpijn' van het Nederlands Huisartsen Genootschap.

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.

[Summary of the practice guideline 'Anxiety disorders' (first revision) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Angststoornissen' (eerste herziening) van het Nederlands Huisartsen Genootschap.

Anxiety disorders are characterised by excessive fears leading to distress or social disability. Anxiety disorders are difficult to recognise. General practitioners (GPs) should consider the possibility more often, especially in patients who make frequent visits with unexplained physical symptoms. The cornerstone of treatment is patient education, which can be supported by information leaflets provided by the Dutch College of General Practitioners. Cognitive behavioural therapy and antidepressants are equally effective therapies in most anxiety disorders. The choice should be made in collaboration with the patient. Pharmacological treatment is the first choice when a comorbid depression is involved. Cognitive behavioural therapy by the GP is optional considering the limitations of skills and time in general practice. Tricyclic antidepressants and selective serotonin re-uptake inhibitors are equally effective with most anxiety disorders. The choice must be made on the basis of side effects, comorbidity, and co-medication. Antidepressant therapy should be given for at least 6-12 months. The GP's choice oftreatment should lead to improvement within 8-12 weeks. Otherwise, consultation of or referral to a specialist in mental health care is mandatory.

Responsiveness, longitudinal- and cross-sectional construct validity of the Pediatric Asthma Quality of Life Questionnaire (PAQLQ) in Dutch children with asthma.

OBJECTIVE: Health-related quality of life is an important measure in evaluations of the management of childhood asthma. In this study, we assessed psychometric properties, responsiveness, and longitudinal and cross-sectional construct validity of the Dutch version of the 23-item Pediatric Asthma Quality of Life Questionnaire (PAQLQ). METHODS: The study group consisted of 238 6-18-year olds with asthma, with complete respiratory symptom diaries in the course of one winter season; each child had one (or more) PAQLQ measurement(s) concerning one (or more) week(s) with relatively many symptoms (n = 238). Each child also had one PAQLQ measurement concerning another week with relatively few symptoms (n = 238). The PAQLQ scores of the 238 children for a week with few symptoms (the symptom diary scores remained below a predefined level everyday) were compared with their PAQLQ scores for another week with many symptoms (on day 1 of that week, symptom diary scores had been above the predefined level). Additionally, in a subgroup of the study group that had experienced two or more 'weeks with many symptoms' (n = 101), we compared the PAQLQ-scores for two different weeks with many symptoms of these children. RESULTS: Only the domain Emotions showed a ceiling effect (>25% had the maximum score). All Cronbach's alpha's of the PAQLQ total score and domains were >0.70, except for Activities (alpha = 0.54). Mean PAQLQ-scores were significantly different (p < 0.01; n = 238) between one week with few symptoms and another week with many symptoms. Contrary, in the subgroup of children with PAQLQ-measurements regarding more than one week with many symptoms (n = 101), mean PAQLQ-scores did not differ significantly (p > or = 0.05) between 1 week with many symptoms and another week with many symptoms. These results indicate responsiveness. (Changes in) lower respiratory tract symptoms, indicative of asthma severity, correlated better with (changes in) PAQLQ scores than (changes in) upper respiratory tract symptoms, which supports the longitudinal and cross-sectional construct validity. CONCLUSION: The assessed properties of the PAQLQ linguistic validation into Dutch were similar to those originally established for the PAQLQ in Canada. This study showed that the Dutch PAQLQ has adequate psychometric properties, excellent responsiveness, and that the longitudinal and cross-sectional construct validity is supported.

Childhood factors associated with asthma remission after 30 year follow up.

BACKGROUND: Factors contributing to either "complete" or "clinical" remission of asthma are important to know since there is no cure for the disease. METHODS: A cohort of 119 allergic asthmatic children was examined three times with a mean follow up of 30 years. They were aged 5-14 years at visit 1 (1966-9), 21-33 years at visit 2 (1983-6), and 32-42 years at visit 3 (1995-6). Complete remission of asthma at visit 3 was defined as no asthma symptoms, no use of inhaled corticosteroids, normal lung function (FEV1 >90% predicted), and no bronchial hyperresponsiveness (PC10 >16 mg/ml). Clinical remission was defined as no asthma symptoms and no use of inhaled corticosteroids. RESULTS: 22% of the group was in complete remission of asthma at visit 3 and a further 30% was in clinical remission (total 52%); 57% of subjects in clinical remission had bronchial hyperresponsiveness and/or a low lung function. Logistic regression analyses showed that a higher FEV1 in childhood and more improvement in FEV1 from age 5-14 to 21-33 were associated with both complete and clinical asthma remission at age 32-42. CONCLUSIONS: Complete remission of asthma was present in a small subset of asthmatics while half the subjects showed clinical remission. Both complete and clinical remission were associated with a higher lung function level in childhood and a higher subsequent increase in FEV1. These results support the view that defining remission only on the basis of symptoms and medication use will overlook subjects with subclinical active disease and possibly associated airway remodelling.

Risk factors for growth and decline of lung function in asthmatic individuals up to age 42 years. A 30-year follow-up study.

Little is known about factors determining the outcome of childhood asthma. The purpose of this longitudinal study was to assess the factors in childhood that determine the level of FEV(1) in early adulthood in asthmatic individuals, and to examine factors associated with decline in FEV(1) during adulthood. Between 1966 and 1969, 119 allergic asthmatic subjects aged 5 to 14 yr were studied (Visit 1). Of these subjects, 101 (85%) were reinvestigated at ages 22 to 32 yr (Visit 2) and 32 to 42 yr (Visit 3). At the first survey and during follow-up, a standardized questionnaire was used, serum total IgE and peripheral blood eosinophils were measured, and physical examination, skin tests, lung function tests, and histamine challenge (provocative concentration causing a 10% decline in FEV(1); PC(10)) tests were performed according to the same protocol. Multiple linear regression analyses were performed with FEV(1) at Visit 2 and with the change of FEV(1) from Visit 2 to Visit 3 as outcome variables. A low FEV(1)% predicted at Visit 1 and PC(10)

Risk factors from childhood to adulthood for bronchial responsiveness at age 32-42 yr.

UNLABELLED: Bronchial responsiveness (BR) is an important risk factor for the development and outcome of asthma. This study assessed childhood risk factors for both the severity of BR in adulthood and either improvement or worsening of BR over time. Finally, we studied cross-sectional risk factors of BR in adulthood. Between 1966 and 1969, 119 allergic asthmatic children (5-14 yr of age) were studied. Of these, 101 (85%) subjects were reinvestigated at age 22-32 yr (visit 2), and at age 32-42 yr (visit 3). Spirometry, PC10 histamine, skin tests, blood eosinophils, and serum total IgE were measured and a questionnaire was used. Higher FEV1 values in childhood were associated with less severe BR at age 32-42 yr independent of other potential risk factors. Larger increases in FEV1 values both from visit 1 to 2 and from visit 2 to 3, a longer time interval from visit 1 to 3, and having pets in childhood were associated with less severe BR at age 32-42 yr. The same factors were found to be associated with less deterioration of BR from visit 2 to 3. In nonsmokers a higher IgE level at visit 2 was a risk factor for an increase in BR. At age 32-42 yr, a low level of lung function and the presence of asthma symptoms were associated with more severe BR, and older age and having pets were associated with less severe BR. IgE was related to more severe BR only in nonsmokers. CONCLUSIONS: A lower lung function in childhood and less improvement in FEV1 over time were associated with more severe BR in adulthood.

Eosinophil and mast cell parameters in children with stable moderate asthma.

UNLABELLED: Mast cells and eosinophils are important cells that contribute to the process of inflammation in asthma either by activating other cells or by secreting products which are potentially toxic to the respiratory epithelium. The influx of these cells in the airways and the secretion of toxic products by these cells is abrogated by inhaled corticosteroids. METHODS: In a double blind randomised, placebo controlled, study in children with stable moderate asthma (N = 34, 15 children received fluticasone propionate (FP), an inhaled corticosteroid, and 19 children used a placebo), we investigated the influence of treatment with FP 100 microg b.d. on various parameters of inflammation: number of eosinophils, secretory products of eosinophils i.e. ECP and EDN (in serum and urine) and a secretory product of mast cells, histamine, which is determined as the compound to which histamine is converted and excreted by the human body: NT-methyl-histamine. RESULTS: Previously we reported that lung function increased and bronchial hyperresponsiveness decreased in the 30 children that completed the study during treatment with FP. In these children we found that none of the laboratory parameters of inflammation changed significantly during treatment with either FP or placebo. However, the decrease in urinary EDN almost reached significance (P = 0.07). CONCLUSIONS: Our results indicate that the number of eosinophils, serum ECP and EDN and urinary EDN as well as urinary NT-methyl-histamine do not reflect asthma disease activity in children with stable moderate asthma. Our data on urinary EDN warrant further study of the use of this parameter to monitor asthma in children.

Addition of salmeterol versus doubling the dose of beclomethasone in children with asthma. The Dutch Asthma Study Group.

Studies in adults revealed that addition of salmeterol to a moderate dose of inhaled corticosteroid resulted in better symptom control and higher PEF compared with doubling the dose of inhaled corticosteroid. The aim of this three group study was to compare the effects of a moderate dose of beclomethasone, the same dose of beclomethasone with salmeterol, and a doubling dose of beclomethasone on lung function and symptoms in children with moderate asthma. A total of 177 children already treated with inhaled corticosteroids, were randomized in a double-blind parallel study either to salmeterol 50 microg twice daily (BDP400+salm), beclomethasone 200 microg twice daily (BDP800), or placebo (BDP400) in addition to beclomethasone 200 microg twice daily. No significant differences between groups were found in FEV1, PD20 methacholine, symptom scores, and exacerbation rates after 1 yr. Salmeterol resulted in slightly better PEF in the first months of treatment. FEV1, and PD20 methacholine significantly improved in all groups. After 1 yr mean changes in FEV1, percent predicted were 4.3% (95% CI 1.3; 7.2), 5.8% (95% CI 2.9; 8.7), and 4.3% (95% CI 2.1; 6.5) for BDP400+salm, BDP800, and BDP400, respectively. Changes in airway responsiveness were 0.60 (95% CI 0.05; 1.14), 1.30 (95% CI 0.73; 1. 87), and 0.80 (95% CI 0.33; 1.27) doubling doses. Growth was significantly slower in the BDP800 group. We conclude that no additional benefit was found of adding either salmeterol or more beclomethasone to a daily dose of 400 microg beclomethasone in this group of children with excellent compliance of medication.

Fluticasone propionate in children with moderate asthma.

Inhaled corticosteroids are considered to be effective and safe to treat children with asthma. These drugs, often used as maintenance treatment, can, however, influence the HPA-axis, which might be reflected by the serum and urine cortisol concentration. The aim of the present study was to investigate the efficacy and safety of fluticasone propionate (FP) 100 microg administered twice a day via a Diskhaler for 3 mo. FP was tested in a double-blind randomized placebo-controlled parallel trial in a group of 34 children with moderate asthma who did not use inhaled steroids for at least 4 wk prior to the study. At home, symptoms and peak flow recordings (PEFR) were noted in a diary. At each visit lung function was measured, and serum and urinary cortisol were determined. During treatment, wheezing decreased and PEFR values increased in the FP group. FEV1 and PC20-histamine increased and the reversibility decreased in the FP group. All changes were significant, with the exception of the change in nocturnal PEFR. Four weeks after cessation of FP all parameters returned to pretreatment values. Serum cortisol did not change significantly in either treatment group. The decrease in urinary cortisol in the FP group was significant only if it was compared with the increase in urinary cortisol in the placebo group. We conclude that FP 100 microg given twice a day is effective in children with moderate stable asthma. Suppression of the HPA-axis by FP 100 microg given twice daily, although not likely, cannot be ruled out by this study since the absence of a significant decrease in urinary cortisol in the FP group could be due to an insufficient number of patients. Additional studies are required to solve this problem.

Use of tracheal auscultation for the assessment of bronchial responsiveness in asthmatic children.

BACKGROUND: It can be difficult to assess bronchial responsiveness in children because of their inability to perform spirometric tests reliably. In bronchial challenges lung sounds could be used to detect the required 20% fall in the forced expiratory volume in one second (FEV1). A study was undertaken to determine whether a change in lung sounds corresponded with a 20% fall in FEV1 after methacholine challenge, and whether the occurrence of wheeze was the most important change. METHODS: Fifteen children with asthma (eight boys) of mean age 10.8 years (range 8-15) were studied. All had normal chest auscultation before the methacholine challenge test. Lung sounds were recorded over the trachea for one minute and stored on tape. They were analysed directly and also scored blindly from the tape recording by a second investigator. Wheeze, cough, increase in respiratory rate, and prolonged expiration were assessed. RESULTS: The total cumulative methacholine dose causing a fall in FEV1 of 20% or more (PD20) was detected in 12 children by a change in lung sounds - in four by wheeze and in eight by cough, increased respiratory rate, and/or prolonged expiration. In two subjects altered lung sounds were detectable one dose step before PD20 was reached. In three cases in whom no fall in FEV1 occurred, no change in lung sounds could be detected at the highest methacholine dose. CONCLUSION: Changes in lung sounds correspond well with a 20% fall in FEV1 after methacholine challenge. Wheeze is an insensitive indicator for assessing bronchial responsiveness. Cough, increase in respiratory rate, and prolonged expiration occurs more frequently.