[Strengths and weaknesses of guidelines: whether or not to prescribe antibiotics in general practice]. / De macht en onmacht van richtlijnen.

Is non-compliance to guidelines regarding antimicrobial treatment in primary care a problem? On the one hand, individual variation in clinical problems warrants deviation from guidelines in some patients. But on the other hand, restrictive use of antibiotics is certainly necessary in primary care. Undertreatment of infectious diseases is not a major risk in primary care, but overtreatment is. Currently, steps are undertaken in the Netherlands to enhance antibiotic stewardship.

[Prevention of severe infections in asplenic patients]. / Preventie van ernstige infecties bij asplenie.

The lifetime risk of dying from sepsis is approximately 2-3% in persons with (functional) asplenia. Both patients and their physicians are not always fully aware of these risks and the implementation of preventive measures is insufficient. Physicians should inform both patients and colleagues on the consequences of lost splenic function. Primary care physicians should screen their lists for patients with (functional) asplenia and offer these patient adequate preventive measures when needed.

[Impaired immunity: risk groups and consequences for general practice]. / Verminderde afweer.

- Due to medication use, comorbidities and/or age, an increasing number of patients have an impaired immunity to infection.- Impaired immunity may lead to an increased risk of (opportunistic) infection, complications from infections, and difficulties in the diagnosis of infections.- Guided by clinical parameters, a general practitioner can classify an impaired immunity as 'clinically irrelevant', 'limitedly relevant' or 'potentially serious'.- Tocilizumab impairs the production of CRP, which makes it unreliable as an infection parameter.- In case of a suspected infection in patients with severe immunosuppression, it will often be necessary to consult a specialist as quickly as possible about further diagnostic procedures and the need for, type and administration route of antimicrobials.- In patients with an impaired immunity, adaptation of the antibiotic policy and prophylactic measures, such as vaccination, may be indicated.- Patients with (functional) asplenia should immediately start antibiotic treatment in case of fever, pending clinical evaluation by a physician.

Effects of a multi-faceted program to increase influenza vaccine uptake among health care workers in nursing homes: A cluster randomised controlled trial.

Despite the recommendation of the Dutch association of nursing home physicians (NVVA) to be immunized against influenza, vaccine uptake among HCWs in nursing homes remains unacceptably low. Therefore we conducted a cluster randomised controlled trial among 33 Dutch nursing homes to assess the effects of a systematically developed multi-faceted intervention program on influenza vaccine uptake among HCWs. The intervention program resulted in a significantly higher, though moderate, influenza vaccine uptake among HCWs in nursing homes. To take full advantage of this measure, either the program should be adjusted and implemented over a longer time period or mandatory influenza vaccination should be considered.

Which determinants should be targeted to increase influenza vaccination uptake among health care workers in nursing homes?

Although health care workers (HCWs) have been recommended to be immunized against influenza, vaccine uptake remains low. So far, research on determinants of influenza vaccination among HCWs has been limited by design, population or theoretical framework. Therefore we conducted a questionnaire study in Dutch nursing homes to assess which demographical, behavioural and organisational determinants were associated with influenza vaccine uptake among HCWs. We were able to accurately predict vaccine uptake based on a 13-item prediction model including two demographical, nine behavioural and two organisational determinants developed with data from 1,125 respondents (response rate 60%). To further increase influenza vaccine uptake, implementation programs should target these determinants.

No intention to comply with influenza and pneumococcal vaccination: behavioural determinants among smokers and non-smokers.

OBJECTIVE: Smoking increases the risk for influenza and pneumococcal disease, but vaccination uptake is lower among smokers than non-smokers. We therefore aimed to determine reasons for not complying with vaccination among smokers and non-smokers. METHOD: In 2005 a self-administered questionnaire was sent to a random sample of Dutch patients (n=4,000) assessing medical, social and behavioural determinants. Independent factors associated with not complying with influenza and pneumococcal vaccination among smokers and non-smokers were assessed by multivariate logistic regression analysis. RESULTS: In all, 1,725 of 4,000 patients returned the questionnaire (response rate: 43%), 426 (25%) were smokers. Among smokers self-reported flu vaccine uptake was 42% and among non-smokers 52% among both only 0,2% received both vaccines. Most important predictors of not complying in smokers and non-smokers were patient's beliefs not to be susceptible to disease (odds ratio (OR) 4.0, 95% confidence interval (CI): 2.0, 8.0 and OR 2.8, CI: 2.0, 3.9), finding it difficult to go to the GP for vaccination (OR 2.5, CI: 1.3, 4.8 and OR 1.8, CI: 1.3, 2.6) and being against vaccination (OR 2.4 CI: 1.3, 4.4 and OR 1.8, CI: 1.3, 2.6), respectively. CONCLUSION: There are no substantial differences in determinants associated with not complying with influenza and pneumococcal vaccination between smokers and non-smokers but there is a trend towards stronger associations in smokers.

[Treatment of patients with herpes zoster by epidural injection of steroids and local anaesthetics: less pain after 1 month, but no effect on long-term postherpetic neuralgia--a randomised trial]. / Behandeling van patiënten met herpes zoster door epidurale injectie van steroïden en lokale anesthetica: minder pijn na 1 maand, maar geen effect op langdurige postherpetische pijn; gerandomiseerd onderzoek.

OBJECTIVE: To assess the effectiveness of a single epidural injection of steroids and local anaesthetics, as a supplement to the standard treatment, for the prevention ofpostherpetic neuralgia in older patients with herpes zoster. DESIGN: Open randomised trial. METHOD: In the period September 2001-February 2004, 598 patients, aged > 50 years, with acute herpes zoster (rash for < 7 days) below dermatome C6, were randomly assigned to receive either standard therapy (oral antiviral agents and analgesics) alone or standard therapy plus an additional single epidural injection of 80 mg methylprednisolone and 10 mg bupivacaine. The primary endpoint was the proportion of patients with zoster-associated pain one month after inclusion. The presence and severity of zoster-associated pain at other time points were secondary endpoints. RESULTS: At one month, pain was reported by 137 (48%) patients in the injection group versus 164 (58%) in the control group (relative risk; RR: 0.83; 95% CI: 0.71-0.97; p = 0.02). After three months, these values were 58 (21%) and 63 (24%), respectively (RR: 0.89; 95% CI: 0.65-1-21; p = 0.47), and at 6 months: 39 (15%) and 44 (17%) (RR: 0.85; 95% CI: 0.57-1-13; p = 0.43). No subgroups were detectable in which the relative risk for pain at one month after inclusion substantially differed from the overall estimate. At one month, the median severity of pain in the injection group was 2 (on a 100-points scale) versus 6 in the control group (p = 0.02). At later follow-up, there was no longer any statistically significant difference in the severity of pain between the two groups. No patient had major adverse events related to the epidural injection. CONCLUSION: A single epidural injection of steroids and local anaesthetics in the acute phase of herpes zoster resulted in a modest decrease in zoster-associated pain in the first month. This treatment did not, however, prevent long-term postherpetic neuralgia.

Rationale and design of the prevention of respiratory infections and management in children (PRIMAKid) study: a randomized controlled trial on the effectiveness and costs of combined influenza and pneumococcal vaccination in pre-school children with recurrent respiratory tract infections.

Health and economic burden of recurrent respiratory tract infections (RTIs) in early childhood is considerable. A systematic review of licensed influenza and pneumococcal vaccines showed substantial efficacy in children, but the health-economic impact of such vaccines among pre-school children with recurrent RTIs is unknown. We therefore, designed a double-blind randomized controlled trial to determine the effectiveness and costs of a combined influenza and pneumococcal vaccination program among a primary care based cohort of children with recurrent episodes of RTI aged between 18 and 72 months. We will enroll 690 children over three consecutive years (2003--2005) who will be randomly allocated to receive vaccinations against influenza and pneumococcal disease, influenza alone or hepatitis B in a similar schedule. Follow up by parental diaries, tympanic temperature measurements, questionnaires and interviews is planned until May 2006. Primary outcome is number of febrile RTIs. Other outcomes include duration and severity of RTI episodes, medical consumption, safety and costs.

The prevalence of bother, acceptance, and need for help in men with erectile dysfunction.

INTRODUCTION: Apart from knowledge on the prevalence of erectile dysfunction (ED), for clinical reasons it is important to obtain information on concern or bother and need for help. However, information is lacking on men with ED who need help but do not seek medical attention. Thus, this study aimed to assess the distribution of bother, acceptance, and need for help in men with ED, and assess characteristics of patients with ED in need for help but not receiving medical attention for ED. METHODS: A total of 5,721 men aged 18 years and older and registered in 12 general practices in the middle of the Netherlands were sent a questionnaire by mail about sexual problems, ED, need for help, and medical attention. Out of 2,117 questionnaires that were returned, 1,481 were completed on ED, bother, and need for help. RESULTS: The prevalence of ED (according to World Health Organization definition) in the 1,481 men was 14.2%. Of these men 67.3% were bothered, 68.7% did not accept ED, and 85.3% wanted help. Surprisingly, 41.9% of men who denied a need for help were bothered and 19.4% did not accept ED. Only 10.4% of men with ED received any medical care. Bother in men with ED was related to increasing age (decreasing above 60 years). Compared with men who already received help for ED, men who wanted help but did not receive it more often suffered from diabetes, neurological problems, and various cardiovascular problems. On the other hand, history of myocardial infarction increased the chance of getting adequate medical attention for ED. CONCLUSIONS: The majority of men with ED are concerned or bothered and perceive a need for help. Most of them do not receive any medical attention. These men are characterized by chronic medical conditions, visiting the physician's office regularly for their medical condition.

Erectile dysfunction in primary care: prevalence and patient characteristics. The ENIGMA study.

The availability of adequate treatment for erectile dysfunction (ED) triggers studies into the prevalence of ED in the general population. Yet, previous studies showed different prevalence estimates partly due to differences in patient selection, in (unclear) definitions of ED and in assessment. ENIGMA has been designed to study the prevalence of ED in the general population of The Netherlands, using the WHO definition with a description of the way of assessment. In all, 5721 mail surveys were sent to all men, aged 18 y and older in 12 general practices in The Netherlands. A total of 5601 were included in the study and 2117 (38%) were completed. A total of 38% of the men reported to have ever had some kind of erectile problem. The prevalence of ED was 17% (6% mild, 4% moderate and 7% complete). Age, diabetes, cardiovascular diseases, penile disorders, irradiation in the pelvic region, relational problems, fear for failure, surmenage, medication use and regular consumption of alcohol were independently related to ED. Men with ED were less content with their (sexual) life and had less confidence in sexual performance. Presence of ED was negatively related to affected happiness in life. ED is commonly found in men and is related to age, medication, comorbidity and lifestyle factors. Men with ED perceive a lower quality of (sex)life. Doctors should be aware of the presence of ED and its consequences in patients.

Impact of various questionnaires on the prevalence of erectile dysfunction. The ENIGMA-study.

The prevalence estimates of erectile dysfunction (ED) vary considerably across studies. These differences may be attributed to used definitions of ED. Quantitative data on the effect of different definitions of ED on the prevalence are lacking, because precise information on the used definition and questionnaire is often absent. Aim of this study was to quantify the effect of using different questionnaires for ED on the prevalence estimates. In all, 5721 mail surveys on sexual problems and ED were sent to all men (aged >18 y) in 12 general practices in the middle of the Netherlands of which 2117 were completed. The questionnaire contained Enigma (WHO), International Index of Erectile Function (IIEF), Cologne Erectile Inventory (KEED) and one question (Boxmeer, Krimpen). The prevalence of ED based on the various questionnaires and the effect of these questionnaires on risk factor relationships was compared. IIEF gave the highest age specific and overall ED prevalence, KEED the lowest. The difference in prevalence was 16.8%. The agreement (kappa coefficient) between the various ED definitions varied from 0.52 (IIEF & KEED) to 0.95 (Enigma & Boxmeer). The number of risk factor relations were similar for the Dutch studies, reduced for the IIEF and KEED. This study provides evidence that differences in questionnaires to assess ED have a considerable effect on the (age specific) prevalence estimates and little on the risk factor relations. The number of questions of the survey appears not to be responsible for differences in the prevalence of ED and risk factor relations, however they affect the response rate. Uniform use is strongly recommended, since a 'golden standard' for ED assessment (by questionnaire) is lacking. A short questionnaire with one or two questions is recommended for example the one from the Boxmeer-study. These data may be used to adjust (age-specific) prevalence rates comparing ED prevalence in the open population across studies.

Design of the Dutch prevention of influenza, surveillance and management (PRISMA) study.

Rationale and design of a study on the cost-effectiveness of the Dutch influenza vaccination campaign are described. During two influenza epidemics, about 75,000 primary care patients recommended for influenza vaccination are included. Cases have fatal or non-fatal influenza, pneumonia, otitis media, acute respiratory disease (ARD), heart failure, myocardial infarction, depression or diabetes dysregulation. Per case four controls are sampled, frequency matched on age and high-risk co-morbidity (<18 years, 18-64, >/=65 healthy, >/=65 with co-morbidity). Baseline and outcome data are retrieved from patient records. During the 1999-2000 influenza A epidemic 5891 (7.9%) high-risk children, 24,848 (33.2%) high-risk adults aged 18-64 years, 18,484 (24.7%) elderly with co-morbidity and 25,527 (34.1%) healthy elderly had been included. The mortality rate was 5.2 per 1000 and 2035 non-fatal outcome events were recorded (incidence rate 27.2/1000).

Confounding by indication in non-experimental evaluation of vaccine effectiveness: the example of prevention of influenza complications.

Randomised allocation of vaccine or placebo is the preferred method to assess the effects of the vaccine on clinical outcomes relevant to the individual patient. In the absence of phase 3 trials using clinical end points, notably post-influenza complications, alternative non-experimental designs to evaluate vaccine effects or safety are often used. The application of these designs may, however, lead to invalid estimates of vaccine effectiveness or safety. As patients with poor prognosis are more likely to be immunised, selection for vaccination is confounded by patient factors that are also related to clinical end points. This paper describes several design and analytical methods aimed at limiting or preventing this confounding by indication in non-experimental studies. In short, comparison of study groups with similar prognosis, restriction of the study population, and statistical adjustment for dissimilarities in prognosis are important tools and should be considered. Only if the investigator is able to show that confounding by indication is sufficiently controlled for, results of a non-experimental study may be of use to direct an evidence based vaccine policy.

Clinical effectiveness of conventional influenza vaccination in asthmatic children.

Influenza immunization rates among young asthmatics remain unsatisfactory due to persistent concern about the impact of influenza and the benefits of the vaccine. We assessed the effectiveness of the conventional inactivated trivalent sub-unit influenza vaccine in reducing acute respiratory disease in asthmatic children. We conducted a two-season retrospective cohort study covering the 1995-6 and 1996-7 influenza outbreaks in 22 computerized primary care practices in The Netherlands. In total, 349 patients aged between 0 and 12 years meeting clinical asthma-criteria were included; 14 children were lost to follow-up in the second season. The occurrence of physician-diagnosed acute respiratory disease episodes including influenza-like illness, pneumonia. bronchitis, bronchiolitis, asthma exacerbation and acute otitis media in vaccinated and unvaccinated children were compared after adjustments for age, prior health care and medication use. The occurrence of acute respiratory disease in unvaccinated children was 28% and 24% in the 1995-6 and 1996-7 season, respectively, and was highest in children under 6 years of age (43%). The overall pooled clinical vaccine effectiveness was 27% (95% confidence interval -7 to 51%, P = 0.11) after adjustments. A statistically higher vaccine protectiveness of 55% (95% CI 20-75%, P = 0.01) was observed among asthmatics under 6 years of age compared with -5% in older children (95% CI -81 to 39%). The occurrence of acute respiratory disease among asthmatic children during influenza epidemics is very high, notably in the youngest. Influenza vaccination may reduce morbidity in asthmatic infants and pre-school children. However, larger, preferably experimental, studies are needed to establish the benefits of vaccination, notably in older asthmatic children.