Long-term follow-up of the AVOD randomized trial of antibiotic avoidance in uncomplicated diverticulitis.

BACKGROUND: The aim of this study was to assess the long-term results in patients with uncomplicated diverticulitis who had participated in the Antibiotics in Acute Uncomplicated Diverticulitis (AVOD) RCT, which randomized patients with CT-verified left-sided acute uncomplicated diverticulitis to management without or with antibiotics. METHODS: The medical records of patients who had participated in the AVOD trial were reviewed for long-term results such as recurrences, complications and surgery. Quality-of-life questionnaires (EQ-5D™) were sent to patients, who were also contacted by telephone. Descriptive statistics were used for the analysis of clinical outcomes. RESULTS: A total of 556 of the 623 patients (89·2 per cent) were followed up for a median of 11 years. There were no differences between the no-antibiotic and antibiotic group in recurrences (both 31·3 per cent; P = 0·986), complications (4·4 versus 5·0 per cent; P = 0·737), surgery for diverticulitis (6·2 versus 7·1 per cent; P = 0·719) or colorectal cancer (0·4 versus 2·1 per cent; P = 0·061). The response rate for the EQ-5D™ was 52·8 versus 45·2 per cent respectively (P = 0·030), and no differences were found between the two groups in any of the measured dimensions. CONCLUSION: Antibiotic avoidance for uncomplicated diverticulitis is safe in the long term.

ANTECEDENTES: El objetivo de este estudio fue evaluar los resultados a largo plazo con respecto a las recidivas, las complicaciones, la cirugía y la calidad de vida (quality of life, QOL) en pacientes con diverticulitis no complicada que participaron en el ensayo clínico aleatorizado Antibióticos en la Diverticulitis Aguda no Complicada (Antibiotics in Acute Uncomplicated Diverticulitis, AVOD). MÉTODOS: Los pacientes con diverticulitis aguda no complicada del lado izquierdo diagnosticada mediante tomografía computarizada se aleatorizaron a los tratamientos sin o con antibióticos en el ensayo AVOD (previamente publicado). Las historias clínicas de los pacientes que participaron en el ensayo se revisaron para conocer resultados a largo plazo, tales como recidivas, complicaciones y cirugía. Se enviaron cuestionarios de calidad de vida (EQ-5D) a los pacientes a los que también se contactó por teléfono. RESULTADOS: Un total de 556 de los 623 pacientes (89,2%) fueron seguidos durante una mediana de 11 años. No hubo diferencias en la recidiva (86 versus 88; P = 0,986), complicaciones (12 versus 14; P = 0,737), cirugía por diverticulitis (17 versus 20; P = 0,719) o cáncer colorrectal (1 versus 6; P = 0,061) entre el grupo sin antibióticos y el grupo con antibióticos. La tasa de respuesta para el EQ-5D fue de 163 frente a 142 (P = 0,030), y no se encontraron diferencias en ninguna de las dimensiones medidas entre los grupos sin antibióticos y con antibióticos. CONCLUSIÓN: El tratamiento de la diverticulitis no complicada evitando la administración de antibióticos fue seguro a largo plazo.

Outpatient, non-antibiotic management in acute uncomplicated diverticulitis: a prospective study.

PURPOSE: The aim of this study was to evaluate outpatient, non-antibiotic management in acute uncomplicated diverticulitis with regard to admissions, complications, and recurrences, within a 3-month follow-up period. METHODS: A prospective, observational study in which patients with computer tomography-verified acute uncomplicated diverticulitis were managed as outpatients without antibiotics. The patients kept a personal journal, were contacted daily by a nurse, and then followed up by a surgeon at 1 week and 3 months. RESULTS: In total, 155 patients were included, of which 54 were men; the mean age of the patients was 57.4 years. At the time of diagnosis, the mean C-reactive protein and white blood cell count were 73 mg/l and 10.5 × 10(9), respectively, and normalized in the vast majority of patients within the first week. The majority of the patients (97.4%) were managed successfully as outpatients without antibiotics, admissions, or complications. In only four (2.6%) patients, the management failed because of complications in three and deterioration in one. These patients were all treated successfully as inpatients without surgery. Five patients had recurrences and were treated as outpatients without antibiotics. Follow-up colonic investigations revealed cancer in two patients and polyps in 13 patients. CONCLUSION: Previous results of low complication rates with the non-antibiotic policy were confirmed. The new policy of outpatient management without antibiotics in acute uncomplicated diverticulitis is now shown to be feasible, well functioning, and safe.

Fluctuating functions related to quality of life in advanced Parkinson disease: effects of duodenal levodopa infusion.

OBJECTIVE: To assess fluctuations in quality of life (QoL) and motor performance in patients with advanced Parkinson disease (PD) treated with continuous daytime duodenal levodopa/carbidopa infusion or conventional therapy. METHODS: Of 18 patients completing a 6-week trial (DIREQT), 12 were followed for up to 6 months and assessed using electronic diaries and the PD Questionnaire-39 (PDQ-39). RESULTS: During the trial and follow-up, major diurnal fluctuations were observed, especially for hyperkinesia, 'off' time, ability to walk and depression. Duodenal infusion was associated with significantly more favourable outcomes compared with conventional treatment for satisfaction with overall functioning, 'off' time and ability to walk, with improved outcomes with PDQ-39. CONCLUSIONS: Relative to conventional treatment, infusion therapy may stabilize and significantly improve motor function and patient's QoL. The potential for daily fluctuation in PD symptoms means single measures of treatment effectiveness can result in bias in effect estimates and hence repeated measures are recommended.

Self-reported dermatological problems and use of prescribed topical drugs correlate with decreased quality of life: an epidemiological survey.

BACKGROUND: Skin problems are common in the population. Although a substantial fraction of the population suffers from skin conditions, we still have little information on how this affects the everyday life of the individuals concerned. OBJECTIVES: To evaluate the impact of skin disease on health-related quality of life (HRQOL) measured with the Short Form-36 (SF-36), a multidimensional generic HRQOL instrument, from an epidemiological perspective. A further aim was to study differences in HRQOL by use of non-prescription and prescription dermatological drugs. METHODS: The survey was carried out in the county of Uppland, Sweden in a random sample of 8000 individuals aged 20-84 years, of whom 5404 (68%) answered the questionnaire. RESULTS: A large part of the population (20.5%) reported dermatological problems and/or use of topical dermatological drugs, with a higher frequency among women (23.3%) than men (17.3%). Persons reporting dermatological problems scored lower on all eight dimensions of the SF-36. This pattern, although weaker, persisted after adjusting for comorbid somatic as well as psychiatric diseases and complaints. Those using topical dermatological drugs on prescription generally scored lower than the other groups with skin problems: in particular, they evaluated personal health as poorer (general health perceptions), perceived more limitations in daily activities (role limitation because of emotional health problems) and felt more tired and worn out (vitality). CONCLUSIONS: The study shows that skin disorders constitute a substantial problem in the population and cause a significant decrease in HRQOL. Furthermore, the results of this population survey point out the need for further population-based studies more specifically aimed at dermatological problems and HRQOL.

Attitudes towards drugs--a survey in the general population.

BACKGROUND: Studies have shown that many drugs have a lower effectiveness in clinical practice than would be expected from results reported in randomised controlled clinical trials. Many factors influence the use of drugs. Personal factors such as knowledge, attitudes, motivation, expectations are considered to be of particular consequence. The aim of the study was to analyse attitudes towards drugs from an epidemiological perspective. DESIGN: Cross-sectional survey SETTING: The county of Uppsala, Sweden, 1995. RESULTS: 5,404 completed the questionnaire (response rate = 68%). A majority either considered drugs as something positive, a help (60%), or as something necessary but evil (38%). A small proportion--around 2%--considered drugs as a danger. There were differences in attitudes according to education and income, self-care orientation, medication knowledge, and state of health. We also found differences in attitudes between users and non-users of certain types of drugs. Users of hypertensive drugs more often considered drugs as necessary but evil than did non-users of these drugs, while users of psychotropic drugs more often viewed drugs as something positive than did patients who did not use psychotropic drugs. CONCLUSION: A better understanding of the general attitudes towards drugs is important when giving both written and oral information to patients and to the public at large. It is also important to be aware of differences in attitudes between various patient groups and that certain patients, e.g., patients prescribed hypertensive drugs, could require more attention from health care professionals.

Epidemiology of analgesic use: a gender perspective.

BACKGROUND AND OBJECTIVE: Women consistently report significantly more frequent analgesic use in epidemiological studies. The aim of this study was to analyse the influence of medical and non-medical factors on the difference in use of analgesics between women and men from a population perspective. METHODS: Cross-sectional survey. Postal questionnaires were sent to a random sample of the general population in the country of Uppland, Sweden (5404 answered the questionnaire, response rate: 68%). RESULTS: 34.8% of the women and 21.4% of the men had used analgesics during the two week recall period (Odds Ratio = 1.96). Social structure, social status, marital status, educational level, economic situation, lifestyle, attitudes toward drugs, medication knowledge and self-care orientation were of minor importance for the difference in use between women and men. Difference in prevalence of various types of pain and ache and the degree of pain experienced were the most influential factors affecting the difference in use. However, when all factors were analysed there remained a substantial difference in use between women and men (OR = 1.39, CI (95%) 1.20 to 1.60). CONCLUSIONS: In the population, women use analgesics much more frequently than men. Consequently women may be at greater risk for adverse effects and dependency. Some of the gender difference is explained by the greater frequency of pain conditions among women, but a significant difference in use still remains to be explained.

Adolescent use of anabolic-androgenic steroids and relations to self-reports of social, personality and health aspects.

BACKGROUND: Over the last decade adolescent males have been shown to use anabolic-androgenic steroids (AAS) in order to improve their sports performance and appearance, as well as in combination with alcohol and psychotropic drugs. However, the risk profile of AAS use is still not well understood. This study analysed the importance of social, personality and health factors for the use of AAS. METHODS: More than 2,700 senior high school students in Uppsala, Sweden, filled out an anonymous closed-response questionnaire. RESULTS: The findings from multiple logistic regression analyses of adolescent males (n = 1,353) showed that immigrant status, average/low self-esteem, average/low perceived school achievement and use of prescription tranquillisers/sedatives had independent significant associations with the use of AAS after controlling for age and previously known factors such as strength training, truancy and heavy alcohol consumption. CONCLUSION: The characteristics of AAS users extend beyond activities such as strength training and multiple drug use to include social, personality and health aspects.

Self-rated health as a predictor of mortality among persons with cardiovascular disease in Sweden.

AIMS: This study analyses the association between cardiovascular diseases with and without drug treatment, self-rated health, and all-cause mortality during a 12-year period. METHODS: Genetic and familial environmental effects were controlled for in subsets of the analyses. Data for these analyses were collected in 1984, 1987, 1990, and 1993 as part of the Swedish Adoption/Twin Study of Aging (SATSA), and through record linkage to mortality data from the National Cause of Death Register through 1996. RESULTS: In multivariate analyses, both cardiovascular disease and low self-rated health were associated with higher mortality. Age, sex, lifestyle, diabetes, respiratory problems, cancer, depression, marital status, and social network were controlled for in the analyses. Furthermore, development of cardiovascular disease and/or drug use is associated with a decline in perceived health and higher mortality rates. The co-twin control analyses suggest that drug-treated cardiovascular disease has a marginal effect on survival beyond the effects of bad self-rated health and genetic liability to a certain survival time. CONCLUSIONS: This study shows that subjective health ratings are important predictors of mortality for persons with cardiovascular disease.

Hypertension and health-related quality of life. an epidemiological study in Sweden.

The aim of this study was to describe the relationship between hypertension and health-related quality of life (HRQL) in a Swedish general population using the 36-item short form questionnaire (SF-36). The study is based on a postal questionnaire that was sent to a random sample of 8000 inhabitants aged 20-84 years (response rate 68%) in Uppsala County, Sweden, in 1995. The results showed that those with hypertension scored lower in the linear regression analyses in most of the eight domains of the SF-36 than those without hypertension after controlling for age, sex, sociodemographic factors, and comorbidity. Diabetes and angina pectoris were related to lower scores in most of the domains of the SF-36. Previous myocardial infarction was associated with lower general health and vitality. Those with a previous stroke had lower scores in physical functioning, general health, vitality, and social functioning. The findings suggest that hypertensives represent a vulnerable population that merits special attention from health care providers and systems. This is especially important given that low HRQL can be a risk factor for subsequent cardiovascular events or complications.

Self-reported side-effects of antihypertensive drugs: an epidemiological study on prevalence and impact on health-state utility.

The aim in this study was to assess the frequency and type of self-reported side-effects among hypertensives in a general population, and to estimate the relationship between drug use and side-effects and health utility using the Rating Scale (RS) method. The study is based on a postal questionnaire that was sent to a random sample of 8000 inhabitants aged 20-84 years (response rate 68%) in Uppsala County, Sweden, in 1995. The results showed that nearly 20% of the users of antihypertensive drugs reported side-effects. Men and women reported side-effects to nearly the same extent. In the linear regression analyses, those with hypertension, with or without medication, rated lower health utilities (-6.0 and -7.1 respectively) than did normotensives after controlling for age and sex. The lowest value, -8.7, was found among drug users who experienced side-effects. Side-effects causing impotence and emotional distress, i.e. insomnia, tiredness and depression had the strongest negative impact on health utility. To conclude, the study showed that side-effects among hypertensives are common. Both the disease and the drug treatment adversely affect the patient's well-being. However, drug treatment was of less importance than that found in prior studies. The findings here stress that side-effects should be taken into greater consideration when evaluating drug treatment.

Factors associated with adolescent use of doping agents: anabolic-androgenic steroids.

AIMS: The purpose was to assess the importance of risk factors such as socio-demographics, sports activities, tobacco use, alcohol consumption, use of certain psychotropic substances and violence in the use of doping agents in adolescents. DESIGN: Cross-sectional survey using anonymous closed response questionnaire. SETTING: Eight senior high schools in Uppsala, Sweden. PARTICIPANTS: A total of 2742 senior high school students; 1592 were in their first year (aged 16-17 years) and 1150 in their third (aged 18-19 years). FINDINGS: Multiple logistic regression analyses revealed that strength training, tobacco use, heavy alcohol consumption, truancy at least once a week and living alone were significantly independently associated in the use of doping agents. Further, the study showed that use of cannabis oil, LSD, amphetamine and opioids were related specifically to anabolic-androgenic steroid use. CONCLUSIONS: Use of doping agents probably involves more than a desire to enhance appearance or sports performance and appears to have much in common with use of alcohol, tobacco and psychotropic drugs.

Drugs up in smoke: a study of caseated drugs in Sweden.

DESIGN: Cross-sectional survey. SETTING: The county of Malmöhus, with 817,000 inhabitants, in the far south of Sweden. All drugs handed in for destruction to the 65 pharmacies during one week in March 1996 were analysed. RESULTS: 92% of the packages were prescription drugs for human use, 7% were over-the-counter drugs, and 1% were for veterinary use. Slightly less than half (48%) had expired when they were handed in for destruction. 36% were unbroken when returned and another 18% of the packages were nearly full. A comparison between the drugs sent in for destruction and the drugs sold in the county gave a ratio of 0.030. Antineoplastic and immunosuppressive drugs, drugs for the respiratory system, antiparasitic products, and cardiovascular drugs were returned to a greater extent than other types of drugs. Drugs for the genito-urinary tract, sex hormones, and drugs for the alimentary tract were returned to a lesser extent. Extrapolated to a whole year the value of caseated drugs was estimated to 60 SEK (5.83 Br,) per person. The value of unbroken packages was 20 SEK (1.94 Br,) per person per year. CONCLUSION: Although not all of the drugs handed in for destruction could have been unnecessarily prescribed or obtained by the patient, a more cautious approach to prescribing of drugs would likely yield significant savings.

The impact of over-the-counter availability of nasal sprays on sales, prescribing, and physician visits.

OBJECTIVE: The aim was to study changes in sales and prescribing of nasal decongestants containing oxymetazoline or xylometazoline, changes in number of physician visits for rhinitis and sinusitis, and changes in public expenditures for physician visits due to the switch of these drugs from prescription to over-the-counter status in Sweden in 1989. DESIGN: Retrospective registry study using the local sales statistics on medicines in the municipality of Tierp from The National Corporation of Swedish Pharmacies and the individual-based computerised registry in Tierp based on health care utilisation and drug use from the Centre for Primary Care. Analyses were carried out during the time period 1988-1995. SETTING: The Swedish community of Tierp with about 20,000 inhabitants. SUBJECTS: The population of Tierp. MAIN OUTCOME MEASURE: Sales of nasal decongestants and dispensed prescriptions of nasal decongestants, physician visits for rhinitis and sinusitis, and public expenditures for these. RESULTS: Sales of nasal sprays increased, while sales of nasal drops decreased. The number of dispensed prescriptions as well as physician visits decreased. The public expenditures estimated for physician visits decreased as well. CONCLUSION: This study shows an increase in sales of nasal decongestants and a significant decrease in prescribing of nasal decongestants and the number of physician visits for rhinitis and sinusitis as well as the public expenditures estimated for these, after the switch from prescription to over-the counter status of nasal sprays in 1989.

The relationship between health-state utilities and the SF-12 in a general population.

It would be a major advance if quality-of-life instruments could be translated into health-state utilities. The aim with this study was to investigate the relationship between the SF-12 and health-state utilities, based on responses to a postal questionnaire sent to a random sample of 8,000 inhabitants, aged 20-84 years, in the general population. The questionnaire included the SF-12, a rating-scale (RS) question, and a time-tradeoff (TTO) question; the response rate was 68%. Age, gender, and the 12 items of the SF-12 were used as explanatory variables in a linear regression analysis of the health-state utilities. The regression models explained about 50% of the variance in the RS answers and about 25% of the variance in the TTO answers. Most of the SF-12 items were related to the health-state utilities in the expected ways, with especially strong results for the RS method. The results suggest that the SF-12 can be converted to health-state utilities, but that further work is needed to reliably estimate the conversion function.

A note on validating Wagstaff and van Doorslaer's health measure in the analysis of inequalities in health.

The aim of this note is to validate Wagstaff and van Doorslaer's approach of constructing a continuous health measure to be used in the analysis of inequalities in health. We calculate health concentration indices for Uppsala County in Sweden based on three different health status measures: health measured according to the WvD approach based on a self-assessed categorical health measure, health measured by the rating scale method, and health measured by the time trade-off method. The concentration index does not differ significantly for the three health status measures, and our results thus support the validity of the WvD method.

Self-rated health among cardiovascular drug users in a study of Swedish twins.

The aim of this study was to analyse the relationship between self-perceived health and cardiovascular disease with and without drug treatment. Mental health and genetic effects were controlled for in the analyses. The data for these analyses were collected in 1984 as part of the Swedish Adoption/Twin Study of Aging (SATSA). In the first set of analyses, 1147 persons (mean age 60 years, 72% older than 50 years) were included. In the second part of the study, twin pairs discordant with respect to having a cardiovascular disease and/or drug use were included in the analyses. Cardiovascular disease was related to poor, self-rated health among both men and women. The proportion with bad health was largest among those with a drug-treated disease. In multivariate analyses, a strong relationship between cardiovascular disease, drug therapy and low self-rated health remained after controlling for mental health. The co-twin control analyses indicate that cardiovascular drugs have at most a marginal negative effect on health beyond the effects of the disease and genetic liability to self-perceived poor health.

Concomitant prescribing of tranquilizers and hypnotics among patients receiving antidepressant prescriptions.

OBJECTIVE: To evaluate concomitant prescribing of tranquilizers and hypnotics in antidepressant treatment with particular focus on the relationship to drug class in patients prescribed antidepressant treatment for depressive disorders. DESIGN AND METHODS: Repeated cross-sectional surveys of Swedish physicians in ambulatory care from 1991 to 1996, including specialty practices. The participation rate was 65-70%. RESULTS: Tranquilizers and hypnotics were prescribed in 36.1% of the visits in which the intention was to treat depression. Concomitant prescribing increased with the patient's age for all antidepressant drug classes. Women received more concomitant prescriptions than men when treated with nonselective monoamine-reuptake inhibitors (NSMRI), mainly tricyclic compounds. Psychiatrists prescribed more concomitant tranquilizers and hypnotics than other physicians, and general practitioners fewer, when treating depression with selective serotonin-reuptake inhibitors (SSRIs), mainly citalopram. A logistic regression model showed that the risk for concomitant prescribing was higher when an NSMRI was prescribed than with other antidepressants. CONCLUSIONS: Concomitant prescribing of tranquilizers and hypnotics was common among antidepressant-treated patients. The most plausible reasons for the high rate of concomitant prescribing were the symptoms of the depression itself and/or the common comorbidity with anxiety disorders seen in this group of patients. The results of this study indicate that the concern about increased tranquilizer and hypnotic use among patients treated with SSRIs suggested in other studies seems to be unfounded in Sweden.

Effects of user charges on the use of prescription medicines in different socio-economic groups.

This study examined the sensitivity towards increases in user charges for different types of drugs and among different socio-economic groups. It was based on responses by 2008 consumers of prescription drugs to a self-administered postal questionnaire sent to a random sample of 8000 inhabitants in Uppsala County in Sweden. The questionnaire included a question about whether the respondents would use fewer prescription drugs if the user charges increased by a specific amount. The increase in user charges was varied between 9 and 150% in five different subsamples. Logistic regression analysis was used to estimate the probability that a respondent would reduce consumption of prescription drugs as a function of the size of the user charges increase, socio-economic characteristics and the type of drug used. Results showed that the price sensitivity decreased with increasing age, income, education and self-rated health status. Price sensitivity was highest for antitussives and lowest for climacteric drugs. If the user charges doubled, 40% of antitussives users would reduce their consumption whereas only 11% of climacteric drugs users would reduce their consumption. It is concluded that sensitivity to increases in user charges varied greatly between different types of drugs and between socio-economic groups. The young, those with poor health status, low education and low income are most likely to decrease consumption of prescription drugs when user charges increase.

Headache and analgesic use in Sweden.

In this study, patterns of analgesic use among persons with headache in the general Swedish population were analyzed in association with health factors, health care utilization, sociodemographic factors, and life-style. Data from the Swedish Survey of Living Conditions for the 2-year period 1988 through 1989 were used. In this survey, a probability sample of the Swedish population aged 16 years and older was interviewed. Persons with headache were identified by the question, "Have you (during the last 2 weeks) had recurrent headache or migraine?" Analgesic use was defined by the question, "Have you (during the last 2 weeks) used prescription or nonprescription analgesics?" Persons who answered both these questions were included in the present study, yielding a study population of 11,975 persons. Sixteen percent of all women and 8.2 percent of all men reported headache. Seventy-four percent of all women with headache reported analgesic use as compared to 64% of all men with headache. Analgesic use increased with increasing age among women but not men. While few of the studied factors were associated with analgesic use among persons with headache, the associations found differed by gender. Poor social network and musculoskeletal pain were associated with analgesic use among men with headache; age, being underweight, and visits to a physiotherapist were associated with analgesic use among women with headache. Those studying medication use among persons with headache might consider including these factors in future studies to help better understand the mechanisms behind the decision to use or avoid analgesics.