Is asthma in 2-12 year-old children associated with physician-attended recurrent upper respiratory tract infections?

Antibiotic use in children and youths with asthma: a population-based case-control study

RATIONALE

Antibiotics are among the most common medications dispensed to children and youths. The objective of this study was to characterise and compare antibiotic use patterns between children and youths with and without asthma.

METHODS

We conducted a population-based nested case-control study using health administrative data from Ontario, Canada, in 2018. All Ontario residents aged 5-24 years with asthma were included as cases. Cases were matched to controls with a 1:1 ratio based on age (within 0.5 year), sex and location of residence. Multivariable conditional logistic regression was used to obtain an odds ratio and 95% confidence interval for having filled at least one antibiotic prescription, adjusted for socioeconomic status, rurality, and presence of common infections, allergic conditions and complex chronic conditions.

RESULTS

The study population included 1 174 424 Ontario children and youths aged 5-24 years. 31% of individuals with asthma and 23% of individuals without asthma filled at least one antibiotic prescription. The odds of having filled at least one antibiotic prescription were 34% higher among individuals with asthma compared to those without asthma (OR 1.34, 95% CI 1.32-1.35). In the stratified analysis, the odds ratios were highest in the youngest group of children studied, aged 5-9 years (OR 1.45, 95% CI 1.41-1.48), and in females (OR 1.36, 95% CI 1.34-1.38).

CONCLUSION

Asthma is significantly associated with increased antibiotic use in children and youths. This association is the strongest in younger children and in females.

Comorbidity in patients with cardiovascular disease in primary care: a cohort study with routine healthcare data

BACKGROUND

Comorbidity is a major public health issue, which challenges health care configured around single diseases.

AIM

To provide an overview of frequent disease combinations of one and two additional chronic diseases and groups among patients with cardiovascular disease (CVD) in general practice.

DESIGN AND SETTING

Medical record data from the Julius General Practitioners' Network of 226 670 patients registered in 2015-2016 in Utrecht, the Netherlands, were collected and examined.

METHOD

Prevalences and combinations of one and two comorbid conditions were determined, by age and sex, in four populations of patients with CVD: heart failure, peripheral arterial disease (PAD), coronary heart disease (CHD), or stroke. Using logistic regression analyses, the authors examined whether comorbid conditions were significantly more prevalent in patients with a specific cardiovascular condition compared with those without.

RESULTS

Low vision, diabetes mellitus, back/neck problems, osteoarthritis, chronic obstructive pulmonary disease (COPD), and cancer were the most prevalent non-cardiovascular conditions and ranked in the top five of non-cardiovascular comorbid conditions in the different CVDs studied, irrespective of patient age and sex. Of these, diabetes, COPD, and low vision were statistically significantly more prevalent in all four cardiovascular conditions when compared with patients without the respective disease. Over the life span, the majority of the comorbid conditions were most prevalent in patients with heart failure, directly followed by those with PAD; they were less prevalent in patients with CHD and stroke.

CONCLUSION

Comorbid conditions are very common in patients with CVD, even in younger age groups. To ensure efficient and effective treatment, organisational adaptations may be required in the healthcare system to accommodate comorbid conditions in patients with CVD.

Do GPs know their patients with cancer? Assessing the quality of cancer registration in Dutch primary care: a cross-sectional validation study

OBJECTIVES

To assess the quality of cancer registry in primary care.

DESIGN AND SETTING

A cross-sectional validation study using linked data from primary care electronic health records (EHRs) and the Netherlands Cancer Registry (NCR).

POPULATION

290 000 patients, registered with 120 general practitioners (GPs), from 50 practice centres in the Utrecht area, the Netherlands, in January 2013.

INTERVENTION

Linking the EHRs of all patients in the Julius General Practitioners' Network database at an individual patient level to the full NCR (∼1.7 million tumours between 1989 and 2011), to determine the proportion of matching cancer diagnoses. Full-text EHR extraction and manual analysis for non-matching diagnoses.

MAIN OUTCOME MEASURES

Proportions of matching and non-matching breast, lung, colorectal and prostate cancer diagnoses between 2007 and 2011, stratified by age category, cancer type and EHR system. Differences in year of diagnosis between the EHR and the NCR. Reasons for non-matching diagnoses.

RESULTS

In the Primary Care EHR, 60.6% of cancer cases were registered and coded in accordance with the NCR. Of the EHR diagnoses, 48.9% were potentially false positive (not registered in the NCR). Results differed between EHR systems but not between age categories or cancer types. The year of diagnosis corresponded in 80.6% of matching coded diagnoses. Adding full-text EHR analysis improved results substantially. A national disease registry (the NCR) proved incomplete.

CONCLUSIONS

Even though GPs do know their patients with cancer, only 60.6% are coded in concordance with the NCR. Reusers of coded EHR data should be aware that 40% of cases can be missed, and almost half can be false positive. The type of EHR system influences registration quality. If full-text manual EHR analysis is used, only 10% of cases will be missed and 20% of cases found will be wrong. EHR data should only be reused with care.

Primary care management of women with breast cancer-related concerns-a dynamic cohort study using a network database

The aim of this study was to determine the incidence, management and diagnostic outcomes of breast cancer-related concerns presented in primary care. A dynamic cohort study was performed in the anonymised routine electronic medical records (EMRs) extracted from 49 General Practices in the Netherlands (163,471 person-years, women aged 18-75). Main Outcome Measures were: (1) incidence rates for breast cancer-related concerns in Primary Care, (2) proportions of these women with and without symptoms of the breast referred for further investigation, (3) proportions of referrals (not) according to the guideline and (4) proportions of women with breast cancer-related concerns diagnosed with breast cancer during follow-up. Breast cancer-related concerns are presented frequently in Primary Care (incidence rate 25.9 per 1,000 women annually). About half these women are referred for further investigation. There is room to improve General Practitioner management, mainly for women with an increased lifetime risk of developing breast cancer. Information concerning family history of cancer is often missing in the EMR. Since cancer is rarely diagnosed during follow-up, particularly when symptoms are absent, reduction of unnecessary concerns is plausible if identification of those without an increased risk is improved.

Treatment of acute rhinosinusitis: discrepancy between guideline recommendations and clinical practice

BACKGROUND

A revised primary care guideline on acute rhinosinusitis (ARS) has been introduced in the Netherlands in 2005, which advocates a more judicious use of antibiotics.

OBJECTIVE

To investigate whether consultation and prescription rates for ARS in adults changed over recent years in order to provide information on family physicians' behaviour before and after introduction of the revised guideline.

METHODS

Retrospective cohort study. All adult patients within the computerized database of Utrecht Primary Care Research Network over the years 2000-09 were included. Clinical diagnoses of ARS were recorded according to the International Classification of Primary Care codes (R75 and/or R09) and drug prescriptions according to the Anatomical Therapeutic Chemical Classification System.

RESULTS

ARS consultation rates revealed a stable pattern, with an average consultation rate of 29 episodes per 1000 person-years. From 2000 to 2005, the antibiotic prescription rate increased from 56 to 62 prescriptions per 100 episodes (P value for time trend <0.05). From 2005 onwards, the antibiotic prescription rate decreased to 56 per 100 episodes in 2009 [rate difference (RD): -6, 95% confidence interval (CI): -10 to -1; P value for difference between 2000-05 and 2005-09 <0.05]. From 2005 to 2009, intranasal corticosteroid (INCS) prescription rate increased from 20 to 31 prescriptions per 100 episodes (RD: 11, 95% CI: 7 to 15; P value for difference between 2000-05 and 2005-09 <0.01). Oral corticosteroid prescription and referral rates remained low.

CONCLUSIONS

Despite strong guideline recommendations to restrict the use of antibiotics and INCS, we found only a modest decrease in antibiotic prescription rates, whereas INCS prescription rates even increased.

Assessment of the association between atopic conditions and tympanostomy tube placement in children

This study assesses the relationship between otitis media and atopic conditions in children by comparing the incidence of tympanostomy tube placement between children with and without atopic conditions: asthma, allergic rhinitis, and atopic dermatitis. Study subjects were a cohort of 323 healthy children who participated in a study of vaccine response. All episodes of tympanostomy tube placement and physician diagnoses of allergic rhinitis and atopic dermatitis were collected through comprehensive medical record review. Asthma status was ascertained through application of established criteria. We compared incidence rates of tympanostomy tube placement between children with and without atopic conditions. We fitted data to a Poisson regression model to calculate relative risk ratios (RRs) and their corresponding 95% confidence intervals (95% CI). Three subjects were excluded who did not have parental authorization for using records for research. Of the remaining 320 subjects, 170 (53%) were male subjects, 268 (94%) were white, 124 (39%) were asthmatic patients, and 20 (6%) had tympanostomy tube placement. Children with asthma before the index date of tympanostomy tube placement were more likely to have tympanostomy tube placement compared with those without asthma (RR, 19.33; 95% CI, 11.41; 32.75; p < 0.001). We found a similar association between asthma ever (before or after index date) and the incidence of tympanostomy tube placement (RR, 1.53; 95% CI, 0.93-2.53; p = 0.095). This was true for children with allergic rhinitis compared with those without allergic rhinitis (RR, 1.70; 95% CI, 1.01-2.86; p = 0.007). Atopic dermatitis was not associated with the incidence of tympanostomy tube placement. Asthma or allergic rhinitis may be unrecognized risk factors for recurrent or persistent otitis media. However, given the small sample size of the study, a cohort study with a larger sample size is necessary.

[Diagnosis and treatment guidelines for difficult-to-control asthma in children]

Children suffering from difficult-to-control asthma (DCA) require frequent appointments with their physician, complex treatment regimes and often admissions to hospital. Less than 5% of the asthmatic population suffer this condition. DCA must be correctly characterised to rule out false causes of DCA and requires making a differential diagnosis from pathologies that mimic asthma, comorbidity, environmental and psychological factors, and analysing the factors to determine poor treatment compliance. In true DCA cases, inflammation studies (exhaled nitric oxide, induced sputum, broncho-alveolar lavage and bronchial biopsy), pulmonary function and other clinical aspects can classify DCA into different phenotypes which could make therapeutic decision-making easier.

Adverse reactions to simultaneous influenza and pneumococcal conjugate vaccinations in children: randomized double-blind controlled trial

In a randomized double-blind controlled trial, the safety was assessed of simultaneous administration of influenza and pneumococcal conjugate vaccines in children with previous physician-diagnosed respiratory tract infections. In total, 579 children aged 18-72 months were assigned to receive simultaneous intramuscular influenza and pneumococcal heptavalent conjugate vaccinations (IV + PV), influenza and placebo vaccinations (IV + plac) or control hepatitis B and placebo vaccinations (HepB + plac) in separate extremities. Local and systemic adverse events were recorded in parental diaries for 7 days after vaccination. No immediate adverse reactions were recorded. In most children local adverse reactions disappeared 2 days after vaccination. Local and systemic reactions were more prevalent (30% and 10% more) in the IV + PV group compared with the IV + plac and HepB + plac group. These results are important for designing future vaccination schedules.

Antibiotics and allergic disorders in childhood

AIM

This paper explores the possible association between antibiotics prescribed in infancy and allergic disorders, mainly eczema and asthma, in childhood.

BACKGROUND

No-one fully understands why childhood asthma and eczema have become so common. Some authorities suggest that there may be an association between eczema and asthma and antibiotics prescribed in childhood; however, others disagree. METHOD/EVALUATION: The available literature was reviewed to examine the links between prescribed antibiotics and childhood eczema and asthma. FINDINGS/KEY ISSUE: Some, but not all, research indicates that antibiotic administration in pregnancy, childbirth or infancy may be linked to childhood asthma and eczema, but much uncertainty remains. None of the papers identified stated the doses of antibiotics prescribed. In addition, we were unable to locate studies reporting the interactions between antibiotics and the developing immune system.

CONCLUSION

Health care professionals should be selective when prescribing antibiotics. Further prospective work is needed to guide the prescribing of antibiotics in childbirth and infancy.

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.

Acute otitis media in schoolchildren: allergic diseases and skin prick test positivity

CONCLUSIONS

Single and repeated episodes of acute otitis media (AOM) in 10-year-old children were associated with reported allergic disease. Further, skin prick test (SPT)-negative children with reported asthma and allergic rhinoconjunctivitis had increased risk of AOM. We suggest that optimal treatment of allergic symptoms may have an effect on AOM in school children.

OBJECTIVE

The objective of the study was to estimate associations between AOM, allergic diseases and SPT positivity in 10-year-old children.

MATERIALS AND METHODS

Population-based cross-sectional study of 3406 10-year-old children living in Oslo. Main outcome measures were questionnaire-based information on AOM and reported physician-diagnosed allergic diseases with symptoms during the last year. In addition, 2657 children were skin prick tested. Logistic regression analyses were performed to estimate associations and control for potential confounders.

RESULTS

One or more episodes of AOM were present in 13.8% (n=470) of the children; 9.7% (n=331) had single episodes, while 4.1% (n=139) had two or more infections. We found a statistically significant association between AOM and reported allergic diseases, strongest for AOM and asthma with odds ratio 2.7 (95% confidence interval 1.8-4.0) and 2.3 (95% confidence interval 1.3-4.3) for single and two or more episodes of AOM, respectively. The risk for AOM was increased in asthmatic SPT-negative children compared with asthmatic SPT-positive children, the odds ratios were 3.0 (1.7-5.4) and 1.5 (0.8-2.8), respectively. The same tendency was found for allergic rhinoconjunctivitis.

Primary care management of respiratory tract infections in Dutch preschool children

OBJECTIVE

To determine age-specific antibiotic prescription and referral rates in preschool children diagnosed with acute respiratory tract infection (RTI) in primary care.

DESIGN

Retrospective cohort study.

SETTING

Research database of the Netherlands University Medical Center Utrecht Primary Care Network.

SUBJECTS

All children aged 0-5 years within the database were included, covering 1998 to 2002 (18,801 child-years).

MAIN OUTCOME MEASURES

Antibiotic prescription and referral rates were determined as percentage of children with at least one prescription or referral within a year, as total number of prescriptions per 1000 child-years, and as percentage of all RTI episodes.

RESULTS

Antibiotics, mostly beta-lactam (80%) and macrolides (16%), were prescribed in 35% of RTI episodes. Annually 13% of the children received at least one antibiotic following an RTI. Antibiotics were prescribed in more than half of episodes of LRTI, sinusitis, AOM, and acute tonsillitis, and in 12-15% of episodes of asthma exacerbation, acute laryngitis, influenza acute, and acute upper respiratory infection (including common cold and pharyngitis). Almost 98% of RTIs were managed in primary care. On average 1% of the children were referred to a paediatrician or ENT specialist following RTI per year, especially after AOM (59% of referrals). Compared with older children, those under two years of age were more often treated with antibiotics (relative risk [RR] 1.4, 95% CI 1.3-1.6) and referred (RR 2.3; 95% CI 1.8-3.0).

CONCLUSION

In the Netherlands most episodes of RTIs in preschool children were managed in primary care and this often involves prescription of antibiotics. Children younger than two years of age receive more often antibiotics for RTI and are also referred more, especially for AOM.

Trends in doctor consultations, antibiotic prescription, and specialist referrals for otitis media in children: 1995-2003

BACKGROUND

Reported trends regarding the incidence of otitis media and antibiotic prescription rates are inconsistent.

OBJECTIVE

Our goal was to assess changes in incidence of consultation rates, antibiotic prescription, and referral rates for otitis media in children over the years 1995-2003.

METHODS

A cohort study including all children aged 0 to 13 years within the research database of the Netherlands University Medical Center Utrecht Primary Care Network covering the period 1995-2003. Otitis media diagnoses were recorded according to the International Classification of Primary Care codes and antibiotic prescription according to the Anatomic Therapeutic Chemical Classification System codes. Otitis media incidence rates were calculated as episodes per 1000 person-years. Antibiotic prescription and referral rates were calculated per 100 otitis media episodes.

RESULTS

From 1995 to 2003, the overall general practitioner consultation rates for acute otitis media and otitis media with effusion declined by 9% and 34%, respectively. In children aged 2 to 6 years and those aged 6 to 13 years, the incidence rates of acute otitis media and otitis media with effusion declined by 15% and 41% and 40% and 48%, respectively. In children <2 years of age, the incidence rates of acute otitis media and otitis media with effusion increased by 46% and 66%, respectively. Antibiotic prescription rates for acute otitis media and otitis media with effusion increased by 45% and 25%, respectively. The referral rate for acute otitis media did not change, whereas the referral rate for otitis media with effusion increased by 45%.

CONCLUSIONS

Consultation rates for otitis media have changed considerably over the last decade, and so have antibiotic prescriptions and specialist referrals. The rising antibiotic prescription rate for otitis media causes concern, because this may induce increasing medical costs and antibiotic resistance.

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.