Wjj Assendelft

Systematic review of the occurrence of infantile colic in the community

AIMS To assess the occurrence of infantile colic in the community and the need for professional help; and to study the influences of potential determinants of infantile colic. METHODS Surveys were identified by a systematic search in Medline (1966–98) and Embase (1988–98). Retrieved publications were checked for references. Studies selected were community based, prospective, and retrospective surveys on the occurrence of infantile colic published in English, German, French, or Dutch. Occurrence rates were calculated as percentages. Methodological quality of the surveys was assessed by two assessors independently with a standardised criteria list containing items on method of data gathering, definition of colic, and drop out rate. RESULTS Fifteen community based surveys were identified. The methodological quality varied considerably and was generally low. Even the two most methodologically sound prospective studies yielded widely varying cumulative incidence rates of 5–19%. Referral rates or the need to seek help because of crying were consistently lower than occurrence rates for prolonged crying as such. Gender, socioeconomic class, type of feeding, family history of atopy, and parental smoking were not shown to be associated with colic. CONCLUSION Occurrence rates of infantile colic vary greatly according to methodological quality. A considerable number of parents reporting prolonged crying do not seek or need professional help.

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.

Women's motives for not participating in preconception counseling: qualitative study

Aims: Information about risk factors and preventive measures given before conception is estimated to prevent 15–35% of adverse pregnancy outcomes. We aimed to identify women’s motives for not responding to an invitation for preconception counseling (PCC) from their general practitioner. Methods: A purposive sample of 11 women who did not respond to an invitation for PCC and who became pregnant within 1 year was interviewed. Results: Three key themes influencing nonresponse emerged from the data: perceived knowledge, perceived lack of risk and a misunderstanding of the aim of PCC. Conclusion: For successful future implementation of PCC, a more tailored approach may be necessary for certain (groups of) women, addressing the reasons why women do not consider themselves part of the target group for PCC.

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.

Preconception counselling initiated by general practitioners in the Netherlands: reaching couples contemplating pregnancy [ISRCTN53942912]

BackgroundTo maximise the potential for reducing the risk of adverse pregnancy outcomes, preconception counselling (PCC) is used to inform couples contemplating pregnancy about general and personal risk factors. Many initiatives have been developed to provide PCC, but none offers it routinely in a presumed low-risk population.The objective of the study was to investigate the extent to which women contemplating pregnancy can be reached when a PCC programme is routinely offered by general practitioners (GPs).Methods30 GPs actively offered PCC to all women aged 18 to 40 over a three-year period. GPs reviewed lists of these women and excluded women with adverse social circumstances. The remaining women received an invitation for PCC. They were requested to indicate whether they were interested in PCC, and if so, when they were contemplating pregnancy. Those both interested and contemplating pregnancy within one year were invited for PCC. All pregnancies occurring within one year of an invitation were monitored. Response rates and percentages of pregnancies preceded by an invitation or actual attendance to PCC were calculated.ResultsOverall, 72–75% of the interested responders, who returned the risk-assessment questionnaire (80%), actually attended PCC. However, the GPs excluded a large number of women. In 2002 27% of all pregnancies occurred in the group of women who had been interested and had indicated that they hoped to get pregnant within one year. Another 33% of the pregnancies occurred in the group of women who had been excluded, 13% in the group who had not responded, and 14% in the group who had not been interested.ConclusionA quarter of the women who became pregnant in the year after the invitation were reached in time. In order to increase this number, methods should be developed to decrease the exclusion of women by the GPs and to increase womens response.

GP-initiated preconception counselling in a randomised controlled trial does not induce anxiety

BackgroundPreconception counselling (PCC) can reduce adverse pregnancy outcome by addressing risk factors prior to pregnancy. This study explores whether anxiety is induced in women either by the offer of PCC or by participation with GP-initiated PCC.MethodsRandomised trial of usual care versus GP-initiated PCC for women aged 18–40, in 54 GP practices in the Netherlands. Women completed the six-item Spielberger State Trait Anxiety Inventory (STAI) before PCC (STAI-1) and after (STAI-2). After pregnancy women completed a STAI focusing on the first trimester of pregnancy (STAI-3).ResultsThe mean STAI-1-score (n = 466) was 36.4 (95% CI 35.4 – 37.3). Following PCC there was an average decrease of 3.6 points in anxiety-levels (95% CI, 2.4 – 4.8). Mean scores of the STAI-3 were 38.5 (95% CI 37.7 – 39.3) in the control group (n = 1090) and 38.7 (95% CI 37.9 – 39.5) in the intervention group (n = 1186).ConclusionPCC from ones own GP reduced anxiety after participation, without leading to an increase in anxiety among the intervention group during pregnancy. We therefore conclude that GPs can offer PCC to the general population without fear of causing anxiety.Trial Registration: ISRCTN53942912

Preventive treatment for migraine in primary care, a population-based study in the Netherlands

Background Preventive treatment of migraine contributes to reducing the impact of migraine but its extent of use in routine care is unknown. Objective The objective of this article is to assess current use, previous use, duration and course of preventive treatment of migraine in Dutch general practice. Methods We conducted a retrospective cohort study, for the period between 1997 and 2007, in the Interdisciplinary Processing of Clinical Information (IPCI) database, a GP research database in the Netherlands (source population of more than half a million subjects). All prevalent and incident migraine patients (N = 7367) were included. Results About 13% of all migraine patients currently use preventive therapy and almost half of migraine patients have prior use. Of those starting with preventive treatment, 56% (95% CI: 54.3–64.7) still used it after nine months. There was a long delay between migraine diagnosis and preventive treatment start. Forty-four percent (95% CI 43.0–45.7) started preventive therapy in the study period. Conclusion This large primary-care database study shows that a limited number of patients are current users of preventive treatment, but many patients have prior use. After diagnosis there is often an extended time before preventive treatment is applied. Also there is often only one attempt. The continuation in time seems appropriate. Preventive therapy in migraine still deserves focus.

De effectiviteit van behandelingen van excessief huilen bij zuigelingen

Vraagstelling Wat is de effectiviteit van behandelingen van excessief huilen bij zuigelingen. Methode Systematisch literatuuronderzoek in Medline, Embase en het Cochrane Controlled Trials Register naar effectiviteitsonderzoek bij zuigelingen < 6 maanden. Artikelen werden door twee onderzoekers onafhankelijk van elkaar geselecteerd en op kwaliteit beoordeeld. Effecten werden berekend als percentage succes. Uitkomstmaten van onderzoek naar identieke interventies werden samengevat met behulp van een random effects-model. Resultaten In totaal werden 27 publicaties geselecteerd. Elimineren van koemelk is effectief, indien de voeding vervangen wordt door hypo-allergene voeding (effect 0,22, 95%-BI 0,09-0,34). Goed onderzoek naar het gebruik van soja laat geen duidelijk effect zien. Het elimineren van koemelk is ook effectief in eerstelijnspopulaties. Dicyclomine is effectief (effect 0,46,95%-BI 0,33-0,60), maar heeft ernstige bijwerkingen. Het advies het aantal stimuli te reduceren is eveneens effectief (effect 0,48, 95%-BI 0,23-0,74). Daarentegen is het advies het kind meer te dragen en wiegen niet succesvol. Van simethicone, voeding met een laag lactosegehalte, geluid in combinatie met ritmisch bewegen, chiropraxie en het gebruik van een speen is de effectiviteit niet aangetoond. Conclusie Excessief huilen bij zuigelingen moet bij voorkeur behandeld worden met het advies aan ouders het aantal stimuli gericht op het kind te verminderen, en met proefbehandeling met hypo-allergene voeding.