Cost of childhood acute otitis media in primary care in the Netherlands: economic analysis alongside a cluster randomised controlled trial

BACKGROUND: Acute otitis media (AOM) is among the most common paediatric conditions managed in primary care. Most recent estimates of the cost of AOM date from a decade ago and lack a full societal perspective. We therefore explored the societal cost of childhood AOM in the Netherlands within the setting of a trial comparing the effectiveness of an intervention aimed at educating general practitioners (GPs) about pain management in AOM compared to usual care. METHODS: Economic analysis alongside a cluster randomised controlled trial conducted between February 2015 and May 2018 in 37 practices (94 GPs). In total, 224 children with AOM were included of which 223 (99%) completed the trial (intervention: n = 94; control: n = 129). The cost of AOM due to health care costs, patient and family costs, and productivity losses by parent caregivers were retrieved from study diaries and primary care electronic health records, during 28-day follow-up. We calculated mean cost (€ and $) per AOM episode per patient with standard deviations (SD, in €) regardless of study group assignment because there was no clinical effect of the trial intervention. In sensitivity analysis, we calculated cost in the intervention and usual care group, after exclusion of extreme outliers. RESULTS: Mean total AOM cost per patient were €565.93 or$638.78 (SD €1071.01); nearly 90% of these costs were due to productivity losses experienced by parents. After exclusion of outliers, AOM cost was €526.70 or $594.50 (SD €987.96) and similar in the intervention and usual care groups: €516.10 or$582.53 (SD €949.69) and €534.55 or $603.36 (SD €920.55) respectively. CONCLUSIONS: At €566 or$639 per episode, societal cost of AOM is higher than previously known and mainly driven by productivity losses by children's parents. Considering its high incidence, AOM poses a significant economic burden that extends beyond direct medical costs. TRIAL REGISTRATION: Netherlands Trial Register no. NTR4920: http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4920

Optimising pain management in children with acute otitis media through a primary care-based multifaceted educational intervention: study protocol for a cluster randomised controlled trial.

Whilst current guidelines highlight the importance of pain management for children with acute otitis media (AOM), there is evidence to suggest that this is not implemented in everyday practice. We have developed a primary care-based multifaceted educational intervention to optimise pain management in children with AOM, and we trial its clinical and cost effectiveness

Paracetamol (acetaminophen) or non-steroidal anti-inflammatory drugs, alone or combined, for pain relief in acute otitis media in children

BACKGROUND: Acute otitis media (AOM) is one of the most common childhood infectious diseases and a significant reason for antibiotic prescriptions in children worldwide. Pain from middle ear infection and pressure behind the eardrum is the key symptom of AOM. Ear pain is central to children's and parents' experience of the illness. Because antibiotics provide only marginal benefits, analgesic treatment including paracetamol (acetaminophen) and non-steroidal anti-inflammatory drugs (NSAIDs) is regarded as the cornerstone of AOM management in children. OBJECTIVES: Our primary objective was to assess the effectiveness of paracetamol (acetaminophen) or NSAIDs, alone or combined, compared with placebo or no treatment in relieving pain in children with AOM. Our secondary objective was to assess the effectiveness of NSAIDs compared with paracetamol in children with AOM. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Issue 7, July 2016; MEDLINE (Ovid, from 1946 to August 2016), Embase (from 1947 to August 2016), CINAHL (from 1981 to August 2016), LILACS (from 1982 to August 2016) and Web of Science (from 1955 to August 2016) for published trials. We screened reference lists of included studies and relevant systematic reviews for additional trials. We searched WHO ICTRP, ClinicalTrials.gov, and the Netherlands Trial Registry (NTR) for completed and ongoing trials (search date 19 August 2016). SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing the effectiveness of paracetamol or NSAIDs, alone or combined, for pain relief in children with AOM. We also included trials of paracetamol or NSAIDs, alone or combined, for children with fever or upper respiratory tract infections (URTIs) if we were able to extract subgroup data on pain relief in children with AOM either directly or after obtaining additional data from study authors. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed methodological quality of the included trials and extracted data. We used the GRADE approach to rate the overall quality of evidence for each outcome of interest. MAIN RESULTS: We included three RCTs (327 children) which were assessed at low to moderate risk of bias.One RCT included 219 children with AOM, and used a three-arm, parallel group, double-blind design to compare paracetamol versus ibuprofen versus placebo. All children also received antibiotics and those with fever > 39 °C could have received paracetamol (30 mg to 60 mg) additionally to the studied treatments.Another RCT involved 156 febrile children (26 of whom had AOM). The study design was a three-arm, parallel group, double-blind design and compared paracetamol versus ibuprofen versus ibuprofen plus paracetamol.The third RCT included 889 children with respiratory tract infections (82 of whom had AOM). This study applied a 3 x 2 x 2 factorial, open-label design and compared paracetamol versus ibuprofen versus ibuprofen plus paracetamol. Study participants were randomised to one of the three treatment groups as well as two dosing groups (regular versus as required) and two steam inhalation groups (steam versus no steam).Authors of two RCTs provided crude subgroup data on children with AOM. We used data from the remaining trial to inform comparison of paracetamol versus placebo (148 children) and ibuprofen versus placebo (146 children) assessments. Data from all included RCTs informed comparison of ibuprofen versus paracetamol (183 children); data from the two RCTs informed comparison of ibuprofen plus paracetamol versus paracetamol alone (71 children).We found evidence, albeit of low quality, that both paracetamol and ibuprofen as monotherapies were more effective than placebo in relieving pain at 48 hours (paracetamol versus placebo: proportion of children with pain 10% versus 25%, RR 0.38, 95% CI 0.17 to 0.85; number needed to treat to benefit (NNTB) 7; ibuprofen versus placebo: proportion of children with pain 7% versus 25%, RR 0.28, 95% CI 0.11 to 0.70; NNTB 6). Very low quality evidence suggested that adverse events did not significantly differ between children treated with either paracetamol, ibuprofen or placebo.We found insufficient evidence of a difference between ibuprofen and paracetamol in relieving ear pain at 24 hours (2 RCTs, 39 children; RR 0.83, 95% CI 0.59 to 1.18; very low quality evidence), 48 to 72 hours (3 RCTs, 183 children; RR 0.91, 95% CI 0.54 to 1.54; low quality evidence) and four to seven days (2 RCTs, 38 children; RR 0.74, 95% CI 0.17 to 3.23; very low quality evidence).Data on the effectiveness of ibuprofen plus paracetamol versus paracetamol alone came from two RCTs that provided crude subgroup data for 71 children with AOM. The small sample provided imprecise effect estimates and we were consequently unable to draw any firm conclusions (very low quality evidence). AUTHORS' CONCLUSIONS: Despite explicit guideline recommendations on its use, current evidence on the effectiveness of paracetamol or NSAIDs, alone or combined, in relieving pain in children with AOM is limited. Low quality evidence indicates that both paracetamol and ibuprofen as monotherapies are more effective than placebo in relieving short-term ear pain in children with AOM. There is insufficient evidence of a difference between ibuprofen and paracetamol in relieving short-term ear pain in children with AOM, whereas data on the effectiveness of ibuprofen plus paracetamol versus paracetamol alone were insufficient to draw any firm conclusions. Further research is needed to provide insights into the role of ibuprofen as adjunct to paracetamol, and other analgesics such as anaesthetic eardrops, for children with AOM

Optimising pain management in children with acute otitis media through a primary care-based multifaceted educational intervention: study protocol for a cluster randomised controlled trial

BACKGROUND: Whilst current guidelines highlight the importance of pain management for children with acute otitis media (AOM), there is evidence to suggest that this is not implemented in everyday practice. We have developed a primary care-based multifaceted educational intervention to optimise pain management in children with AOM, and we trial its clinical and cost effectiveness. METHODS: This cluster randomised controlled trial aims to recruit 250 children aged 6 months to 10 years presenting with AOM to general practitioners (GPs) in 30 primary care centres (PCCs) across the Netherlands. GPs in the PCCs allocated to the intervention group receive a blended GP educational programme (online and face-to-face training). The intervention asks GPs to proactively discuss pain management with parents using an information leaflet, and to prescribe paracetamol and ibuprofen according to current guidelines. GPs in both groups complete an online module illustrating various otoscopic images to standardise AOM diagnosis. GPs in the PCCs allocated to the control group do not receive any further training and provide 'care as usual'. During the 4-week follow-up, parents complete a symptom diary. The primary outcome is the difference in parent-reported mean earache scores over the first 3 days. Secondary outcomes include both number of days with earache and fever, GP re-consultations for AOM, antibiotic prescriptions, and costs. Analysis will be by intention-to-treat. DISCUSSION: The optimal use of analgesics through the multifaceted intervention may provide symptom relief and thereby reduce re-consultations and antibiotic prescriptions in children with AOM. TRIAL REGISTRATION: Netherlands Trial Register, NTR4920 . Registered on 19 December 2014

Secundaire plantenstoffen in een eikenbos : Tanninen

Aan de hand van literatuuronderzoek wordt een inventarisatie gegeven van de secundare plantenstoffen die in de soorten uit he! eikebos voorkomen. Aangegeven wordt waar deze stoffen in de plant voorkomen en welke functie zij vervullen. Van de verschillende groepen secundaire plantenstoffen worden de tanninen besproken in het algemeen en in relatie tot vraat door herbivoren. Het blijkt dat met name de concentratic van c—tanninen in de plant en het vezelgehalte van de plant de voedselkeuze van de herbivoren beïnvloeden. Vervolgens wordt de functie van tanninen in eikebladeren en varens besproken. De hoeveelbeid tanninen in het eikeblad blijkt gedurende het groeiseizoen toe te nemen. Dit gaat samen met een afname van de populaties en aantallen larven op het blad. De concentratie tanninen in varens is het gehele seizoen constant. Verschillende soorten insecten zijn in staat om varens als voedselbron te benutten.

De invloed van verschillende beheersmaatregelen op de kweldervegetatie van Schiermonnikoog

In het zomerseizoen 1981 is onderzoek gedaan naar de effecten van verschillende beheersmaatregelen op de vegetatie. Het onderzoek had betrekking op een maaibeheer, beweiding door pinken en een maaibeheer met nabeweiding door schapen. De onderzoeksgebieden zijn beschreven m.b.v. een landschapskartering op vegetatiekundige grondslag. Deze karteringsmethode is ontleend aan Doing(1974). De landschapseenheden zijn gevormd op grond van geomorfologie, bodemopbouw, waterhuishouding, vegetatiesamenstelling en -hoogte. Uit bet onderzoek bleek, dat de onderzoeksgebieden geomorfologisch in drieën te delen waren: dekzanden, oeverwallen en veengronden. Binnen deze geomorfologische eenheden waren de verschillen in bodemopbouw en waterhuishouding gering. Hieruit wordt geconcludeerd dat de verschillen in vegetatiesamenstelling en -hoogte binnen de geomorfologische eenheden, waarschijnlijk veroorzaakt worden door verschillen in voorgeschiedenis en beheer. De vegetatie op de veengronden was vnl. in te delen bij het Calthion palustris. Bij een maaibeheer kan deze vegetatie zich ontwikkelen naar een goed ontwikkelde Calthion palustris vegetatie. Op plaatsen waar verrijking optreedt, vindt óf een ontwikkeling naar een Filipendulion plaats (droge plaatsen), óf een ontwikkeling naar een Magnocaricion (natte plaatsen). Bij beweiding treedt meer variatie in de vegetatie op dan bij een maaibeheer: a) de verschillen in vegetatiehoogte waren groter, b) de vegetatie-eenheden vormen een meer bemeste vorm van het Calthion palustris. Een maaibeheer met nabeweiding en een beweidingsbeheer, lijken een vergelijkbaar effect op de vegetatie te hebben. De vegetatie op de oeverwallen behoort tot de verruigde vormen van het Calthion palustris en het Cynosurion cristati. Bij het huidige beheer zullen deze vegetaties zich kunnen handhaven. De vegetatie op de dekzanden behoort vnl. tot het Agropyro- Rumicion crispi. Deze 'bemeste' vegetaties zullen zich waarschijnlijk kunnen handhaven, omdat de pinken een voorkeur voor deze dekzanden vertonen en hier het grootste deel van hun mest deponeren.

The impact of visual impairment on adults with an intellectual disability

textabstractOver forty years ago, the Danish ophthalmologist Mette Warburg was the fi rst to ask attention for the increased risk of visual impairment in people with intellectual disabilities (Warburg, 1963, 1975). She based this on her clinical experience and fi rst evaluations in groups of adults in Danish day care centers. She claimed in an early stage that the risk increased with more severe levels of intellectual disability (Warburg, 1983). Warburg has long remained a voice in the wilderness. Incidental colleagues, among them Lena Jacobson in Sweden, performed ophthalmological evaluations in larger groups and reported an overrepresentation of ocular pathologies (Jacobson, 1988). However, problems with assessment of visual function in people who were not able to cooperate with Snellen or picture card acuity tests, remained a barrier to identify those with impairments. Gradually, acuity tests using matching cards, developed for assessment in young children by Sheridan & Gardiner (1970) and by Lea Hyvärinen (Hyvärinen et al., 1980), started to be applied in children and adults with moderate intellectual disabilities. In the United States, Davida Teller developed the preferential looking card for assessment of visual acuity in babies and toddlers (Dobson et al., 1978; Teller, 1979), after which Jackie van Hof-van Duin successfully applied this card in Dutch children and adults with severe or profound intellectual disabilities (Mohn & Hof-van Duin, 1983). Th e next academic group systematically addressing visual functioning in this population, specifi cally people with Down syndrome, was the optometry department of Cardiff University in Wales, led by Margareth Woodhouse (Woodhouse et al., 1993). Next to the Teller card, this group developed the Cardiff card, with line pictures in stead of stripes (Woodhouse et al., 1992; Adoh et al., 1992). In this way, visual acuity assessment became feasible in principally all persons with intellectual disabilities who are not able to cooperate with routine diagnostics

Ontwatering

Deel 7 uit de serie: Oecologische gevolgen van de ruilverkavelingen 'Rolde'en 'Anloo'