Biomedical subjects
Publications and source records attributed to D Pittrow.
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Aim of the study is a comprehensive clinical-epidemiological description of the prevalence of arterial hypertension and diabetes among primary care patients along with an assessment of doctor's recognition rates and prescription behaviour. The paper describes methods and design of the study and provides background information on the sampling process, instruments used as well as characteristics of doctors and patients. The study is based on a nationally representative sample of 1,912 primary care doctors and 45,000 patients that attended the doctors' office on the target days. The patients were also characterized by laboratory tests. The first stage of study consisted of a comprehensive description of the doctors' characteristics in terms of psychosocial, qualification- and provider aspects as well as attitudes towards hypertension and diabetes and their management. In the second stage all patients completed a questionnaire to describe their health behaviour and attitudes as well as the treatment history and therapy. In the third stage all patients were characterized by their doctors in terms of their diagnostic status and their past and current interventions.
With regard to the management of hypertension and diabetes, HYDRA reveals that doctors report multiple problems in their everyday practice. Being confronted with an average of 73 patients a day, with almost every second having either diabetes or hypertension, frequently associated with multiple comorbid conditions, the core obstacle is the time factor. Doctors do not have sufficient time to perform diagnostic tests and especially no time for non-drug interventions of any type. Further available treatment guidelines are only used in 1 out of 2 doctors. Further they seem not to affect doctors performance significantly.
Almost every second patient seeing a primary care doctor suffers from arterial hypertension and about every fifth has diabetes mellitus. These diseases often occur at the same time. They are associated in more than 80% of the cases with other severe concomitant and subsequent diseases (heart attack, stroke, renal failure, neuropathy etc.). The magnitude especially of subsequent and concomitant diseases, the dimension of the personal suffering and the immense diagnostic and therapeutic challenges for the doctors have been massively underestimated so far. The article informs about the prevalence of the above disease, and structure of the problem. Before the background of an extremely high patient load seen by German General Physicians, the mainstay challenge is highlighted how to achieve further improvements of the quality of care on the basis of scientific guidelines alone, without a concomitant change in the system structure.
Recent studies have shown the beneficial effects of a blockade of the renin-angiotensin system (RAS) not only for blood pressure reduction but also end organ protection. One of the markers that is closely correlated with the increased cardiovascular risk is microalbuminuria. A common mediator for the development of both, microalbuminuria and end organ damage seems to be Angiotensin II, the blockade of which apparently reduces microalbuminuria as well as end organ damage. Therefore we had a closer look into pathophysiology of microalbuminuria and the relevance for end organ damage and discuss current medical strategies to alleviate these diseases.
Microalbuminuria has been widely appreciated in recent years to be a valuable risk marker for an increased cardiovascular disease morbidity and mortality. Thus guidelines for the treatment of type-2-diabetes in Germany and the US recommend an annual screening as soon as the diagnosis of diabetes is established and a quarterly control when microalbuminuria is present. While nationally representative epidemiologic data from the US have been available, data from Germany, especially from the primary care sector are missing. This is especially important in light of the gatekeeper function of the primary care physician. The "Hypertension and Diabetes Risk Screening Study" (HYDRA) has been identifying 37.8% of patients with hypertension and diabetes to have a positive dipstick test for microalbuminuria on the study day while only 12.5% of these are diagnosed by the doctor as having nephropathy. These patients additionally show a high burden of associated comorbidities and thus call for early detection and intervention especially because effective therapy is available. Although screening for microalbuminuria is recommended in the guidelines the value of a routine screening for microalbuminuria in primary care is under recognized.
The examination of renal function in the daily practice may give important information on the risk status of a given patient. For example, the diagnosis of microalbuminuria carries high predictive value for a future cardiovascular risk of patients with hypertension, diabetes, congestive heart failure, as well as myocardial infarction. The findings of the Hypertension and Diabetes Screening and Awareness Study (HYDRA) indicate that screening for microalbuminuria is performed not often enough in patients with diabetes or hypertension, respectively, and a positive screening finding often does not trigger necessary consequences as for additional diagnosis or therapy.
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AIMS: The non-benzodiazepine hypnotics zolpidem and zopiclone, which are indicated for short-term treatment of insomnia, were considered originally by physicians as almost devoid of abuse and dependence potential. Several recent publications, however, have suggested that both agents carry a significant risk of abuse. To substantiate and re-evaluate this situation, the world literature was reviewed for cases of dependence of both agents; these cases were analysed in order to identify certain underlying patterns, if evident. METHODS: A systematic review based on a Medline literature search was conducted including the years 1966-2002 to assemble all available clinical case reports that were analysed for typical features of abuse and dependence according to prespecified criteria. Only case reports were of interest, and clinical studies were excluded. No limitations as to language or publication year were applied. The terms 'zolpidem', 'zopiclone' and 'abuse', 'dependence', 'addiction', 'withdrawal' and 'intoxication' were used to identify relevant publications. Potentially relevant citations were retrieved and assessed for inclusion independently by two authors. RESULTS: A total of 36 cases for zolpidem were identified, most of them reported in recent years, and 22 cases for zopiclone. Both sexes were involved to a similar extent; and cases were reported in all age groups. In extreme cases, dose increases reached a factor of 30-120 above the recommended doses. The majority of patients had a history of former drug or alcohol abuse and/or other psychiatric conditions. CONCLUSION: On the basis of world-wide prescription numbers, which are approximately twofold higher for zolpidem (1,338,774,000 tablets from June 2001 to June 2002 in Europe, Japan and United States) than for zopiclone (664,897,000 tablets during the same period in Europe and Japan), the relative incidence of reported dependence similar for both drugs and remarkably lower than that of benzodiazepines used for the treatment of disturbed sleep. The findings offer the conclusion that zolpidem and zopiclone are relatively safe drugs. However, as both drugs are psychotropic drugs, patients with a history of abuse or dependence and those with psychiatric diseases seem to be at increased risk of abuse of these agents.
BACKGROUND: It is still unclear whether the strength of the association between elevated plasma homocysteine (HC) levels and peripheral arterial disease (PAD), coronary artery disease (CAD) and cerebrovascular disease (CVD) is similar. METHODS: Fasting homocysteine plasma levels were measured in 6880 unselected primary care patients aged 65 years or older. Presence of PAD was determined with the ankle brachial index, and both CAD and CVD were recorded according to patient history. RESULTS: Median homocysteine levels in the total sample (58.0% females, mean age 72.5 years, mean body mass index 27.3 kg m-2) differed between patients with and without PAD: 15.2 micro mol L-1 (95% confidence interval [CI] 14.8; 15.7, vs. 13.9 micro mol L-1 (CI: 13.8; 14.1; P < 0.001). Peripheral arterial disease prevalence moderately increased from 13.0% in the lowest HC quintile to 24.3% in the highest quintile (crude odds ratio [OR], 2.1 [CI: 1.7; 2.6]). The frequency of atherothrombotic manifestations in the patients' history increased nearly linearly across the homocysteine quintiles in the univariate analysis. However, the association diminished substantially after adjusting for known interfering variables: the ORs between the HC highest fifth vs. lowest fifth (adjusted for age, gender, smoking status, diabetes, hypertension lipid disorders, and estimated glomerular filtration rate levels) for PAD decreased to 1.4, for CAD to 1.0 (NS), and for CVD to 1.1. (NS). CONCLUSIONS: Elevated HC is only slightly more related to PAD than to CAD and CVD. After adjustment for known risk factors, the effect size is small, and an association can no longer be observed between homocysteine and CAD and CVD.
AIM: To evaluate the efficacy and tolerability of a single daily dose of a fixed combination of 95 mg metoprololsuccinate (MS) and 12.5 mg hydrochlorothiazide (HCTZ) in the first-line treatment of non-pretreated hypertensives, or additional (add-on) to ongoing antihypertensive medication. METHOD: 14,964 patients aged 18 years or older treated by 2808 family doctors in Germany were included in a noncontrolled observational study. Most patients had at least one concurrent disease or concomitant medication of one kind or another. The primary target parameters for efficacy was the lowering of the systolic blood pressure (SBP) and diastolic blood pressure (DBP) after 8 weeks and for tolerability the number of patients reporting adverse events (AE). RESULTS: 65.4% of the patients received MS/HCTZ in the form of first-line treatment, the remainder as add-on therapy. The mean blood pressure decrease for the overall group by the end of the study was -24.5/-13.6 mmHg (baseline: 166.7/97.3 mmHg; p < 0.0001 for SBP and DBP). 92.2% of the patients experienced a decrease in SBP of > or = 10 mmHg. The mean heart rate decreased by 10.2 beats (baseline 81.4; p < 0.0001). The blood pressure decreased both in patients receiving MS/HCTZ alone and in those receiving it as an add-on to other antihypertensives. Only 1.4 of the patients reported AE. CONCLUSION: The MS/HCTZ controlled release combination was safe, efficacious and well-tolerated both as first-line and add-on therapy for essential hypertension.
BACKGROUND AND OBJECTIVE: Only a few studies have been done in Germany on the use of drugs in homes for the elderly and nursing homes. This is the first retrospective and longitudinal pharmaco-epidemiological study comparing the pattern of drug prescriptions for patients in nursing or for-the-elderly homes with that for health-insured ambulant patients or those not requiring care, all of them of the same age-group. PATIENTS AND METHODS: The samples were taken from a cohort of 3592 members of a company health insurance in Berlin, aged 60 years or over (912 men, 2680 women) who had been insured throughout 1999. The insurance company's database provided anonymous information on the insured and their doctors, details of drug prescriptions and hospital treatment. The patients were divided into three groups, group A: all those requiring care who lived in homes for the elderly or nursing homes (n=996); group B: all ambulant patients receiving care (n=1603), and group C: patients not requiring care, matched to the other groups for age and sex (n=993). All drugs were classified according to the anatomical-therapeutic-chemical WHO codes and listed by defined daily dosage (DDD). RESULTS: Those in group A received on average 3.6 DDD daily, those of group B 4.6 DDD, and those of group C 3.0 DDD. The relevant cost was 714 Euro (group A), 1126 Euro (group B) and 539 Euro (group C) per person in 1999. Indications of inadequate treatment concerned the use of psychopharmaceuticals (neuroleptics, antidepressives, hypnotics), analgesics, digitalis glycosides, antidiabetic drugs, diuretics, laxatives, and drugs of unproven efficacy. 15% of home residents received prescription from doctors on emergency call. These drugs were often continued beyond the immediate treatment. CONCLUSION: These data provide evidence of the lacking quality in the drug treatment of the elderly.
The combination of artesunate and mefloquine is currently one of the most effective treatments against multidrug-resistant Plasmodium falciparum malaria. To improve patient compliance to such a combination, the two agents have been combined in a prepacked single blister. Patients were instructed to simultaneously co-administer the drugs once a day for three days. In the present randomized, double-blind, parallel group, comparative, single center study in Thailand, this concept was investigated in 204 adults and children with acute, uncomplicated P. falciparum malaria. Patients were randomized into two treatment groups and received once a day over a three-day period the following: Group A received artesunate, 4-5 mg/kg/day, and mefloquine, total dose = 25 mg/kg, approximately 8.5 mg/kg/day, simultaneously. Group B received artesunate, 4-5 mg/kg/day, and mefloquine, total dose = 25 mg/kg, sequentially (i.e., no mefloquine dose on the first day, 15 mg/kg on the second day, and 10 mg/kg on the third day). Both treatment groups showed no relevant differences in baseline demographic and clinical characteristics. Intent-to-treat analysis revealed a cure rate at day 28 (primary endpoint) of 100% in group A and 99% in group B (difference not significant). The secondary endpoints of mean time to fever clearance (group A = 34 hours, group B = 31 hours) and mean time to parasite clearance (group A = 44 hours group B = 48 hours) were similar between groups (both differences not significant). Tolerability was good in both treatment groups, with no difference in the overall incidence of adverse events. There was a low incidence of nausea/vomiting (4.9% in both groups) and central nervous system side effects (4.9% in group A versus 8.8% in group B). These were comparable between groups and generally of a mild nature. The three-day combination of artesunate and mefloquine (Artequin, Mepha, Ltd., Aesch, Switzerland) with the introduction of mefloquine on day 1 offers a practical dosing regimen that is highly effective and well tolerated in patients of different ages with uncomplicated P. falciparum malaria. It is likely that the prepacked blister approach translates clinically into a better patient compliance, thereby contributing to limit the development of drug resistance.
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AIM: To estimate the point prevalence of insomnia, recognition and prescription behavior in primary care. METHODS: Nationwide sample of 539 primary care settings along with their characterization (stage 1). Standardized assessment of all attenders (N = 19.155 patients) on the NISAS target day using a sleep questionnaire (PSQI) and additional questions to cover psychosocial and additional clinical variables. All patients were evaluated by the primary care doctors using a standardized clinical appraisal questionnaire, including a CGI-rating. RESULTS: Prevalence insomnia according to DSM-IV was 26.5%. Recognition of presence of any clinically significant sleep disorder was 72%, recognition of insomnia was poor 54.3%. 85.6% of insomnia patients were rated as chronic. Close to 50% of all insomnia cases did not receive a specific insomnia therapy. Herbals, followed by hypnotics and sedatives and antidepressants were the three most frequent treatments applied, psychotherapy was only seldomly indicated. DISCUSSION: NISAS provides for the first time nationally representative estimates of interventions for insomnia in primary care. The relatively low treatment rates and the high proportion of chronic patients receiving longterm prescription of benzodiazepines seem to be critical. Priorities for future agenda to improve this situation are discussed.
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