[Medical education in the Netherlands: little attention paid to the cultural diversity of patients]. / Medisch onderwijs in Nederland: weinig aandacht voor culturele diversiteit van patiënten.

OBJECTIVE: To ascertain how much attention is given to cultural diversity in the eight medical faculties in Dutch universities. DESIGN: Interviews. METHOD: In the period January-June 2001 interviews were held with 76 people in medical faculties: policy makers, teachers and students. RESULTS: Medical courses scarcely devoted any attention to the fact that physicians need to deal with a multicultural society. Only the medical courses at the Free University of Amsterdam and Nijmegen University had included a compulsory module in this subject. The other universities were aiming for a more integrated treatment of the subject. However, for the time being, the acquisition of information about cultural diversity (specific diseases in different ethnic groups, different conceptions about health and disease and possibilities for solving communication problems) depended mainly on the personal interest of the teacher and the choices of the medical students. CONCLUSION: Cultural diversity receives little attention in the medical courses at the eight Dutch university medical faculties. A national approach to this problem is therefore recommended, with the setting up of an interfaculty workgroup to develop good teaching material on subjects related to cultural diversity.

Intercultural training of medical students.

Until recently the Utrecht Medical School had a traditional curriculum with a predominantly biomedical orientation and strong emphasis on curative medicine. In 1997 an experimental 'Multi-cultural Family Attachment Course' started at the Utrecht Medical School with 20 second-year medical students. Each student was attached to a native Dutch and an ethnic minority family with a newborn or chronically ill child. In a period of 1.5 years students had to visit each family at home four times. The students monitored growth and development of the child and discussed several aspects of health and disease with the parents according to a structured schedule. In regular group sessions students reported back their experiences. In this way, the influence of socioeconomic circumstances, culture and environment on health becomes a real-life experience. This paper aims to describe some aspects of this pilot-course and the reactions of the students.

[Good results from circumcisions of Muslim boys performed outside the hospital]. / Gunstige resultaten bij circumcisie van moslimjongens buiten het ziekenhuis.

OBJECTIVE: To describe the experience with circumcision of Moslem boys under local anaesthesia outside the hospital. DESIGN: Prospective, descriptive. METHOD: A total of 94 circumcisions under local anaesthesia were performed from April through November 1997 in a Health Centre of the Municipal Health Service, Utrecht, the Netherlands. Pain and unrest of the boys were scored on a scale from 1 to 10 by the operating surgeon (1 = no pain/patient fully calm; 10 = unbearable pain/patient in panic). Postoperative follow-up was only done on request of the parents/fosterers. The reasons for these follow-ups were recorded. One week after the circumcision the parents/fosterers were asked if there were any complications and whether they were satisfied with this method. RESULTS: The median age was 3 years (range: 2-24). The pain during the operation was scored by the surgeon with a median of 1 (1-6) while unrest scored a median of 3 (1-9). Thirteen children were seen again because of bleeding (n = 4), haematoma (n = 2), swelling (n = 7). One week after the operation 89% of 70 parents/fosterers interviewed by telephone were content with the treatment. The social aspect of this way of circumcision was much appreciated. CONCLUSION: Circumcisions under local anaesthesia outside the hospital are feasible. Complications were according to published figures and most parents were content. With this procedure a cost reduction of 70% may be achieved in comparison with clinically performed circumcision under general anaesthesia.

Relationship between allergic manifestations and Toxocara seropositivity: a cross-sectional study among elementary school children.

Toxocara (the cause of visceral larva migrans in humans) and allergy have in common both elevated immunoglobulin E (IgE) levels and eosinophilia. In the present study, we investigated: 1) associations between Toxocara seropositivity and allergic manifestations; 2) risk factors for Toxocara infection; and 3) differences in Toxocara seroprevalence, allergic manifestations and the associations between these two, in children from urban and rural environments. Blood samples from 1,379 Dutch urban and rural elementary schoolchildren, were examined for Toxocara antibodies, eosinophil numbers, total IgE concentrations, and the occurrence of inhaled allergen-specific IgE. Questionnaires investigating respiratory health and putative risk factors for infection were completed. It was found that 8% of the children had Toxocara antibodies, occurring significantly less often in females than in males. The means of total serum IgE levels and blood eosinophils were significantly higher in the Toxocara-seropositive than in the seronegative group. Allergic asthma/recurrent bronchitis was found in 7% of the children, allergic reaction on animal contact in 4%, and IgE to at least one inhaled allergen in 16%. These variables were associated with Toxocara seroprevalence. Inhaled allergen-specific IgE and asthma/recurrent bronchitis occurred significantly less often in rural than in urban areas, and significantly less often among girls than among boys. Furthermore, occurrence of allergen-specific IgE increased significantly with age. No association existed between Toxocara seroprevalence and assumed risks, i.e. contact with pet animals and public playgrounds. In conclusion, our results indicate that allergic manifestations occur more often in Toxocara-seropositive children. A relationship with an already existing allergic condition is plausible.

The benefits of school screening for scoliosis in the central part of The Netherlands.

The Netherlands has well-organized school health services, and children are assessed on a regular basis for scoliosis among other disturbances and pathologies. The purpose of this study was to assess the benefits of an annual screening programme for scoliosis in the Netherlands. Three cohorts of 10,000 children sampled at 10, 12 and 14 years of age, respectively, were followed for 3 years. Children with a positive bending sign were referred to a second screening stage, in which external asymmetry was quantified. Children diagnosed via the programme (group 1) were compared with those children who had been referred for treatment independently of the screening (group 2). The total number of children in these groups combined was then compared with the number that would have been expected on the basis of accepted prevalence figures for idiopathic scoliosis given in current literature. Over 30,000 children were screened. Although the programme established a total of 57 cases of definite scoliosis (0.18%), the 34 cases (0.11%) already known, mainly detected by previous school health checks, were more severe regarding the risk of progression and treatment. The annual screening programme did not detect a single case that needed surgery. These figures provide the basis on which to decide for or against adopting an annual screening programme for scoliosis; the decision is a socio-political one. Based on this study, we expect all scoliotic patients needing treatment should be detected in time if periodic health checks will be maintained biennially. On medical grounds, it is our view, that screening for scoliosis should not be performed in the Netherlands annually.

School screening for scoliosis: the value of quantitative measurement.

Several studies advocate quantification of the bending test or performing surface topography to reduce the referral rate and to increase the specificity of the bending test in screening for scoliosis. Within the framework of a school screening project all children with a positive bending test were reexamined with measurement of rib hump height, angle of trunk rotation and moiré topography. In the period 1983-1986, out of three cohorts of 10,000 children of 10, 12 and 14 years of age, 3,069 were reexamined, of whom 1931 again tested positive (63%). The value of the three techniques in terms of sensitivity and specificity within the reexamined group was evaluated with regard to the Cobb angle on a spinal radiograph, which was made in 671 cases. A reduction in referrals of 37% was found. No significant difference in the ability to detect scoliosis was found between the three techniques mentioned. It is concluded that measurement techniques are valuable in school screening programmes. In particular, if instead of a single cut-off value, a range within which the examination should be repeated is chosen, high sensitivity and high specificity can be combined. Angle of trunk rotation measurement seems to be the easiest method of screening.

Spinal rotation meter: development and comparison of a new device.

Quantification of the bending test became necessary within a large school screening for scoliosis, which started in 1983 in the central part of the Netherlands. Measurement of the angle of trunk rotation appeared to be the easiest method for the school doctors involved. Since at that time no device was commercially available, a device was developed to permit an easy and reliable angle measurement. Methodological qualities of the device in the measurement of the Cobb angle on radiographs are reported. The results of interobserver variation in measurement of the angle of trunk rotation and in the determination of the Cobb angle on radiographs using this device are compared with data from other studies reported in the literature. We did not find important differences in interobserver variation. Measurements of the Cobb angle with the new device could not be distinguished from the Cobb angle determination using conventional techniques. Therefore, we conclude that the spinal rotation meter described here is a reliable device for the measurement of scoliosis parameters.

Variation in Cobb angle measurements in scoliosis.

In order to determine the reliability of the Cobb angle measurement as it is used in the clinical management of scoliosis, a methodological survey was carried out. In the measurement of a Cobb angle two phases can be distinguished: (a) the production of a spinal radiograph and (b) the measurement of the angle itself. In respect of the first phase, the variation in production of the radiographs was calculated on Cobb angle measurements made by one investigator on serial radiographs of patients who underwent spinal fusion for scoliosis and therefore had a fixed spinal curvature. For the second phase, the accuracy of Cobb angle measurement was investigated by comparing measurements on the same radiographs of 46 scoliosis patients obtained by three investigators, namely two orthopaedic surgeons and an orthopaedic fellow who was assigned to a school screening project. Results were expressed as a Spearman correlation coefficient and a standard deviation of the differences. The Spearman correlation coefficient was 0.98 for the repeated radiographs (production variation) and also 0.98 for the repeated measurements on one radiograph (interobserver measurement variation). The standard deviation of the differences in Cobb angle for the repeated radiographs amounted to 3.2 degrees and for the repeated measurements on one radiograph it was 2.0 degrees. Although there is a good reproducibility of the Cobb angle measurement between different investigators, the variation in production of a spinal radiograph is an important source of error. This should be taken into account when making decisions in scoliosis management.

Growth in length and weight from birth to 2 years of a representative sample of Netherlands children (born in 1988-89) related to socioeconomic status and other background characteristics.

Of nearly 1900 live-born singletons, born from April 1988 to October 1989 inclusive, nine measurements of length and weight have been taken between the ages of 1 and 24 months. In the first part of the study, differences in attained length and weight at 1 and 2 years of age are analysed according to socioeconomic status (SES). Multiple regression analyses are used to investigate the association of SES and other background characteristics with length and weight. The second part focuses on the analysis of differences in linear length and weight gain in the first 2 years of life, using a two-step regression technique. At 1 and 2 years of age, differences in attained length and weight and in length and weight gain according to SES are small and not significant, except for the children of Mediterranean parents in the low-SES group, who are significantly heavier than children of all other groups and gain significantly more in weight compared to children of Dutch parents in the low-SES group. Of all the factors studied it appears that parental height, birthweight, parity and ethnic descent of the parents are associated with attained length and weight at 1 and 2 years of age. Of these factors, ethnic descent, however, is not associated with length gain. A small but statistically significant catch-up growth is found in children of mothers who smoked during pregnancy.

School screening for scoliosis: methodologic considerations. Part 1: External measurements.

In order to determine the applicability of school screening techniques for scoliosis, a methodologic survey was carried out within the framework of a school screening project. The accuracy of the measurements of rib hump height, angle of trunk rotation, and of moiré topography was investigated by assessing the intraobserver and interobserver variation. The validity of these techniques was tested by comparing their outcome to the Cobb angle. Intraobserver variation was measured over both short and long time intervals. The interobserver variation was determined among two orthopaedic surgeons and among a group of six doctors. Results are expressed in a Spearman correlation coefficient and a standard deviation. The Spearman correlation ranges from 0.46 (moiré) to 0.75 (rib hump height) in intraobserver variation, and from 0.60 (rib hump height) to 0.70 (angle of trunk rotation) in interobserver variation. The standard deviations illustrate the interobserver range of the measurements, for rib hump height, 3.7 mm, for rotation, 2.3 degrees, and for moiré, 0.7 lines. The validity of the three methods varied from 0.40 to 0.53 as correlated with the angle of Cobb. The conclusion is that these methods can be applied in school screening techniques, but that they do not allow a sharp distinction between normal and pathologic cases. Instead, it is preferable to define the borderline in terms of a danger zone rather than a strict single value. The danger zone for the rib hump height should be 5-10 mm, for the rotation 3-7 degrees, and for the moiré topography 1-3 lines. Recordings in these zones should be repeated within a few months.

Implications of growth surveys in social and curative pediatrics.

The main characteristics of children are growth, development, gradually building up of resistance and decrease of vulnerability. The biometric parameters of choice for a general medical assessment of growth and (physical) development are attained height, weight for height, at infancy and pre-school age neuro-motoric development, and at adolescence the successive stages of secondary sex characteristics. In 1955, 1965, and 1980 nation-wide representative growth and development surveys were performed in the Netherlands. The results of such studies serve multiple purposes: they provide reference data for individual medical assessment, and contribute to the description of the health situation of the population by the study of secular changes. The data are also in use in the construction of our living environment and may supply a biological basis for governments policies concerning young people.

[Preventive screening in Child Health Services]. / Preventief onderzoek in de Jeugdgezondheidszorg.

Early detection in the framework of secondary prevention is an important task, although not the only one, of youth health care, 'the preventive and socio-medical complement of curative medicine'. The primary aim of youth health care is 'promoting and protecting health, growth and development of children and youths'. Periodic health examinations (PHE'S) are an effective and efficient mean to this end. Like all medical consultations PHE is characterised by the integration of its two components: the analysis which focuses on the individual child and its environment (history and physical examination) and the synthesis (general health education and specific counseling). Moreover PHE provides the basis for epidemiological research, collective health education and policy-planning. Complementary examination of a child, usually less extensive than PHE, is executed on the basis of an individual indication. For practical reasons groups of children may be examined in screening-programs. It is preferable to incorporate screening results in the total medical assessment, which is the result of a series of individual PHE'S. Fractionated and isolated screening-programs are not in accordance with the intrinsic value of youth health care. Therefore an integral approach of the child and its environment demands the maximum incorporation into the PHE of systematic and standardized methods of examination. The concept of the 'group at risk' threatens to supplant the search for the 'child at risk'. Collective health education programs are supplementary to individual counseling and health education, but cannot replace the latter.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of hyperoxia on performance capacity of firemen.

We examined the effect of O2-enriched air upon performance capacity and some physiological and psychological variables. Eight firemen were studied during seven bouts of 2 min treadmill-running while breathing air with 21 or 40% oxygen. The duration of the resting periods between the working bouts was chosed by the subjects themselves, with the instructions to rest as short as possible. Total resting time decreased by 29% and total amount of air used by 6%, under the 40% oxygen condition. There were no differences in 1) minute ventilation during working periods (when the subjects breathed 40% oxygen respiratory rate decreased whereas tidalvolume increased), 2) heart rate reached during working periods, 3) subjective feelings of fatigue as indicated by the subjects at the end of every working period. Advantages of the use of O2-enriched air by firemen are discussed and it is concluded that breathing air with 40% oxygen does not mean an extra physiological or psychological load for the organism. Finally, possible factors that made a subject decide to start again are discussed and the importance of the respiratory rate in this decision is indicated.