[Summary of the practice guideline 'Otitis externa' (first revision) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Otitis externa' (eerste herziening) van het Nederlands Huisartsen Genootschap.

* The practice guideline 'Otitis externa', first developed by the Dutch College of General Practitioners in 1995, has been revised and updated. * It is no longer recommended to perform a KOH test on material collected from the auditory canal in patients with otitis externa. * Eardrops that contain both acid and corticosteroids are preferred over eardrops that contain acid only. * Suitable options include acidic eardrops with hydrocortisone 1% FNA and acidic eardrops with triamcinolone acetonide 0.1% FNA at a dose of 3 drops thrice daily. * The guideline contains a detailed discussion of the ototoxicity of eardrops in patients with tympanic membrane perforation. * Management of these patients, however, remains unchanged: the preferred approach is aluminium acetotartrate eardrops 1.2% FNA.

[Summary of the practice guideline 'Otits media with effusion' (second revision) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Otitis media met effusie' (tweede herziening) van het Nederlands Huisartsen Genootschap.

Most children pass through a period of otitis media with effusion, which can be considered as a normal reaction of the body to viral or bacterial infections. The general practitioner provides education and advice regarding the favourable prognosis of the hearing loss and is alert to the detection of high-risk groups and an aberrant course. In most children with otitis media with effusion, the general practitioner can wait for the disease to take its natural course. Children with persistent otitis media with effusion whose development is retarded should be referred to an otorhinolaryngologist. The former screening for perceptive hearing loss in infants resulted in the detection of many children with otitis media with effusion. Children with abnormal results on the new form of neonatal auditory screening should preferably be referred to a centre for audiology.

Migrants and the meaning of parenthood: involuntary childless Turkish migrants in The Netherlands.

BACKGROUND: Parenthood motives of infertile Turkish migrant men and women in The Netherlands are compared with those of infertile Dutch men and women. Additionally, the question of whether the importance of various parenthood motives of Turkish migrants are related to the degree of adaptation to the Dutch culture was investigated. METHODS: Questionnaires were administered to 58 involuntary childless Turkish migrant men and women and 162 involuntary childless Dutch men and women. RESULTS: Individual parenthood motives were most important to both Turkish migrant and Dutch men and women. While social motives were quite important to Turkish migrants, they were unimportant to Dutch men and women. Four aspects of adaptation (norms and values, social integration, skills, absence of feelings of loss related to migration) were negatively related to the importance of social parenthood motives for Turkish migrant women. For Turkish migrant men two aspects of adaptation (traditions and absence of loss) were negatively related to the importance of social parenthood motives. CONCLUSION: Turkish migrant and Dutch men and women differ in the importance of social motives. However, Turkish migrants who are more adapted to the Dutch culture give less importance to social parenthood motives.

Lesbian families and family functioning: an overview.

OBJECTIVES: In the last 30 years a growing body of studies on lesbian parents and the development of children has been published. METHODS: Four computerized databases were identified studies for inclusion in this review of research on lesbian families, namely PsychInfo, Educational Resources Information Centre (ERIC), Medline, and the Social Sciences Citation Index. RESULTS: Forty-four empirical studies on lesbian families published between 1978 and 2003 were reviewed. In the research on lesbian families two phases were identified. To begin with, systematic studies on lesbian families focused on lesbian families with children who were born in a previous heterosexual relationship. More recently, studies included lesbian families whose children were born to the lesbian couple (planned lesbian families). In both phases, articles reporting results on children's development (such as sexual identity, emotional/behavioral development, social relationships and cognitive functioning), and parental functioning (such as mental psychological health and parenting skills). This paper presents and discusses major finding of the reviewed articles. CONCLUSION: Studies in both phases have emphasized that lesbian and heterosexual families are very much alike. However, it is the stigma of lesbianism that makes the family situation of lesbian families different. PRACTICE IMPLICATIONS: Healthcare workers should be informed about the similarities and differences between lesbian families and heterosexual families, and about the non-traditional family situation of planned lesbian families.

Functional tubal therapy for persistent otitis media with effusion in children: myth or evidence?

Otitis media with effusion (OME), a form of inflammatory middle ear disease, is a common reason for young children to visit their family doctor and to have surgery. Tubal dysfunction plays a major role in the pathogenesis. In case of persistent OME, there seems to be a logical rationale for a favourable effect on the tubal dysfunction of a functional active motoric approach combined with behavioral changes (hygiene), and as a consequence for a therapeutic effect on the middle ear disease. The basic principles of this functional treatment are: active ventilation of the middle ear, correction of immature and undesirable deviant mouth habits, increasing swallowing frequency, activating jaw and palate movements, and encouraging the use of chewing gum. The bases for this functional therapy are critically analysed, and it may be concluded that all of these principles rely upon evidence based physiological mechanisms. However, the limited available clinical data from the literature are reviewed, and appear as methodologically weak. The results of an own prospective randomized pilot study comparing functional treatment with watchful waiting may be considered encouraging, since a borderline significance level was reached with a small amount of subjects.

Current indications for (adeno)tonsillectomy in children: a survey in The Netherlands.

OBJECTIVE: Despite the fact that (adeno)tonsillectomy is one of the procedures most frequently performed on children, studies of current indications are scarce. The purpose of this study is to determine the indications for (adeno)tonsillectomy in children younger than 15 years of age according to Dutch ENT surgeons and general practitioners (GPs). METHODS: During a period of 8 months, 18 ENT surgeons in seven ENT practices and 210 referring GPs filled out standard questionnaires for 349 children listed for tonsil surgery. RESULTS: Apart from recurrent tonsillitis (ENT: 40%, GP: 35%), findings such as enlarged tonsils (ENT: 42%, GP: 24%) and tonsillar crypt debris (ENT: 29%, GP: 17%) and non-specific symptoms such as listlessness (ENT: 28%, GP: 19%) and poor appetite (ENT: 28%, GP: 16%) were considered important criteria for surgery. Symptoms of obstructive sleep apnea were present in 25% (ENT) and 6% (GP) of patients but were considered indicative for surgery in only 11% (ENT) and 4% (GP). In contrast to ENT surgeons, GPs considered otitis media and hearing loss relatively important for (adeno)tonsillectomy. CONCLUSIONS: Apart from the generally accepted indications such as recurrent tonsillitis and obstructive sleep apnea, other indications play an equally important role in the decision to perform tonsil surgery in The Netherlands.

Three days of pivmecillinam or norfloxacin for treatment of acute uncomplicated urinary infection in women.

Pivmecillinam is a unique beta-lactam antimicrobial that has been used for the treatment of acute uncomplicated urinary infection for > 20 y. Since this agent was introduced, the quinolone antimicrobials have become widely used for the same indication. This study compared the efficacy of a 3-d regimen of pivmecillinam 400 mg b.i.d. with norfloxacin 400 mg b.i.d. Women aged between 18 and 65 y presenting with symptoms of acute cystitis of < 7 d duration were eligible for enrollment; 483 were randomized to receive pivmecillinam and 471 to receive norfloxacin. In each group, 30% of women had negative urine cultures prior to therapy. Bacteriologic cure at early post-therapy follow-up was achieved in 222/298 (75%) pivmecillinam patients and 276/302 (91%) norfloxacin patients [p < 0.001; 95% confidence interval (CI) 12.0-21.8]. Clinical cure/improvement at Day 4 following initiation of therapy was observed in 434/457 (95%) women who received pivmecillinam and 425/442 (96%) who received norfloxacin (p = 0.39; 95% CI 1.5-3.9). Early post-therapy (11 +/- 2 d) clinical cure was achieved in 360/437 women (82%) who received pivmecillinam and 381/433 (88%) who received norfloxacin (p = 0.019; 95% CI 0.9-10.3). In women aged < or = 50 y, early clinical cure rates were 294/351 (84%) for pivmecillinam and 299/340 (88%) for norfloxacin (p = 0.11; 95% CI 1.0-9.4). Adverse effects were similar for both regimens, and there was no evidence of the emergence of organisms of increasing resistance with therapy. Short-course therapy with norfloxacin was superior to that with pivmecillinam in terms of bacteriologic outcome, although differences in clinical outcome were less marked. In conclusion, short-course therapy with pivmecillinam is an effective empirical treatment for pre-menopausal women.

National differences in incidence of acute mastoiditis: relationship to prescribing patterns of antibiotics for acute otitis media?

BACKGROUND: Operating on the principle that most acute otitis media (AOM) episodes resolve without antibiotics, doctors in the Netherlands usually manage AOM in children with initial observation. Prescription of antibiotics is limited to children with a complicated course of AOM and those categorized as high risk. Consequently only 31% of patients with AOM receives antibiotics, compared with >90% in most other countries. OBJECTIVE: To substantiate the suggestion that this restrictive use of antibiotics leads to a higher incidence of acute mastoiditis. METHODS: A comparative study across several European countries, Canada, Australia and the United States was performed in the period 1991 to 1998. The incidence rate of acute mastoiditis was defined as the total number of patients age 14 years and younger discharged from all hospitals with the primary diagnosis of acute mastoiditis, during a specified period (usually 5 years), divided by the number of person years (py) in that same age range and period. The latter was calculated by totaling the midyear population estimate of children age 14 years and younger of each year. The 95% confidence intervals and incidence rate ratios were calculated to compare the observed rates. RESULTS: The incidence rate of acute mastoiditis in the Netherlands, with a low antibiotic prescription rate for AOM, was 3.8/100,000 py; in Norway and Denmark, with high prescription rates, the incidence rate was comparable at 3.5/100,000 py and 4.2/100,000 py, respectively. In all other countries with very high prescription rates, incidence rates were considerably lower, ranging from 1.2 to 2.0/100,000 py. The incidence rate in the Netherlands was about twice that in the United States (rate ratio, 0.5). CONCLUSION: The incidence rate of acute mastoiditis in the Netherlands is higher than in many countries with higher antibiotic prescription rates. Although the potential benefits of restricted use of antibiotics (i.e. cost reduction, fewer side effects from antibiotics and less antimicrobial resistance) are beyond dispute, such strategy may be associated with a somewhat higher incidence of acute mastoiditis.

Assessment of a telephone helpline on infertility provided by a patient association.

An assessment was made of 161 telephone calls to volunteers of the Dutch association of infertility patients 'Freya'. The unpaid volunteers all had personal experience with infertility. The majority of callers were childless women. On average the callers had been experiencing infertility for 4 years and had already a considerate history of medical examinations. Calls were made throughout the day until late at evening. Most calls were focused at information gathering, especially about the real experience of treatment and the behaviour and quality of medical staff. Also, emotions regarding infertility were an important topic of the conversation. Sometimes informative questions were an introduction for bringing up emotional problems. The telephone helpline appears to be an easily accessible and empathic source of information and help for infertile persons.

A cross-national study of acute otitis media: risk factors, severity, and treatment at initial visit. Report from the International Primary Care Network (IPCN) and the Ambulatory Sentinel Practice Network (ASPN).

BACKGROUND: Treatment of acute otitis media (AOM) differs worldwide. The Dutch avoid antimicrobials unless fever and pain persist; the British use them for 5 to 7 days, and Americans use them for 10 days. If effects of therapies are to be compared, it is necessary to evaluate rates of risk factors, severity of attacks, and their influence on treatment decisions. We wanted to compare the prevalence of risk factors for AOM and evaluate their association with severity of attacks and of severity with antimicrobial treatment. METHODS: We undertook a prospective cohort study of 2,165 patients with AOM enrolled by primary care physicians; 895 were enrolled from North America, 571 were enrolled from the United Kingdom, and 699 were enrolled from The Netherlands. The literature was searched using the key words "acute otitis media," "severity," and "international comparisons." RESULTS: The prevalence of several AOM risk factors differs significantly among patients from the three country networks; these factors include race, parent smoking habits, previous episodes, previous episodes without a physician visit, tonsillectomy or adenoidectomy, frequency of upper respiratory tract infections, day care, and recumbent bottle-feeding. Dutch children have the most severe attacks as defined by fever, ear discharge, decreased hearing during the previous week, and moderate or severe ear pain. In country-adjusted univariate analyses, increasing age, exposure to tobacco smoke, day care, previous attacks of AOM, previous attacks without physician care, past prophylactic antimicrobials, ear tubes, adenoidectomy, and tonsillectomy all contribute to severity. Only country network, age, history of AOM, previous episode without physician care, and history of adenoidectomy and tympanostomy tubes are independently related to increased severity, while current breast-feeding is protective. Severity of attacks influences treatment decisions. Dutch children are least likely to receive antimicrobials, and even for severe attacks the British and Dutch physicians usually use amoxicillin or trimethoprim-sulfa; North American children with severe attacks are more likely to receive a broad-spectrum second-line antimicrobial. CONCLUSION: Dutch children have the highest ratings in all severity measures, possibly reflecting parental decisions about care seeking for earaches. When comparing groups of patients with AOM, it is necessary to adjust for baseline characteristics. Severity of episode affects physician treatment decisions. Adoption of Dutch guidelines restricting use of antimicrobials for AOM in the United States could result in annual savings of about $185 million.

Tympanometry interpretation by primary care physicians. A report from the International Primary Care Network (IPCN) and the Ambulatory Sentinel Practice Network (ASPN).

BACKGROUND: The accuracy of data gathered by primary care clinicians in practice-based research networks (PBRNs) has been questioned. Tympanometry, recently recommended as a means of improving accuracy of diagnosing acute otitis media, was included as an objective diagnostic measure in an international PBRN study. We report the level of agreement of interpretations of tympanograms between primary care physicians in PBRNs and experts. METHODS: Primary care physicians in PBRNs in the Netherlands, United Kingdom, United States, and Canada enrolled 1773 children aged 6 to 180 months who contributed 6358 tympanograms during 3179 visits. The physicians were trained in the use and interpretation of tympanometry using the Modified Jerger Classification. We determined the level of agreement between physicians and experts for interpretation of tympanograms. One comparison used the 6358 individual ear tracings. A second comparison used the 3179 office visits by children as the unit of analysis. RESULTS: The distribution of expert interpretation of all tympanograms was: 35.8% A, 30% B, 15.5% C1, 12% C2, and 6.8% uninterpretable; for visits, 37.8% were normal (A or C1), 55.6% abnormal (B or C2), and 6.6% could not be classified. There was a high degree of agreement in the interpretation of tympanograms between experts and primary care physicians across networks (kappa=0.70-0.77), age groups of children (kappa=0.69-0.73), and types of visits (kappa=0.66-0.77). This high degree of agreement was also found when children were used as a unit of analysis. CONCLUSIONS: Interpretations of tympanograms by primary care physicians using the Modified Jerger Classification can be used with confidence. These results provide further evidence that practicing primary care physicians can provide high-quality data for research purposes.

Persistent otitis media with effusion: can it be predicted? A family practice follow-up study in children aged 6 months to 6 years.

BACKGROUND: Otitis media with effusion (OME) has a high rate of spontaneous resolution, and a policy of waiting and watching for 3 months is justified. The decision about further treatment should be individualized, depending on duration and symptoms. Knowledge of the determinants for persistent OME would be helpful for identifying patients with a need for active treatment or increased monitoring for complications. METHODS: A total of 433 children aged 6 months to 6 years were monitored for 3 months in the offices of 57 family physicians. A questionnaire pertaining to determinants was completed. The outcome measures were: presence of unilateral or bilateral OME or bilateral OME after 3 months. The outcome was determined on the basis of tympanometry results. We performed bivariate and multivariate analyses. RESULTS: The presence of an upper respiratory tract infection (URTI) at the follow-up visit was associated with finding OME at that visit. When a URTI was present, no other determinants for persistent OME were found. When absent, the determinants for persistent bilateral OME were: no history of adenoidectomy, an episode of acute otitis media (AOM) in the first year of life, and month of entry into the study (June-November). For persistent unilateral or bilateral OME, the only significant determinant was an episode of AOM in the first year of life. CONCLUSIONS: Childrenwith 1 or more of the following factors need special attention for prevention of the sequelae of persistent OME: no history of adenoidectomy, AOM in the first year of life, and the presence of bilateral OME in the period between June and November.

Primary care based randomised, double blind trial of amoxicillin versus placebo for acute otitis media in children aged under 2 years.

OBJECTIVE: To determine the effect of antibiotic treatment for acute otitis media in children between 6 months and 2 years of age. DESIGN: Practice based, double blind, randomised, placebo controlled trial. SETTING: 53 general practices in the Netherlands. SUBJECTS: 240 children aged 6 months to 2 years with the diagnosis of acute otitis media. INTERVENTION: Amoxicillin 40 mg/kg/day in three doses. MAIN OUTCOME MEASURES: Persistent symptoms at day four and duration of fever and pain or crying, or both. Otoscopy at days four and 11, tympanometry at six weeks, and use of analgesic. RESULTS: Persistent symptoms at day four were less common in the amoxicillin group (risk difference 13%; 95% confidence interval 1% to 25%). The median duration of fever was two days in the amoxicillin group versus three in the placebo group (P=0.004). No significant difference was observed in duration of pain or crying, but analgesic consumption was higher in the placebo group during the first 10 days (4.1 v 2.3 doses, P=0.004). In addition, no otoscopic differences were observed at days four and 11, and tympanometric findings at six weeks were similar in both groups. CONCLUSIONS: Seven to eight children aged 6 to 24 months with acute otitis media needed to be treated with antibiotics to improve symptomatic outcome at day four in one child. This modest effect does not justify prescription of antibiotics at the first visit, provided close surveillance can be guaranteed.

Perspectives of new reproductive and diagnostic techniques among biologists and physicians, social scientists and ethicists.

The introduction and acceptance of new techniques in the field of reproductive medicine and antenatal genetic diagnosis is a complicated process in which biomedical professionals, and also social scientists and ethicists, play an important role. In this study the attitudes, expectancies and opinions of a panel of biological and medical professionals working in the field of this new technology are compared with those of a panel of concerned social scientists, psychologists, ethicists and leading members of patient groups. Various aspects of the new techniques are investigated: the present and future feasibility, the potential importance, the ethical evaluation and the social acceptance. The social-ethical panel appears to be much more reluctant regarding the importance, ethical values and social acceptability of new techniques than the biomedical panel, in particular, for preimplantation genetic diagnosis and fetal cell sorting large differences exist.

Tympanometry by general practitioners: reliable?

BACKGROUND: The diagnosis of otitis media with effusion (OME) is difficult using only medical history and otoscopy. Tympanometry may, therefore, be helpful in the diagnosis and follow-up of OME in general practice. Studies regarding the reliability of tympanogram production and validation of tympanogram outcome have been performed. OBJECTIVE: To gain insight into the usability of microtympanometry and the degree of agreement and accuracy of tympanogram classification in general practice. METHODS: Data were collected in the offices of 49 general practitioners (GP's). The usability of the microtymp was monitored against a checklist. GP's (39) classified 47 tympanograms according to Jerger's modified classification, designating them as 'OME', 'no OME' or 'interpretion impossible'. The gold standard was the consensus over the 47 tympanograms reached by three doctors very experienced in tympanometry. RESULTS: Of the general practitioners, 61% handled the microtymp faultlessly. The overall inter-observer agreement was moderate to substantial; with respect to the gold standard 74% of the general practitioners had a satisfactory to almost perfect agreement. These results were achieved after instruction and training; longer practice produced no significant improvement in the agreement. CONCLUSION: After training and instruction microtympanometry is a reliable diagnostic instrument in general practice. The classification of tympanograms is satisfactory. Classification problems arise when the curve is not a good one. Additional criteria for the assessment of the curves are proposed.