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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.

Throughout recorded history, humans have tried to influence the sex of their offspring, through pregnancy injunctions, infanticide, and infant/child neglect. Reproductive technologies developed in the late 20th century allow determination of the sex of the offspring during pregnancy, making "sex selection" through abortion possible. Especially in parts of East and South Asia, sex selection against female fetuses has had dramatic consequences for male/female sex ratios. However, "newer" new reproductive technologies, such as prenatal genetic diagnosis and DNA-weighted semen selection, can now be applied for sex selection; eventually, the latter technology may become easily accessible as a noninvasive method. The prospects of these new technologies for sex selection must be considered in the light of cultural values surrounding son preference / daughter discrimination in many parts of the world, most notably Asia, as well as preferences for a "gender-balanced" family in much of the West. The ethical issues surrounding these technologies, such as the right to life and the equal treatment of female children, are potentially profound, but legislating the appropriate use of these "newest" new reproductive technologies will be difficult.

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.

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.

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.

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.

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.

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.

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.

Background: Appropriate use of antibiotics is one of the major issues in medicine today. In most countries, acute otitis media in children is treated with antibiotics; however, the efficacy of antibiotic use in every acute otitis media is a controversial issue. It may be worthwhile looking for special risk groups that benefit more from antibiotic treatment for acute otitis media. Children under two years of age with acute otitis media are at risk of poor outcome., Aim: To assess whether the current high prescription rates of antibiotics for acute otitis media in children under two years of age (being a risk group for poor outcome) are based on an established increased efficacy., Method: Systematic literature review and a quantitative analysis with an assessment of the methodological quality of published trials, comparing antibiotic treatment with non-antibiotic treatment in acute otitis media in children aged under two years., Results: Six trials were included. Trials from before 1981 had a poor methodological quality. Four were suitable for the quantitative analysis. Only two of them were truly placebo-controlled. Of these two, one included only recurrent acute otitis media and the other included only non-severe episodes. With these restricted data, no statistically significant difference was found between antibiotic-treated children and controls under two years of age with acute otitis media, judged on the basis of clinical improvement within seven days (common odds ratio = 1.31; 95% CI = 0.83-2.08)., Conclusion: The current high prescription rates of antibiotics among children under two years of age with acute otitis media are not sufficiently supported by evidence from published trials. New randomized placebo-controlled trials using reliable methodology are needed in this young age group.

The worldwide problem of multiple resistant strains should be attacked by a more adequate, rational prescription behaviour of antibiotics. As most upper respiratory tract infections (URTIs) have a viral cause and are selflimiting, antibiotics should be used for certain indications only. The development of evidence based guidelines, based on outcome studies in the field of URTIs carried out in general practice populations is recommended. The general practitioners (GPs) with defined practice populations are in a key position for research and a restrictive antibiotic policy. Several RCTs are carried out in general practice indicating that antibiotic prescriptions can be reduced. This will contribute to the decrease of resistant strains.

When couples are confronted with infertility they may choose among several options: medical help, adoption, fostering, alternative medicine and focusing on other life goals. The frequency of choices and motivations for these options were investigated among 131 infertile couples. Husbands and wives answered a structured questionnaire. The medical option was chosen in more than 80% of the cases. Also, this choice is made very quickly. Other options were considered at a later time, and chosen much later than the medical option. The most frequently mentioned motive for seeking help is the desire to have a child. This motive is reported in all forms of help seeking Motives for medical consultation are often seeking information, understanding the cause of infertility and physical complaints. Altruistic motives are rather important when considering adoption, and very important when considering foster-care.

The present study compares child-rearing among IVF parents (45 couples), other formerly infertile parents (35 couples) and fertile parents (35 couples) with a child between 2 and 4 years of age. Both mothers and fathers answered a questionnaire on parenting behaviour and on their child. The IVF mothers and other previously infertile mothers reported a higher emotional involvement with their child, and a greater parental competence compared to the fertile mothers. The IVF mothers rated their children more often as "social' and less often as "obstinate' than the other mothers. No significant differences were found among the fathers.

The perception of the diagnosis of infertility and the openness of patients about infertility was investigated among 108 infertile couples. Husbands and wives answered a structured questionnaire. The perception of diagnosis was in 38% of the cases different from the medical diagnosis. Patients perceived the diagnosis of male infertility more frequently, and the diagnosis of female infertility less frequently, than these diagnoses were made. Also there are significant differences in the perception of diagnosis between husbands and wives. Among the respondents there is a tendency to ascribe the diagnosis of infertility to themselves. It is important that physicians make sure that the patients have understood the received information. Family and friends are in almost all cases informed about the infertility problem, colleagues and acquaintances in about 60% of the cases, neighbors in about 40% of the cases. The reaction to openness is positive. Husbands are less open about male infertility than about female infertility. A selective choice of confidants and a subtle way of conveying the information generally lead to a positive reaction to the disclosure of infertility.

The present study compares the evidence of pregnancy and delivery among in-vitro fertilization (IVF) parents (45 couples), other formerly infertile parents (35 couples) and fertile parents (35 couples). All deliveries concerned primaparous women and singleton births. In addition, the burden of fertility treatments was investigated. Results show that the psychological burden of the treatments exceeds the physical burden. Fertility treatments were judged very worthwhile. Complications during pregnancy were more frequently reported by IVF mothers and other initially infertile mothers than by fertile mothers. However, controlling for the older age in both formerly infertile groups (IVF and non-IVF), no significant difference was found. No differences appeared regarding the evaluation of the development of the delivery. IVF parents and other infertile parents evaluated the pregnancy as more stressful than fertile parents. However, mothers experienced their delivery as more exceptional, and fathers experienced the pregnancy as more exceptional. In addition, IVF fathers enjoyed the pregnancy more than fathers from the other groups.

Objective: To investigate the relation between the age of women and their probability of conceiving, and to analyse the factors that influence the age at which couples desire to have their first child., Method: A national survey among women between the ages of 25 and 49. A random sample of 8050 households were approached. In these households 3295 women between the ages of 25 and 49 answered a short questionnaire about planning of the first pregnancy and fertility. Also sociodemographic data were gathered., Results: There was little variation in probability of conceiving between the ages of 20 and 28; around 65% to 70% after 6 months, just below 90% after 12 months and about 93% after 2 years. The pregnancy rate after 6 months started to decrease after the age of 33, while pregnancy rate after 1 and 2 years decreased gradually from the age of 28 to 75% and about 80% respectively at the age of 35. The year of birth of the woman (the factor 'time') was the most important factor influencing the age at which couples desire their first child. In addition demographic factors particularly a high level of education, and furthermore a high professional level and a high level of family income were associated with the desire to have the first child at a relatively late age.

Objective: to determine the accuracy of a handheld, portable tympanometer, the microtymp, in comparison with a reference instrument, the AR 85 tympanometer, and with the gold standard: presence or absence of middle-ear fluid., Design: comparison of results from the microtymp with results from the reference tympanometer, the AR 85 and the gold standard., Setting: University Children's Hospital, Utrecht and the General Hospital, Overvecht, Utrecht., Subjects: 142 children (284 ears) aged between 6 months and 12 years, who were referred by their General Practitioner or Ear, Nose and Throat surgeon for myringotomy and/or tympanostomy tube insertion., Main Outcome Measures: tympanometry with the AR 85 and presence or absence of middle-ear fluid., Results: In 243 ears, of the included 284 ears, the test results of the microtymp were compared with those of the reference instrument, the AR 85 tympanometer. Sensitivity 0.96 (95% C.I.: 0.93, 0.99), Specificity 0.81 (95% C.I.: 0.71, 0.91). In 233 ears, of the included 284 ears, the test results of the microtymp were compared with the gold standard. Sensitivity 0.94 (95% C.I.: 0.90, 0.98), specificity 0.48 (95% C.I.: 0.37, 0.59)., Conclusion: The microtymp is a valid instrument for diagnosing middle-ear effusions. The results of the microtymp are highly comparable with traditional tympanometers: high sensitivity and much lower specificity. Use in primary care can increase diagnostic accuracy of otitis media with effusion (OME) and makes follow-up possible. This will help to discriminate between those OME cases who need further treatment and those who will resolve spontaneously.

The objective of the study was to investigate long-term infertile couples in regard to their well-being. The design of the study consisted of a structured questionnaire. Husband and wife answered a written questionnaire each in a different place in their home. Wives and husbands of 108 childless couples with a long-term infertility participated. Seven dimensions of (negative) well-being were measured: depression, anxiety, hostility, health complaints, guilt/blame, self-esteem and sexuality. Results showed that sexual behavior was (still) often ruled by the constraints of procreation. Also a third of the women reported as a consequence of infertility a low self-esteem concerning their womanhood. Infertile women were more anxious, more depressed, displayed more hostility and reported more health complaints. There was no similar difference between long-term infertile men and men in general. In conclusion long-term infertile women showed a significantly-lower level of well-being compared with women in general. A third of the infertile women and a fifth of the infertile men had serious well-being problems. This group can be considered as needing emotional help and counselling in learning to live with their childlessness.