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Objectives: The objectives of this study were to investigate the difference in timing of the first antenatal visit between ethnic groups and to explore the contribution of several noneconomic risk factors., Design: Prospective cohort study., Setting: All independent midwifery practices in the city of Amsterdam and all six Amsterdam hospitals., Population: Consecutive cohort of pregnant women (n = 12 381). Ethnic groups were distinguished by country of birth., Methods: Questionnaire data showed possible risk factors for late start. A Cox-proportional hazards model was created with (1) only ethnic group and (2) the addition of all significant risk factors, both time fixed and time dependent., Main Outcome Measures: Gestational age at first visit., Results: The questionnaire was returned by 8267 pregnant women (response rate 67%). All non-Dutch ethnic groups were significantly later in starting antenatal care during the whole duration of pregnancy compared with the ethnic Dutch group (hazard ratio [95% CI]: other Western, 0.83 [0.76-0.90]; Surinamese, 0.62 [0.56-0.68]; Antillean, 0.56 [0.45-0.70]; Turkish, 0.62 [0.55-0.69]; Moroccan, 0.56 [0.52-0.62]; Ghanaians, 0.50 [0.43-0.58] and other non-Western, 0.61 [0.56-0.67]). The range at which 90% were in care varied between 16 weeks and 3 days for Dutch and 24 weeks and 4 days for Ghanaians. These differences disappeared almost totally in the non-Dutch-speaking ethnic groups when the following risk factors were added to the model: poor language proficiency, low maternal education, teenage pregnancy, multiparity and unplanned pregnancy. The differences remained in the Dutch-speaking ethnic groups., Conclusions: We observed a disturbing delay by all ethnic groups in the timing of their first antenatal visit. In women born in non-Dutch-speaking, non-Western countries, these differences were explained by a higher prevalence of the risk factors: poor language proficiency in Dutch, lower maternal education and more teenage pregnancies. In women born in Dutch-speaking, non-Western countries, the disparities cannot be explained by higher prevalence of these risk factors, indicating that cultural factors play a role.

Objective: To investigate the role of language proficiency as determinant of folic acid knowledge and use in a multi-ethnic pregnancy cohort., Design: Prospective cohort study., Setting and Population: Pregnant women from Amsterdam attending obstetric care for their first antenatal visit. Number approached: 12,373 women, response rate: 67% (8266 women aged 14-49 years). Ethnicity was based on the country of birth: the Netherlands, Surinam, Antilles, Turkey, Morocco, Ghana, other non-Western and other Western countries., Main Outcome Measures: Knowledge about and use of folic acid supplements in pregnancy as elicited in a multilingual questionnaire, as well as determinants of these in ethnic groups separately., Results: Both periconceptional folic acid use and knowledge were significantly lower among Ghanaian, Moroccan, Turkish, and other non-Western women than among women born in the Netherlands or other Western countries. Language proficiency in Dutch was a major determinant of knowledge in all the ethnic groups with a mother tongue other than Dutch [adjusted odds ratios (OR): Western 3.2, non-Western (all countries combined) 7.5], while educational attainment was of secondary importance. Knowledge in turn was the strongest determinant of use (adjusted OR: Western 17.4, non-Western 27.0)., Conclusions: Periconceptional folic acid supplement use among women born in non-Dutch-speaking non-Western countries is low, reflecting a lack of knowledge that is determined by the inability to speak and understand the language of the country of residence. Measures to tackle this problem include the provision of linguistically appropriate information via ethnic health advisors, and language courses integrating health education for immigrants.

Objective: To estimate the prevalence of parental actions to stop infant crying that may threaten infant health, and to determine specific risk groups regarding these actions., Design: Descriptive., Method: Before their visit to a well-baby clinic in the Netherlands, parents of 3345 infants aged 1-6 months (96.5% response) filled out an anonymous questionnaire on actions that they undertook to stop their child crying., Results: At 6 months, 5.6% (95% confidence interval: 4.2-7.0%) of all the parents reported having smothered, slapped, or shaken their infant at least once because of its crying. The highest risks for detrimental parental actions were run by infants of parents from non-industrialised countries, of parents with no or only a part-time job, and of parents who had judged their infant's crying as excessive., Conclusion: Clinicians should be aware of the observed risk factors for abuse of young children known to cry a lot, in order to help parents to cope with this crying.

Objective: To determine the number of teenage births and abortions in Amsterdam, the Netherlands, in total and according to age and ethnic origin., Design: Retrospective analysis of routinely collected data., Method: Based on data collected from the municipal population register and the abortion clinics in Amsterdam, birth rates, abortion rates and abortion ratios were calculated for the period 1996-1998. The birth rate was the number of live births and the abortion rate the number of abortions per 1000 teenage girls. The abortion ratio was the number of abortions per 100 pregnancies., Results: The average birth rate and abortion rate for the period 1996-1998 were 3.2 and 7.6 for 14- to 16-year-old girls respectively, and 25.0 and 29.5 for 17- to 19-year-old girls respectively. Among 14- to 16-year-old girls 70 pregnancies out of 100 ended in an abortion and among 17- to 19-year-old girls 54 pregnancies out of 100. In both age groups the birth rate for Surinamese, Antillian, Moroccan, Turkish and Ghanian girls was higher than for Dutch girls. There was one exception: Moroccan girls aged 14-16 years did not have a higher birth rate than Dutch girls of the same age. Surinamese, Antillian and Ghanian girls aged 14-16 years and 17-19 years also had a higher abortion rate compared with Dutch girls of the same age. The Turkish and Moroccan girls did not have (much) higher abortion rates. In both age groups the abortion ratio was lowest for Turkish teenagers and highest for Ghanian teenagers. The figures for second-generation immigrant teenagers were more akin to those of the native Dutch girls than those of first-generation immigrants., Conclusion: In Amsterdam unwanted pregnancies were most frequent in Surinamese, Antillian and Ghanian teenage girls. To prevent these pregnancies further research into the (cultural) determinants of sexual behaviour is necessary.

Objective: To investigate the prevalence of breastfeeding amongst infants in Amsterdam prior to and following an active breastfeeding policy that has been operating in Amsterdam since 1993; investigate the link between ethnic origin and breastfeeding and the reasons mothers give for stopping breastfeeding., Design: Retrospective, descriptive study., Method: During the period 1998 to 2000, 1274 mothers in six child health centres in Amsterdam, the Netherlands, were asked about how they had fed their infant, aged 6 to 8 months, from the first week onwards, and their reasons for starting formula feeding. The breastfeeding percentages were compared with a study for the period 1992 to 1993., Results: During the first week of the infant's life, 87% of the mothers gave breastfeeding, and at 25 weeks this figure was 30%. For the period 1998 to 2000, the breastfeeding rate at 15 weeks was higher compared with the period 1992 to 1993, 45.1% as opposed to 36.4%. An increased percentage of breastfed infants were found in each ethnic group studied. More Turkish and Moroccan mothers than Dutch mothers started to breastfeed, and they breastfed for a similar period. Surinam mothers started breastfeeding as often as Dutch mothers, but breastfed for a shorter period. Concern about inadequate milk supply was stated as the most important reason for starting formula feeding (44%). This was also the most important reason stated by each of the ethnic groups, Dutch (139/411; 34%), Surinam (63/129; 49%), Moroccan (70/130; 54%) and Turkish women (42/67; 63%)., Conclusion: An active breastfeeding policy in Amsterdam that has been operating since 1993 has been accompanied by an increase in the number of breastfed infants. This has also been the case in non-Dutch groups. Health programmes should devote greater attention to mothers' concerns about a shortage of milk.

Objective: To examine if in Amsterdam there are social or cultural groups of children with a relatively low vaccination coverage for diphtheria, pertussis, tetanus and poliomyelitis (DPTP) and mumps, measles and rubella (MMR)., Design: Descriptive cross-sectional study., Method: In the Department of Child Health Care of the Municipal Health Service of Amsterdam all 83,217 children aged 2-12 years living in Amsterdam on the 1st of January 2000 were analysed for vaccination and sociodemographic data collected routinely by the Department of Child Health Care. The sociodemographic data concerned sex, year of birth, country of birth of the mother and child, name of the school and postal code of the home address. Schools were grouped by (religious) affiliation on the basis of the Amsterdam school guide 1999/2000. Based on postal codes children were classified by the neighbourhoods in which they were living. Neighbourhoods were grouped by socio-economic status based on data from the Central Bureau for Statistics., Results: The overall vaccination rates of DPTP and MMR were 92.4% and 93.5% respectively. No important variation in vaccination coverage was identified between more and less affluent neighbourhoods. The uptake rate among foreign children was sometimes slightly higher and sometimes slightly lower compared with native children. Especially foreign children born abroad (Surinam, Antilles, Morocco, Turkey) were not fully vaccinated: 70.9% were fully immunized for DPTP, 79.5% for MMR. Children who visited anthroposophical schools were considerably less frequently fully immunized compared with children visiting other schools: for DPTP and MMR 81.0 and 59.9% respectively versus 94.4 en 95.3% for children attending general municipal schools., Conclusion: The vaccination coverage was high in children in Amsterdam. Further improvement of the vaccination uptake might be achieved by a more outreaching attitude to children born abroad, and by more intensely informing sceptical parents about the benefits and (supposed) dangers of vaccinations.

Previous research has shown that in the Netherlands there is a certain degree of preventable mortality associated with long-distance travel, particularly among children of ethnic minority descent. In 1985 a health promotion campaign was launched in Amsterdam with the aim of reducing travel-related deaths by increasing knowledge in ethnic minority communities about the risks involved in travel. In the present study, two data sets are used to examine the possible effects of this health promotion campaign on travel-related mortality in children. The first data set, which was collected locally, indicates that the number of Amsterdam children dying abroad has dropped considerably since 1985. This is particularly true within one group which is highly likely to exhibit risky travel behavior. The second data set, which was collected nationally, shows that an upward trend in mortality among children aged 0-14 years before 1985 has in fact changed into a downward trend since 1985. A similar pattern is observed in the Netherlands as a whole, but to a significantly less pronounced degree than in Amsterdam. Although the influence of extraneous factors can never be fully dismissed, the analysis provides support for the conclusion that the health promotion campaign did in fact succeed in reducing the number of travel-related deaths.

Objective: To investigate whether the prevalence of asthmatic symptoms among children in the Netherlands has changed., Design: Literature study., Method: Investigations into the prevalence of children with asthmatic symptoms were collected from Medline, Embase and various libraries if they had been performed between 1984/'85 and 1994/'95 and had used the so-called WHO or Region list. 23 studies were selected with data on 76,353 elementary school pupils. Linear regression analysis, weighed for the number of children, was used to determine if the proportions of children with asthmatic symptoms had increased over the years., Results: In 10 years the prevalence of recent shortness of breath had increased by 107% (from 4.16 to 8.63%), that of recent wheeze by 16% (from 10.64 to 12.35%), that of recent attacks of breathlessness with wheezing by 17% (from 5.29 to 6.19%), and for chronic cough by 259 (from 1.05 to 3.77%) to 272% (from 3.14 to 11.68%). The prevalence of doctor-diagnosed asthma had increased by 120% (from 2.82 to 6.19%)., Conclusion: There had been a pronounced increase in the percentage of primary schoolchildren with asthmatic symptoms between 1984/'85 and 1994/'95. The prevalence of doctor-diagnosed asthma increased faster then did key symptoms of asthma.

Objective: To examine whether ethnic origin is related to care giving styles relevant to sudden infant death., Design: Prospective/retrospective, descriptive., Method: In six child health care centres in Amsterdam, the Netherlands, data about sleep position, bedclothes and passive smoking of infants aged 1-5 months were collected by face-to-face interviews of mothers visiting these centres between February 1997 and October 1998., Results: Eligible for the study were 1815 infants, 919 boys and 896 girls, mean age 2 months. In Amsterdam 12.5% of infants were usually or sometimes put to sleep in a prone position, 31.0% usually or now and then in a side position (but not in a prone position) and 56.5% usually in a supine position. Prone sleeping position was more frequent among Surinamese infants and less frequent among Moroccan infants compared with Dutch infants. Overall use of a duvet among infants was 22.7%. Use of duvets was higher among allochtonous infants; after controlling for demographic factors this difference was not significant, however. 6.3% of the infants had slept in the previous night with a pillow. Use of a pillow was much more frequent among allochtonous than among autochtonous infants: 13% versus 1.2%. Maternal daily smoking during pregnancy and daily smoking by mothers or others at home at time of interview was found in 15.1% and 25.8% of the infants respectively. Almost no Moroccan mothers smoked during pregnancy (0.4%), while Turkish mothers smoked as much as Dutch mothers (18.5% and 21.6% respectively). No differences in daily smoking at home were found between Surinamese, Moroccan and Dutch families (circa 26%). However, daily smoking at home was much more frequent in Turkish families (43.8%)., Conclusion: Health education about a safe sleeping position, about safe bedclothes and about the dangers of passive smoking is still needed. Education programmes to prevent sudden infant death must take into account ethnic differences in care giving styles. Special attention must be paid to the use of a pillow among allochtonous infants.

Background: Although the mu-opioid agonist morphine affects ventilatory control in men and women in different ways, no data exist regarding the influence of sex on the ventilatory effects of inhalational anesthetics. The authors compared the effect of sevoflurane on the ventilatory response to isocapnic hypoxia in healthy young men and women., Methods: Breath-to-breath ventilatory responses to hypoxic steps (number of hypoxic steps, four-six; duration, 3 min; end-tidal oxygen tension, approximately 50 mmHg; end-tidal carbon dioxide tension clamped at approximately 4 mmHg above resting values) were assessed in nine men and nine women without and with low-dose sevoflurane (end-tidal concentration, 0.25%). The bispectral index of the electroencephalogram was measured concomitantly., Results: Sevoflurane reduced the hypoxic ventilatory sensitivity significantly in both sexes (men: control, 0.62 +/- 0.17 vs. sevoflurane, 0.38 +/- 0.19 l x min(-1) x %(-1); women: control, 0.52 +/- 0.30 vs. sevoflurane, 0.34 +/- 0.15 l x min(-1) x %(-1)). Sevoflurane-induced reductions of the hypoxic responses were not different in the men and women. During sevoflurane inhalation, the bispectral index values decreased equally in men and women., Conclusion: In contrast to morphine, the influence of a low dose of the inhalational anesthetic sevoflurane on the ventilatory response to hypoxia is independent of sex.

Background and Objectives: The clinical utility of a new parasacral approach for conduction block of the sciatic nerve was investigated, with critical examination of onset, extent, and success rates when this block was used for surgical procedures below the knee., Methods: Thirty ASA I-III patients presenting for surgery on the lower limb were enrolled. All received 30 mL of 1.5% lidocaine with 1:200,000 epinephrine following nerve stimulator identification of the sciatic nerve at < or =0.2 mA or less. Trans-sartorial saphenous nerve blocks were performed to provide anesthesia to the medial leg., Results: Overall success for surgical anesthesia with this block was 97%. All components of the sacral plexus could be blocked with this approach, and 93% of patients displayed evidence of obturator nerve motor block. However, no patient displayed evidence of obturator sensory anesthesia that could be mapped. Saphenous nerve blocks were 100% effective in providing surgical anesthesia for the procedures performed., Conclusions: The parasacral approach to the sciatic nerve exhibits a high success rate, resulting in anesthesia of the entire sacral plexus and generally in motor block of the obturator nerve was an interesting observation.

Objective: To investigate whether ethnic origin is related to the prevalence of bedwetting among children and how parents handle bedwetters., Design: Descriptive study., Setting: Department of Youth Health Care in Amsterdam, the Netherlands., Method: Parents of children who attended a child health centre in 1992/1993 were interviewed using a questionnaire. A total of 1506 children aged 3-4, 2422 aged 5-6 and 2081 aged 11-12 years participated in the study., Results: The prevalences of bedwetting were 24.6%, 15.7% and 5.4% at 3-4, 5-6 and 11-12 years of age respectively. Moroccan and Turkish 3-4-year-olds wet their beds just as often as Dutch children, Surinamese 3-4-year-olds less often. However, Surinamese, Moroccan and Turkish school children wet their beds more often than their Dutch classmates. For Dutch children the prevalence of bedwetting at the age of 5-6 was clearly lower than at the age of 3-4, in contrast with Surinamese, Moroccan and Turkish children. Non-Dutch bedwetters were rewarded less often for a dry night and punished more often for a wet night than Dutch bedwetters, even at the age of 3-4., Conclusion: Bedwetting by school children still occurs often, and more often among non-Dutch than among Dutch children. Possibly, differences between Dutch and non-Dutch parents in the ways they deal with bedwetting plays a part. Appropriate information and support of (especially non-Dutch) parents of young children can perhaps reduce the prevalence of bedwetting at later ages.

Objective: To determine the causes of death among Amsterdam children dying abroad., Design: Retrospective study., Setting: Department of Youth Health Care in Amsterdam, the Netherlands., Method: Analysis was based on the data bank of the Department of Youth Health Care, which contains the items sex, age and ethnic origin of decreased children as well as time, place and cause of death., Results: A total of 791 Amsterdam children (1 week-14 years old) died during the period 1982-1993. Of these children 98 (12.4%) died outside the Netherlands; of two the place of death was unknown. A relatively large proportion of decreased Turkish and Moroccan children died while abroad, 24.7% and 34.2% respectively. The distribution of causes of death among children dying in the Netherlands differed from children dying abroad. The most important causes abroad were accidents (especially car accidents), infections (especially gastrointestinal infections) and congenital disorders. Children who died of accidents were mainly between 1 and 9 years old. Fatal infections were primarily seen in children 0 years old and of Moroccan origin, and in the period 1982-1985. Children who died of congenital abnormalities were mostly of Moroccan origin., Conclusion: Mortality among Turkish and Moroccan Amsterdam children often occurred outside the Netherlands. Mortality in children visiting foreign countries was mainly the result of preventable causes such as accidents and infections.

Objective: To investigate whether breast feeding is related to family type, family size, maternal education, maternal occupational status and ethnic origin., Design: Descriptive study., Setting: Six child health centres in Amsterdam, the Netherlands., Method: In the period 1992-1993 the feeding practices of 961 children of 3 months were investigated by interviewing their mothers., Results: In Amsterdam 21% of infants were exclusively breast-fed, 15% of infants were breast and formula fed and 64% of infants were exclusively formula fed. After adjustment for potential confounding variables, breast-feeding was associated with mother's educational level and ethnic origin. The breast feeding rate was 49% for mothers with a high education and 26% for mothers with a low education. Among Dutch mothers the frequency of breast-feeding was 37%, and among Surinam, Moroccan and Turkish mothers the frequencies of breast feeding were 16%, 34% and 43% respectively., Conclusion: These results suggest that besides socioeconomic factors cultural factors also play a part in the breast feeding practices of mothers. To promote breast feeding culture-based perceptions with respect to feeding and nursing of infants should be considered.

Blockade of conduction in the saphenous nerve is important in providing surgical anaesthesia in the lower leg. Unfortunately, previously described techniques have lacked clinical effectiveness in practice. We developed a transsartorial approach for conduction block of the saphenous nerve. We first confirmed its potential clinical utility in 12 cadaveric specimens by demonstrating that the saphenous nerve was consistently stained by injections of methylene blue. Subsequently, we compared the relative rates of successful saphenous nerve block and the extent of conduction block provided by three techniques: (1) transsartorial saphenous nerve block (TSSNB), (2) above knee femoral paracondylar field block (FPFB), and (3) below knee field block (BKFB) of the saphenous nerve in 20 ASA I volunteers. The transsartorial saphenous nerve block proved to be highly successful (80% success rate) and was superior to the other two approaches in providing cutaneous analgesia to pinprick in the saphenous nerve distribution (P < 0.05). The success rates of the BKFB and FPFB were 65% and 40% respectively. A successful block with the transsartorial approach provided complete anaesthesia of the medial malleolus in 94% of subjects whilst the BKFB and FPFB provided complete anaesthesia of the medial malleolus in less than 40% of the successful blocks. We recommend the transsartorial approach for more effective block of the saphenous nerve.

Three case reports are presented to illustrate the existence and importance of reflex bradycardic responses that can occur during maxillofacial surgical procedures. All three patients were healthy young adults undergoing operations which did not include any manipulation of orbital structures. After the patients had been anaesthetized for some time and were haemodynamically stable, profound bradycardia or ventricular asystole occurred suddenly in response to manipulations of the bony structures of the maxilla or mandible, or dissection of, or traction on, the attached soft tissue structures. The parasympathetic supply to the face is carried in the trigeminal nerve. Alternative afferent pathways must exist via the maxillary and/or mandibular divisions, in addition to the commonly reported pathway via the ophthalmic division of the trigeminal nerve in the classic oculocardiac reflex. The efferent arc involves the vagus, regardless of which branch of the trigeminal nerve transmits the afferent impulses. All patients undergoing maxillofacial procedures should be monitored carefully for reflex bradycardia and ventricular asystole.