Arthur M. Bohnen

Pain in children and adolescents: a common experience

&NA; Little is known about the epidemiology of pain in children. We studied the prevalence of pain in Dutch children aged from 0 to 18 years in the open population, and the relationship with age, gender and pain parameters. A random sample of 1300 children aged 0–3 years was taken from the register of population in Rotterdam, The Netherlands. In the Rotterdam area, 27 primary schools and 14 secondary schools were selected to obtain a representative sample of 5336 children aged 4–18 years. Depending on the age of the child, a questionnaire was either mailed to the parents (0–3 years) or distributed at school (4–18 years). Of 6636 children surveyed, 5424 (82%) responded; response rates ranged from 64 to 92%, depending on the subject age and who completed the questionnaire. Of the respondents, 54% had experienced pain within the previous 3 months. Overall, a quarter of the respondents reported chronic pain (recurrent or continuous pain for more than 3 months). The prevalence of chronic pain increased with age, and was significantly higher for girls (P<0.001). In girls, a marked increase occurred in reporting chronic pain between 12 and 14 years of age. The most common types of pain in children were limb pain, headache and abdominal pain. Half of the respondents who had experienced pain reported to have multiple pain, and one‐third of the chronic pain sufferers experienced frequent and intense pain. These multiple pains and severe pains were more often reported by girls (P<0.001). The intensity of pain was higher in the case of chronic pain (P<0.001) and multiple pains (P<0.001), and for chronic pain the intensity was higher for girls (P<0.001). These findings indicate that chronic pain is a common complaint in childhood and adolescence. In particular, the high prevalence of severe chronic pain and multiple pain in girls aged 12 years and over calls for follow‐up investigations documenting the various bio‐psycho‐social factors related to this pain.

Correlates for Erectile and Ejaculatory Dysfunction in Older Dutch Men: A Community‐Based Study

OBJECTIVES: We estimated correlates for erectile dysfunction (ED) (defined as a report of erections of severely reduced rigidity or no erections) and ejaculatory dysfunction (EjD) (defined as a report of ejaculations with significantly reduced volume or no ejaculations) in a large community sample of older men.

Prevalence of erectile dysfunction: a systematic review of population-based studies.

A systematic review was conducted on the prevalence of erectile dysfunction (ED) in the general population. Studies were retrieved which reported prevalence rates of ED in the general population. Using a specially developed criteria list, the methodological quality of these studies was assessed and data on prevalence rates were extracted. We identified 23 studies from Europe (15), USA (5), Asia (2) and Australia (1). On our 12-item criteria list, the methodological quality ranged from 5 to 12. The prevalence of ED ranged from 2% in men younger than 40 y to 86% in men 80 y and older. Comparison between prevalence data is hampered by major methodological differences between studies, particularly in the use of various questionnaires and different definitions of ED. We stress the importance of providing all necessary information when reporting on the prevalence of ED. Moreover, international studies should be conducted to establish the true prevalence of ED across countries.

Erectile and ejaculatory dysfunction in a community-based sample of men 50 to 78 years old: prevalence, concern, and relation to sexual activity ☆

OBJECTIVES To determine the prevalence rates of erectile and ejaculatory dysfunction, associated bother, and their relation to sexual activity in a population-based sample of elderly men.Methods. Data were collected from 1688 men by way of self-administered questionnaires (including the International Continence Society male sex questionnaire) and measurements at a health center and urology outpatient department. RESULTS The prevalence of significant erectile dysfunction (ie, erections of severely reduced rigidity or no erections) increased from 3% in men 50 to 54 years old to 26% in men 70 to 78 years old. In the same age strata, the prevalence of significant ejaculatory dysfunction (ie, ejaculations with significantly reduced volume or no ejaculations) increased from 3% to 35%. Pain or discomfort during ejaculation was rare (1%) and independent of age. In general, men were more concerned about erectile dysfunction than about ejaculatory dysfunction. However, most men had no or only little concern about their dysfunction. The percentage of men who reported being sexually active declined with increasing age and was lower in men with erectile and ejaculatory dysfunction and in men without a partner. In sexually active men, 17% to 28% had no normal erections, indicating that with advancing age normal erections are not an absolute prerequisite for a sexually active life. CONCLUSIONS Erectile and ejaculatory dysfunction are common in elderly men. The results of this study indicate that these conditions are much less of a problem for older men than previously suggested.

NORMAL VOIDING PATTERNS AND DETERMINANTS OF INCREASED DIURNAL AND NOCTURNAL VOIDING FREQUENCY IN ELDERLY MEN

PURPOSE We determined the normal value of diurnal and nocturnal voiding frequency, and its determinants in a population based sample of elderly men. MATERIALS AND METHODS We collected data on 1,688 men 50 to 78 years old recruited from the population of Krimpen, The Netherlands. Measurements consisted of self-administered questionnaires, including the International Prostate Symptom Score (I-PSS), a 3-day frequency-volume chart, transrectal prostatic ultrasound, uroflowmetry and post-void residual urine volume measurement. RESULTS Diurnal voiding frequency is independent of age and more frequent in men with benign prostatic hyperplasia (BPH). Nocturia 2 or more times is present in 30% of men 50 to 54 and in 60% of those 70 to 78 years old, while nocturia 3 or more times is present in 4% and 20%, respectively. In addition, nocturia is strongly associated with BPH and nocturnal polyuria but apparently not with cardiovascular symptoms, hypertension or diabetes mellitus. We noted poor agreement of the responses on the frequency-volume charts and the I-PSS question on nocturia. Using the I-PSS leads to a higher prevalence of nocturia. CONCLUSIONS Diurnal frequency is independent of age (median 5 voids, interquartile range 4 to 6) but higher in men with BPH. Nocturia increases with advancing age and is more frequent in men with nocturnal polyuria. BPH is an independent risk factor for nocturia and increased diurnal voiding frequency. In those with nocturia there is a great difference in subjective symptoms and objective data, indicating that the weight of the I-PSS question on nocturia for making treatment decisions should be reconsidered.

Erectile dysfunction prospectively associated with cardiovascular disease in the Dutch general population: results from the Krimpen Study

The possible relationship between erectile dysfunction and the later occurrence of cardiovascular disease while biologically plausible has been evaluated in only a few studies. Our objective is to determine the relation between ED as defined by a single question on erectile rigidity and the later occurrence of myocardial infarction, stroke and sudden death in a population-based cohort study. In Krimpen aan den IJssel, a municipality near Rotterdam, all men aged 50–75 years, without cancer of the prostate or the bladder, without a history of radical prostectomy, neurogenic bladder disease, were invited to participate for a response rate of 50%. The answer to a single question on erectile rigidity included in the International Continence Society male sex questionnaire was used to define the severity of erectile dysfunction at baseline. Data on cardiovascular risk factors at baseline (age smoking, blood pressure, total- and high-density lipoprotein cholesterol, diabetes) were used to calculate Framingham risk scores. During an average of 6.3 years of follow-up, cardiovascular end points including acute myocardial infarction, stroke and sudden death were determined. Of the 1248 men free of CVD at baseline, 258 (22.8%) had reduced erectile rigidity and 108 (8.7%) had severely reduced erectile rigidity. In 7945 person-years of follow-up, 58 cardiovascular events occurred. In multiple variable Cox proportional hazards model adjusting for age and CVD risk score, hazard ratio was 1.6 (95% confidence interval (CI): 1.2–2.3) for reduced erectile rigidity and 2.6 (95% CI: 1.3–5.2) for severely reduced erectile rigidity. The population attributable risk fraction for reduced and severely reduced erectile rigidity was 11.7%. In this population-based study, a single question on erectile rigidity proved to be a predictor for the combined outcome of acute myocardial infarction, stroke and sudden death, independent of the risk factors used in the Framingham risk profile.

Strong effects of definition and nonresponse bias on prevalence rates of clinical benign prostatic hyperplasia: the Krimpen study of male urogenital tract problems and general health status.

Objective To estimate the prevalence of benign prostatic hyperplasia (BPH) in the community, and study the influence of BPH definition, age and response bias on prevalence rates.

Assessment of Decision Support for Blood Test Ordering in Primary Care: A Randomized Trial

The majority of general practitioners in the Netherlands have replaced traditional paper-based patient records with computer-based records; physicians enter patient data themselves in the computer during patient encounters (1). The use of electronic patient records creates new opportunities to influence physician behavior through implementation of decision support systems (2-7). In recent years, researchers have documented various computer-based decision support systems that have influenced physician behavior (8-17). Other investigators, however, have reported that computer-based decision support has not affected patient care (18). To resolve the issue, investigators have compared the results of studies that were conducted in different settings, used different methods, and involved different populations (19). Studies comparing different methods of providing computer-based decision support in randomized trials are not available. In the Netherlands, 3% to 4% of patient encounters with general practitioners in primary care result in the ordering of blood tests (20). However, ordering of blood tests is not always appropriate (21-29). Researchers argue that excessive ordering of tests causes physicians to pursue evaluation of false-positive results, which in turn leads to additional unnecessary diagnostic examinations (30-35). Two methods have proven effective in reducing the number of tests ordered by Dutch general practitioners. The first method is based on restricting the number of tests that are listed on an order form. Zaat and colleagues (36, 37) developed a restricted paper order form that replaced the existing form. The second method involves introduction of indication-oriented order forms that are based on clinical practice guidelines (38-40). We hypothesized that an indication-oriented order form based on guidelines, which would provide an optimally restricted list of tests that are relevant for a specific indication, would be more effective in decreasing the number of tests ordered compared with an order form that provides an initially limited list of tests. We therefore conducted a randomized trial to compare the effect of two versions of BloodLink, a computer-based clinical decision support system, on blood test ordering among Dutch general practitioners. Methods Participants In August and September 1995, all 64 practices (94 general practitioners) in the region of Delft, the Netherlands, were invited to participate in the study. Only practices that had replaced their paper-based patient records with electronic records and were using the computer during patient encounters were eligible. A total of 46 practices (62 general practitioners) agreed to participate. Randomization To avoid contamination, we performed random allocation at the level of the practice (41, 42). The practices were first stratified by type: solo practices or group practices (two or more general practitioners in the same practice). Each practice was subsequently assigned by simple random allocation to use BloodLink-Restricted or BloodLink-Guideline for the full study period. A researcher who was not involved in the study and was blinded to the identity of the practices performed the randomization by using a random-numbers table. After randomization, 22 practices involving 30 general practitioners were assigned to use BloodLink-Restricted and 24 practices involving 32 general practitioners were assigned to use BloodLink-Guideline. Intervention We developed two versions of BloodLink, a computer-based decision support system. BloodLink-Restricted initially displays a reduced list of tests, whereas BloodLink-Guideline is based on the guidelines of the Dutch College of General Practitioners. Both versions of BloodLink are integrated with the computer-based patient record (43). The option to use BloodLink was added to the screen that the general practitioner uses when entering data in the electronic patient record during patient encounters. The general practitioner can activate BloodLink to order blood tests as an alternative to using paper order forms. Because the total number of tests that can be ordered is too large to display on a computer screen, a set of tests is presented for selection. If the physician requires additional tests that are not currently displayed, he or she can type the first few letters of the names of the required tests, and the system will present all possible matches (including those corresponding to possible typing errors of the general practitioner) for selection. The number of tests that the general practitioners had at their disposal was the same both before and during the intervention (52 clinical chemistry tests and 46 microbiological tests). Options for specific instructions to the laboratory (for example, urgent processing or fasting values) are available. Once the physician has made his or her selections, BloodLink prints a patient-specific test order form and instructions for the laboratory and updates the patient record with the tests that have been ordered. The only difference between the two versions of BloodLink is the method used to present the initial set of tests to the general practitioner. BloodLink-Restricted is based on the idea of a restricted order form. It offers the general practitioner an initial set of 15 tests that have been shown to cover most of the clinical situations seen in primary care (36). BloodLink-Restricted can be viewed as a general electronic order form that presents only 15 tests on the screen, together with a field labeled other tests that allows the physician to request any other blood test (43). The 15 tests are alanine aminotransferase, aspartate aminotransferase, total bilirubin, cholesterol, creatinine, erythrocyte sedimentation rate, free thyroxine, -glutamyltransferase, glucose (and fasting glucose), glycosylated hemoglobin, hemoglobin, mean corpuscular volume, PaulBunnell, potassium, and thyroid-stimulating hormone. At any time, the physician can customize tests for individual patients by adding or deleting tests. BloodLink-Guideline is based on the guidelines of the Dutch College of General Practitioners. By January 1996, the Dutch College of General Practitioners had published 54 guidelines. Some guidelines focus on symptoms that are frequently seen in the primary care setting, such as acute diarrhea, acute sore throat, low back pain, alcohol abuse, fever in children, and sleeping disorders. Other guidelines focus on common diseases in primary care, such as diabetes, asthma, depression, dementia, and eczema. Finally, a set of guidelines covers preventive medicine. We reviewed the most recent version of each guideline, available in January 1996, and noted whether it contained a reference to a blood test (44). We determined the clinical situation in which the test should be performed (indication) and the tests that should be performed in that situation (advised tests). When general practitioners activate the system, BloodLink-Guideline first provides an overview of the available guidelines. The names of these guidelines are familiar to Dutch general practitioners. The general practitioner selects the appropriate guideline. A guideline may describe several different indications for requesting blood tests; for example, the guideline for blood tests and liver disease mentions 10 different indications. After the indication has been identified, the system proposes the relevant tests. The general practitioner then decides whether to adhere to the protocol. At any time, the physician can customize tests for individual patients by adding or removing tests from the proposed list. Although new guidelines are published at regular intervals, the currently available guidelines cover only a limited set of indications for blood tests (44). In the absence of national guidelines, local or regional guidelines may be used. The version of BloodLink-Guideline used during the clinical trial in the Delft region included three regional guidelines for anemia, AIDS, and clotting disorders, in addition to all national guidelines. Even with these additional guidelines, BloodLink-Guideline does not cover all possible indications for blood tests in primary care. To deal with these situations, the general practitioner can select the heading other indication and order any test. Protocol Before the study, the general practitioners were using two paper order forms: one for clinical chemistry and one for microbiology. After BloodLink was installed, one of the authors gave a brief orientation presentation to the participating practitioners. During a 3-month phase-in period, the general practitioners were allowed to use BloodLink in their practices to become acquainted with the system. After this period, the general practitioners were asked whether they were willing to participate in the trial. The study period was March 1996 through February 1997. Physicians always had the choice to use either the BloodLink software or the paper forms to order clinical chemistry and microbiology tests; thus, paper order forms were still available during the entire intervention period. When the general practitioner ordered blood tests during a patient encounter, only one order form was generated regardless of whether the general practitioner used paper forms or BloodLink. The electronic patient record monitored use of BloodLink by the practitioners. To include the requests for blood tests that were made by using traditional paper forms, we retrieved from the regional laboratory all requests for blood tests. Outcomes We counted the number of order forms that the laboratory received from the general practitioners and the number of tests on each form. The main outcome measure was the average number of tests per order form (including paper forms) per practice (summary variable). We defined the most frequently ordered tests as the tests that accounted for 80% of the total number of tests ordered. For these tests, we compu

Abdominal Symptoms: Do They Predict Gallstones?: A Systematic Review

Background: Our objective was to evaluate the diagnostic accuracy of abdominal symptoms in gallstones in studies using ultrasonography or oral cholecystography as the reference standard and to assess the extent to which variability in diagnostic accuracy is explained by patient selection and other characteristics of study design.Methods: A Medline search (1966–1998) was conducted in combination with reference checking for further relevant publications. Two independent assessors selected controlled studies that included patients 18 years of age. Articles were excluded if sensitivity and specificity could not be extracted or the included patients were at extraordinary risk for gallstones. Seven abdominal symptoms were evaluated. Modification of the diagnostic accuracy by clinical setting, extent of the disease, blinding, age, and sex was analysed by using logistic regression. Results:A total of 24 publications were included. The symptoms ‘biliary colic’, ‘radiating pain’, and ‘analgesics used’ were consistently related to gallstones. The setting of the study had a significant effect on the diagnostic accuracy of these symptoms. The unadjusted, pooled diagnostic odds ratios, however, were low (2.6 (95% confidence interval, 2.4–2.9), 2.8 (2.2–3.7), and 2 (1.6–2.5), respectively). The diagnostic odds ratio of biliary colic increased with the extent of gallstone disease (13.3 (4.2–42). Conclusions:Although biliary colic was specific for gallstones, 80% of the referred patients with gallstones presented with other abdominal symptoms. There is no current evidence that justifies the use of single abdominal symptoms, other than biliary colic, in the diagnosis of symptomatic gallstones. Further research should focus on the prognosis of patients with non-specific abdominal symptoms and gallstones.

Comparison between two devices for measuring hip joint motions

Objective: To compare the reliability of measurements of hip motions obtained with two instruments, an electronic inclinometer and a two-arm goniometer, and to investigate whether the two instruments, and different body positions, produce the same measurement data. Methods: Maximal active and passive hip movements were measured simultaneously with both instruments, in nine subjects during 10 consecutive measurements at short intervals. Results: Intra-observer variability was lower with the inclinometer in measurements of passive hip rotations. The two instruments showed equal intra-observer variability for hip movements in general. The inclinometer showed lower inter-observer variability in the measurements of active internal rotation. More rotational movement was measured with the two-arm goniometer; more extension and flexion with the inclinometer. Also, more rotational movement was found in the prone position compared to sitting and supine positions. Conclusions: The inclinometer is more reliable in measurements of hip rotation. For hip movements in general the two-arm goniometer is just as accurate when used by only one observer. The two instruments, and some positions, are not interchangeable during consecutive measurements.