http://repub.eur.nl/res/aut/2190/ List of Publications en http://repub.eur.nl/static-eur/img/logo.png http://repub.eur.nl http://repub.eur.nl/res/pub/33174/ 2011-12-07T00:00:00Z Context: Since the introduction of biologic therapies, the pharmacological treatment approach for juvenile idiopathic arthritis ( JIA) has changed substantially, with achievement of inactive disease as a realistic goal. Objective: To determine the response to therapy after initiation of etanercept therapy among patients with JIA and to examine the association between baseline factors and response to etanercept treatment. Design, Setting, and Patients: The Arthritis and Biologicals in Children Register, an ongoing prospective observational study since 1999, includes all Dutch JIA patients who used biologic agents. All biologically naive patients who started etanercept before October 2009 were included, with follow-up data to January 2011. Among the 262 patients, 185 (71%) were female, 46 (18%) had systemic-onset, and the median age at initiation of etanercept treatment was 12.4 years. Main Outcome Measures: Excellent response (inactive disease or discontinuation earlier due to disease remission), intermediate response (more than 50% improvement from baseline, but no inactive disease), and poor response (less than 50% improvement from baseline or discontinuation earlier due to ineffectiveness or intolerance) evaluated 15 months after initiation of etanercept. Results: At 15 months after treatment initiation, 85 patients (32%) were considered excellent responders; 92 (36%), intermediate responders; and 85 (32%), poor responders. Compared with an intermediate or poor response, an excellent response was associated with lower baseline disability score (range, 0-3 points, with 0 being the best score; adjusted odds ratio [OR] per point increase, 0.49; 95% CI, 0.33-0.74); fewer diseasemodifying antirheumatic drugs (DMARD) (including methotrexate) used before initiating etanercept (adjusted OR per DMARD used, 0.64; 95% CI, 0.43-0.95), and younger age at onset (adjusted OR per year increase, 0.92; 95% CI, 0.84-0.99). Compared with an intermediate or excellent response, a poor response was associated with systemic JIA (adjusted OR systemic vs nonsystemic categories, 2.92; 95% CI, 1.26-6.80), and female sex (adjusted OR female vs male, 2.16; 95% CI, 1.12-4.18). Within the first 15 months of etanercept treatment, 119 patients experienced 1 or more infectious, noninfectious, or serious adverse events, including 37 among those with an excellent response, 36 with an intermediate response, and 46 with a poor response. Within the first 15 months of treatment, 61 patients discontinued etanercept treatment, including 4 with an excellent response, 0 with an intermediate response, and 57 with a poor response. In a secondary analysis of 262 patients with a median follow-up of 35.6 months after initiation of etanercept, a range of 37% to 49% of patients reached inactive disease. The mean adherence to etanercept was 49.2 months (95% CI, 46.4-52.0) for patients with an excellent response after 15 months, 47.5 months (95% CI, 44.9-50.1) for patients with an intermediate response, and 17.4 months (95% CI, 13.6-21.2) for patients with a poor response. Conclusions: Among patients with JIA who initiated treatment with etanercept, onethird achieved an excellent response, one-third an intermediate response, and onethird a poor response to therapy. Achievement of an excellent response was associated with low baseline disability scores, DMARDs used before initiating etanercept, and younger age at onset of JIA. Achievement of a poor treatment response was associated with systemic JIA and female sex. http://repub.eur.nl/res/pub/31720/ 2011-02-01T00:00:00Z Objectives: To evaluate the effectiveness of tumour necrosis factor (TNF) blockers in juvenile psoriatic arthritis (JPsA). Methods: The study was a prospective ongoing multicentre, observational study of all Dutch juvenile idiopathic arthritis (JIA) patients using biologicals. The response of arthritis was assessed by American College of Rheumatology (ACR) paediatric response and Wallace inactive disease criteria. The response of psoriatic skin lesions was scored by a 5-point scale. Results: Eighteen JPsA patients (72% female, median age onset 11.1 (range 3.3-14.6) years, 50% psoriatic skin lesions, 39% nail pitting, 22% dactylitis) were studied. The median follow-up time since starting anti-TNFα was 26 (range 3-62) months. Seventeen patients started on etanercept and one started on adalimumab. After 3 months of treatment 83% of the patients achieved ACR30 response, increasing to 100% after 15 months. Inactive disease reached in 67% after 39 months. There was no discontinuation because of inefficacy. Six patients discontinued treatment after a good clinical response. However, five patients flared and restarted treatment, all with a good response. During treatment four patients (two JPsA and two JIA patients with other subtypes) developed de novo psoriasis. In four of the nine patients the pre-existing psoriatic skin lesions improved. Conclusion: Anti-TNFα therapy in JPsA seems effective in treating arthritis. However, in most patients the arthritis flared up after treatment discontinuation, emphasising the need to investigate optimal therapy duration. The psoriatic skin lesions did not respond well and four patients developed de novo psoriasis. http://repub.eur.nl/res/pub/22419/ 2010-11-01T00:00:00Z Abstract Background: Assessing prescription patterns of asthma medication for children is helpful to optimize prescribing by general practitioners (GPs). The aim was to explore prescription patterns in children with physician-diagnosed asthma and its determinants in general practice. Methods: We used the Second Dutch National Survey of General Practice (DNSGP-2) with children aged 0-17 years registered in 87 general practices. All children with at least one asthma prescription were included (n = 2993). Prescription rates and prescription of continuous (≥3 prescriptions/year) versus intermittent asthma medication were calculated. Data, including several GP characteristics, were analysed using multivariate logistic regression accounting for clustering within practices. Results: During one year, 16% of the children with physician-diagnosed asthma (n = 3562) received no asthma medication. Of the 2993 children with asthma receiving asthma medication (on average 2.9 prescriptions/year), 61% received one or two prescriptions, 39% received three or more. Continuous medication with a bronchodilator and/or a corticosteroid was prescribed in 22% of these children. One out of 5 children receiving continuous medication was prescribed a bronchodilator only. In 7.5% of the prescriptions, asthma medications other than bronchodilators or corticosteroids were prescribed. Prescribing asthma medication varied widely between practices, but none of the children and GP determinants had an independent effect on prescribing continuous versus intermittent medication. Conclusion: In general practice, the annual number of asthma prescriptions per child with asthma is relatively low. One in 20 children is prescribed bronchodilators only continuously, indicating room for improvement. Child and GP characteristics cannot be used for targeting educational efforts. http://repub.eur.nl/res/pub/28202/ 2010-11-01T00:00:00Z This study aimed to determine disease activity patterns in juvenile systemic lupus erythematosus (jSLE) and its relation to early treatment. All jSLE patients who visited the outpatient departments of three Dutch university hospitals for at least 6 months were included. Data were retrospectively collected from each patient visit and hospitalization. Patient characteristics, clinical and laboratory findings categorized in organ systems, flare rate, medication use and disease course were analysed. Included were 35 patients (female 77%; White 47%) with a total follow-up of 142 years. Median age at diagnosis was 12.8 years. Flare rate was 0.45/ patient-year. An organ system not earlier involved was affected in 34% of flares. Identifiable disease activity patterns were: chronic active (49%), relapse remitting (14%) and long quiescence (37%), with no significant difference in organ involvement at diagnosis. Positive anti-Sm and non-White ethnicity were significantly associated with a chronic active pattern. In 14 patients with severe symptoms at diagnosis, treatment with intravenous cyclophosphamide and/or biologics and/or intravenous methylprednisone in the first 6 months resulted in a long quiescence pattern in seven patients. In conclusion, distinct disease activity patterns are identifiable in children. Suppression of disease with early aggressive treatment may decrease the rate of progression. http://repub.eur.nl/res/pub/27451/ 2010-02-01T00:00:00Z Objective. Juvenile idiopathic arthritis (JIA) is a heterogeneous disease involving chronic arthritis. The clinical course is characterized by a fluctuating pattern of active and inactive disease. We have described in detail the clinical course in different JIA subtypes during the first 2 years after diagnosis and studied its relationship to disease activity in the following years. Methods. Detailed clinical data on different parameters describing the disease activity in sequential time periods covering the first 2 years after diagnosis were retrieved from the charts of 311 patients with JIA and compared between subtypes. In a cohort of 146 patients, the relation of these different clinical variables to the course of disease in the following 3 years was evaluated. Results. The percentage of time with active disease in the first 2 years differed significantly between subtypes. In all subtypes, a broad spectrum of activity was observed. The time with active disease in the first 2 years was the most significant factor associated with the duration of active disease in the following years. Conclusion. Different percentages of time with active disease have been observed between JIA subtypes in the first 2 years. The cumulative duration of activity varied widely within each subtype. Regarding the prognosis of the individual patient, the clinical course in the first 2 years appears to be predictive of the clinical course in the following years. Patients that have less time with active disease in the first 2 years are not likely to develop an unremitting clinical course later on. http://repub.eur.nl/res/pub/27394/ 2010-01-01T00:00:00Z Objective: To evaluate changes in health-related quality of life (HRQoL) in patients with refractory juvenile idiopathic arthritis (JIA) who are being treated with etanercept. Methods: 53 patients with JIA from seven Dutch centres were included. HRQoL was measured by the Childhood Health Assessment Questionnaire (CHAQ), Child Health Questionnaire (CHQ) and Health Utilities Index mark 3 (HUI3) at the start and after 3, 15 and 27 months of treatment. At the same time points the following JIA disease activity variables were collected; physician's global assessment through the visual analogue scale (VAS), number of active and limited joints and erythrocyte sedimentation rate. A statistical method linear mixed models was used to assess outcomes over time. Results: During etanercept treatment both disease-specific and generic HRQoL outcomes improved dramatically. Significant improvements were shown after 3 months and these improvements continued at least up to 27 months of treatment. The disease-specific CHAQ, including VAS pain and wellbeing, showed a significant improvement in all domains. The generic health-profile measure CHQ improved for all the health concepts except for "family cohesion", which was normal. The generic preference-based HUI3 showed impairment and, subsequently, significant improvement in the more specific domains ("pain", "ambulatory", "dexterity"). In accordance disease activity variables also improved significantly over time. Conclusion: This study shows that the HRQoL of patients with refractory JIA can be substantially improved by the use of etanercept for all aspects impaired by JIA. Information on HRQoL is crucial to understand the complete impact of etanercept treatment on patients with JIA and their families. http://repub.eur.nl/res/pub/24704/ 2009-12-01T00:00:00Z Objective. To develop a reliable and user-friendly digital Childhood HAQ (CHAQ) to facilitate systematic monitoring of disease activity at the outpatient clinic in juvenile idiopathic arthritis (JIA) patients. Methods. The digital CHAQ was tested with patients who visited the outpatient paediatric rheumatology clinic of the Erasmus MC Sophia Children's Hospital. These patients completed in a randomized order the paper form and digital CHAQ while being observed. Validity was tested by comparing outcomes with the paper form CHAQ. User-friendliness was evaluated through a short questionnaire. Results. A digital CHAQ was developed and revised several times according to our observations. Outcome is automatically calculated and can be printed. Fifty-one patients completed both the digital and paper form CHAQ. Correlation coefficient between both outcomes of the CHAQ Disability Index was 0.974. No statistically significantly differences in median outcome were found in visual analogue scale (VAS) pain (25.6 vs 25.9mm) and VAS well-being (20.1 vs 19.5 mm). Although the mean time (5.06 min) to complete the digital CHAQ was significantly longer than the mean time (3.75 min) to complete the paper form, the majority of patients (75%) preferred the digital version. User-friendliness received maximum positive score. Conclusion. We developed a reliable and user-friendly digital CHAQ, which can be easily and systematically completed during routine clinic visits. Such digitalization of questionnaires can be applied in any field to make systematic monitoring of disease activity in daily practice possible. http://repub.eur.nl/res/pub/17398/ 2009-09-21T00:00:00Z http://repub.eur.nl/res/pub/16734/ 2009-07-01T00:00:00Z PURPOSE: The obesity epidemic in children is spreading at alarming rates. Because musculoskeletal problems can influence physical activity, we compared the frequency of musculoskeletal problems in overweight and obese children with that in normal-weight children. METHODS: We performed a cross-sectional database and face-to-face interview study that included 2,459 children aged 2 to 17 years from Dutch family practices. We collected data on self-reported height and weight (body mass index), self-reported musculoskeletal problems in the 2 weeks before the interview, number of family physician consultations for musculoskeletal problems in 1 year, and age (2 age-groups were analyzed: 2 to 11 years and 12 to 17 years, because of the proxy interview in the youngest age-group). We calculated the odds ratio (OR) and 95% confidence interval (CI) for musculoskeletal problems in overweight and obese children, compared with normal-weight children. RESULTS: Overweight and obese children in both age-groups (2 to 11 years and 12 to 17 years) reported significantly more musculoskeletal problems (OR = 1.86; 95% CI, 1.18-2.93; and OR = 1.69; 95% CI, 1.08-2.65, respectively) than normal-weight children. The total group of children who were overweight or obese reported more lower extremity problems than did the normal-weight children (OR = 1.62; 95% CI, 1.09-2.41); furthermore, they reported more ankle and foot problems than children who were of normal weight (OR = 1.92; 95% CI, 1.15-3.20). Overweight and obese children aged 12 to 17 years consulted their family physicians more often with lower extremity problems than did the normal-weight children (OR = 1.92; 95% CI, 1.05-3.51). CONCLUSION: This study shows that overweight and obese children more frequently experience musculoskeletal problems than do normal-weight children. http://repub.eur.nl/res/pub/27208/ 2009-07-01T00:00:00Z http://repub.eur.nl/res/pub/24660/ 2009-06-15T00:00:00Z Background. In recent decades, studies on the management of common foot problems in children have suggested that in many cases, there is no indication for treatment. It is not known whether these studies have changed daily practice. Objective. Our aim was to establish and compare incidence and referral rates for foot problems in children in 1987 and 2001. Methods. A comparison was made of two large consecutive surveys in Dutch general practice performed in 1987 (86 577 children aged 0-17 years) and 2001 (87 952 children aged 0-17 years), which were carried out by The Netherlands Institute for Health Services Research. Both surveys included a representative sample of the Dutch population. Incidence and referral rates were calculated and, data were stratified for age group and gender. Results. Compared to 1987, in 2001 the overall incidence rate of foot problems presented to the family physician (FP) decreased substantially from 80.0 [95% confidence interval (CI) 77.0-84.7] to 17.4 (95% CI 16.5-18.3) per 1000 person-years (P < 0.0001). The incidence rate of flat feet decreased from 4.9 (95% CI 4.0-5.9) per 1000 person-years in 1987 to 3.4 (95% CI 3.0-3.8) per 1000 person-years in 2001 (P = 0.001). The distribution of referrals to other primary health care professionals and medical specialists has almost reversed in favour of primary health care professionals. Conclusion. Total incidence rate of musculoskeletal foot problems seen by the FP has decreased substantially, between 1987 and 2001. http://repub.eur.nl/res/pub/24877/ 2009-05-01T00:00:00Z Objective: We undertook an observational study to obtain a complete overview of the long-term effectiveness and safety of etanercept in patients with different juvenile idiopathic arthritis (JIA) subtypes. Methods: At baseline we collected patient and disease characteristics of all Dutch patients with JIA who started treatment with etanercept. Disease activity was evaluated (at start of the study, after 3 months and then yearly) according to the JIA core set of the American College of Rheumatology paediatric definition for 30, 50 and 70% improvement (ACR Pedi 30, 50 and 70). Use of etanercept and concomitant drugs was monitored. Adverse events were recorded. Results: We included 146 patients with JIA with a median follow-up of 2.5 years per patient (range 0.3-7.3). JIA subtypes represented: 27% systemic, 8% polyarticular rheumatoid factor positive, 38% polyarticular rheumatoid factor negative, 19% oligoarticular extended, 3% enthesitis-related and 5% psoriatica. Most patients (77%) met the criteria of the ACR Pedi 30 in the first 3 months of treatment. For the majority of patients this improvement was sustained; 53 (36%) of all patients met the remission criteria. No other second-line agents were needed in 43 patients. Although patients with systemic JIA responded initially less to etanercept therapy than patients from other subtypes, those who did respond showed equal effectiveness in the long term. Serious adverse events rate was low (0.029 per patient year). Conclusions: Etanercept is effective and safe in JIA, even for a large proportion of the patients with systemic JIA. The greatest improvement occurred in the first 3 months of treatment, and was sustained for a long time in most patients (up to 75 months). http://repub.eur.nl/res/pub/30361/ 2008-09-08T00:00:00Z Objectives. Most clinical studies use paper case record forms (CRFs) to collect data. In the Dutch multi-centre observational study on biologicals we encountered several disadvantages of using the paper CRFs. These are delay in data collection, lack of overview in collected data and difficulties in obtaining up-to-date interim reports. Therefore, we wanted to create a more effective method of data collection compared with CRFs on paper in a multi-centre study. Methods. We designed a web-based register with the intention to make it easy to use for participating physicians and at the same time accurate and up-to-date. Security demands were taken into account to secure the safety of the patient data. Results. The web-based register was tested with data from 161 juvenile idiopathic arthritis patients from nine different centres. Internal validity was obtained and user-friendliness guaranteed. To secure the completeness of the data automatically generated e-mail alerts were implemented into the web-based register. More transparency of data was achieved by including the option to automatically generate interim reports of data in the web-based register. The safety was tested and approved. Conclusions. By digitalizing the CRF we achieved our aim to provide easy, rapid and safe access to the database and contributed to a new way of data collection. Although the web-based register was designed for the current multi-centre observational study, this type of instrument can also be applied to other types of studies. We expect that especially collaborative study groups will find it an efficient tool to collect data. http://repub.eur.nl/res/pub/30286/ 2008-07-18T00:00:00Z http://repub.eur.nl/res/pub/28896/ 2008-04-15T00:00:00Z Objective. Temporomandibular joint (TMJ) involvement is a frequent feature in cross-sectional prevalence studies among patients with juvenile idiopathic arthritis (JIA). In this followup study, patients were reviewed after 5 years to study the course of TMJ involvement in relation to disease characteristics. Methods. Children with JIA from a previous study on TMJ involvement were included. A rheumatologic evaluation including the 6 parameters of the JIA core set and an orthodontic evaluation including an orthopantomogram (OPT) were performed. OPTs were scored according to Rohlin's grading system (grades 0-5). Results. The overall prevalence of patients with condylar alterations decreased from 49% to 40%. Improvement of the alterations was seen in 69% of the initially affected condyles, and consequently improvement was seen in 83% of the initially affected patients. Normalization of the alterations was seen in 67% of the improved condyles, and consequently in 44% of the patients. This proves that the condyle has a regenerative capacity. Improvement was related to low disease activity and a less extensive therapeutic regimen. Conclusion. In patients with JIA, condylar alterations can improve and even regenerate. Condylar improvement is associated with a low disease activity. http://repub.eur.nl/res/pub/29347/ 2008-02-01T00:00:00Z http://repub.eur.nl/res/pub/28767/ 2008-01-15T00:00:00Z Objective. To validate a core set of outcome measures for the evaluation of response to treatment in patients with juvenile dermatomyositis (DM). Methods. In 2001, a preliminary consensus-derived core set for evaluating response to therapy in juvenile DM was established. In the present study, the core set was validated through an evidence-based, large-scale data collection that led to the enrollment of 294 patients from 36 countries. Consecutive patients with active disease were assessed at baseline and after 6 months. The validation procedures included assessment of feasibility, responsiveness, discriminant and construct ability, concordance in the evaluation of response to therapy between physicians and parents, redundancy, internal consistency, and ability to predict a therapeutic response. Results. The following clinical measures were found to be feasible, and to have good construct validity, discriminative ability, and internal consistency; furthermore, they were not redundant, proved responsive to clinically important changes in disease activity, and were associated strongly with treatment outcome and thus were included in the final core set: 1) physician's global assessment of disease activity, 2) muscle strength, 3) global disease activity measure, 4) parent's global assessment of patient's well-being, 5) functional ability, and 6) health-related quality of life. Conclusion. The members of the Paediatric Rheumatology International Trials Organisation, with the endorsement of the American College of Rheumatology and the European League Against Rheumatism, propose a core set of criteria for the evaluation of response to therapy that is scientifically and clinically relevant and statistically validated. The core set will help standardize the conduct and reporting of clinical trials and assist practitioners in deciding whether a child with juvenile DM has responded adequately to therapy. http://repub.eur.nl/res/pub/35996/ 2007-12-01T00:00:00Z Introduction: Dermatophytosis is a common skin infection in children. Although the epidemiology is relatively unknown it is becoming a major health problem in some countries. We determine the incidence and management of dermatophytosis in Dutch general practice in 1987 and 2001. Methods: We used data of all children aged 0-17 years derived from two national surveys performed in Dutch general practice in 1987 and 2001 respectively. All diagnoses, prescriptions and referrals were registered over a 12 months period by the participating general practitioners (GPs), 161 and 195 respectively. Data were stratified for socio-demographic characteristics. Results: Compared to 1987, in 2001 the total reported incidence rate of dermatophytosis in children in general practice increased from 20.8 [95%CI 18.9-22.8] to 24.6 [95%CI 23.5-25.7] per 1,000 person years. Infants (<1 year), girls, children in rural areas and children of non-western immigrants more often consulted the GP for dermatophytosis in 2001. In both surveys GPs treated the majority of children with dermatophytosis with topical drugs, especially with azoles. Conclusions: The reported incidence rate of dermatophytosis in children in general practice increased; however it is unclear whether this is a consequence of an increasing prevalence in the population or a changing help seeking behaviour. GPs generally follow the national guideline for the treatment of dermatophytosis in children. http://repub.eur.nl/res/pub/35135/ 2007-11-01T00:00:00Z Objectives: A previous 24-week randomised trial demonstrated that sulfasalazine (SSZ) treatment was superior to placebo (PLAC) in suppressing disease activity in patients with oligo- and polyarticular onset juvenile idiopathic arthritis (JIA). The current study determines the long-term outcome of the trial participants and evaluates whether the benefits of SSZ allocation are sustained over time. Methods: Between 2001 and 2003, 32 SSZ and 29 PLAC patients (90% of all patients) were prospectively examined clinically and by chart review, median 9 years (range 7 to 10) after trial inclusion. In the follow-up assessment, variables of the American College of Rheumatology Pediatric 30 (ACR Pedi 30) criteria were collected. The assessor was blinded to trial treatment allocation. Results: After the trial, patients had been routinely followed in rheumatology referral centres, and treated at the discretion of the attending physician. Almost all patients continued or started disease-modifying antirheumatic drugs (DMARDs) (SSZ 91%, PLAC 93%; SSZ treatment in about 80%). DAAARD treatment appeared less intensive in the SSZ group as evidenced by a significantly shorter duration of SSZ use (median 2.5 vs 5.2 years; p = 0.02) and a trend towards less use of methotrexate and other DMARDs. More than one-third of the patients reported long periods of non-compliance with DMARD treatment in both groups. At follow-up, 74% of the patients had active joints, and 30% showed active polyarthritis. Almost all outcome scores were better for SSZ compared with PLAC patients. Differences (often exceeding 50%) were significant for the number of active joints, patients' overall well-being, number of patients with episodes of clinical remission off medication (CROM) and duration of these episodes, patients in CROM and ACR Pedi 30 response at follow-up. Additional exploratory analyses performed to detect potential confounders related to patient characteristics or follow-up treatment showed that DMARD treatment compliance was positively correlated with an ACR Pedi 30 response (odds ratio 3.8, 95% confidence interval (CI) 1.1 to 13.4; p = 0.03). Adjusted for compliance, an SSZ patient was 4.2 times as likely as a PLAC patient to be an ACR Pedi 30 responder at follow-up (95% CI 1.3 to 14.3; p = 0.02). Conclusions: This follow-up study shows that effective suppression of disease activity by SSZ treatment early in active disease in JIA patients has beneficial effects that persist for many years. Given these results, compliance with DMARD treatment deserves serious attention. http://repub.eur.nl/res/pub/36043/ 2007-08-03T00:00:00Z Objective: Temporomandibular joint (TMJ) involvement is a frequent feature in cross-sectional prevalence studies among juvenile idiopathic arthritis (JIA) patients. The cross-sectional design makes it almost impossible to study the incidence. Follow-up data on TMJ involvement are sparse. In this study patients were reviewed with an interval of a minimum of 1 year and a maximum of 2 years to study the yearly incidence of TMJ involvement and to obtain follow-up data on TMJ involvement and orthopantomogram (OPT) alterations. Methods: Children with JIA from a previous study on TMJ involvement were included. OPTs were scored according to Rohlin's grading system (grade 0-5). A paediatric rheumatologist measured the level of disease activity during the interval. Results: Eighty-nine of the 97 patients were included in this study with a mean follow-up of 14 months. The yearly incidence of TMJ involvement was 7.1% in patients with JIA. Improvement on the OPT was seen in 27 patients (66%), and 19 of these patients no longer showed any signs of TMJ involvement. Worsening on the OPT was seen in four patients (10%). Disease activity was significantly lower in the improved patients than in the patients with worsening. Conclusion: Condylar lesions due to arthritis can improve over time, indicating a regenerative capacity of the mandibular condyle. As condylar improvement seems to be associated with low disease activity, it is important to consider the TMJ when deciding on a therapeutic regimen. http://repub.eur.nl/res/pub/35451/ 2007-05-01T00:00:00Z http://repub.eur.nl/res/pub/14084/ 2006-08-31T00:00:00Z BACKGROUND: Sepsis or bacteraemia, however rare, is a significant cause of high mortality and serious complications in children. In previous studies skin disease or skin infections were reported as risk factor. We hypothesize that children with sepsis or bacteraemia more often presented with skin diseases to the general practitioner (GP) than other children. If our hypothesis is true the GP could reduce the risk of sepsis or bacteraemia by managing skin diseases appropriately. METHODS: We performed a case-control study using data of children aged 0-17 years of the second Dutch national survey of general practice (2001) and the National Medical Registration of all hospital admissions in the Netherlands. Cases were defined as children who were hospitalized for sepsis or bacteraemia. We selected two control groups by matching each case with six controls. The first control group was randomly selected from the GP patient lists irrespective of hospital admission and GP consultation. The second control group was randomly sampled from those children who were hospitalized for other reasons than sepsis or bacteraemia. We calculated odds ratios and 95% confidence intervals (CI). A two-sided p-value less than 0.05 was considered significant in all tests. RESULTS: We found odds ratios for skin related GP consultations of 3.4 (95% CI: [1.1-10.8], p = 0.03) in cases versus GP controls and 1.4 (95% CI: [0.5-3.9], p = 0.44) in cases versus hospital controls. Children younger than three months had an odds ratio (cases/GP controls) of 9.2 (95% CI: [0.81-106.1], p = 0.07) and 4.0 (95% CI: [0.67-23.9], p = 0.12) among cases versus hospital controls. Although cases consulted the GP more often with skin diseases than their controls, the probability of a GP consultation for skin disease was only 5% among cases. CONCLUSION: There is evidence that children who were admitted due to sepsis or bacteraemia consulted the GP more often for skin diseases than other children, but the differences are not clinically relevant indicating that there is little opportunity for GPs to reduce the risk of sepsis and/or bacteraemia considerably by managing skin diseases appropriately. http://repub.eur.nl/res/pub/13995/ 2006-04-04T00:00:00Z BACKGROUND: We aimed to investigate incidence rates of urinary tract infections in Dutch general practice and their association with gender, season and urbanisation level, and to analyse prescription and referral in case of urinary tract infections. METHOD: During one calendar year, 195 general practitioners in 104 practices in the Netherlands registered all their patient contacts. This study was performed by the Netherlands Institute for Health Services Research (NIVEL) in 2001. Of 82,053 children aged 0 to 18 years, the following variables were collected: number of episodes per patient, number of contacts per episode, month of the year in which the diagnosis of urinary tract infection was made, age, gender, urbanisation level, drug prescription and referral. RESULTS: The overall incidence rate was 19 episodes per 1000 person years. The incidence rate in girls was 8 times as high as in boys. The incidence rate in smaller cities and rural areas was 2 times as high as in the three largest cities. Throughout the year, incidence rates varied with a decrease in summertime for children at the age of 0 to 12 years. Of the prescriptions, 66% were in accordance with current guidelines, but only 18% of the children who had an indication were actually referred. CONCLUSION: This study shows that incidence rates of urinary tract infections are not only related to gender and season, but also to urbanisation. General practitioners in the Netherlands frequently do not follow the clinical guidelines for urinary tract infections, especially with respect to referral. http://repub.eur.nl/res/pub/13990/ 2006-03-21T00:00:00Z BACKGROUND: The increasing proportion of skin diseases encountered in general practice represents a substantial part of morbidity in children. Only limited information is available about the frequency of specific skin diseases. We aimed to compare incidence rates of skin diseases in children in general practice between 1987 and 2001. METHODS: We used data on all children aged 0-17 years derived from two consecutive surveys performed in Dutch general practice in 1987 and 2001. Both surveys concerned a longitudinal registration of GP consultations over 12 months. Each disease episode was coded according to the International Classification of Primary Care. Incidence rates of separate skin diseases were calculated by dividing all new episodes for each distinct ICPC code by the average study population at risk. Data were stratified for socio-demographic characteristics. RESULTS: The incidence rate of all skin diseases combined in general practice decreased between 1987 and 2001. Among infants the incidence rate increased. Girls presented more skin diseases to the GP. In the southern part of the Netherlands children consulted their GP more often for skin diseases compared to the northern part. Children of non-Western immigrants presented relatively more skin diseases to the GP. In general practice incidence rates of specific skin diseases such as impetigo, dermatophytosis and atopic dermatitis increased in 2001, whereas warts, contact dermatitis and skin injuries decreased. CONCLUSION: The overall incidence rate of all skin diseases combined in general practice decreased whereas the incidence rates of bacterial, mycotic and atopic skin diseases increased. http://repub.eur.nl/res/pub/17755/ 2006-02-01T00:00:00Z BACKGROUND: Impetigo is a common skin infection in children. The epidemiology is relatively unknown, and the choice of treatment is subject to debate. OBJECTIVE: The objective of our study was to determine the incidence and treatment of impetigo in Dutch general practice, and to assess trends between 1987 and 2001. METHODS: We used data from the first (1987) and second (2001) Dutch national surveys of general practice. All diagnoses, prescriptions and referrals were registered by the participating general practitioners (GPs), 161 and 195, respectively. RESULTS: The incidence rate of impetigo increased from 16.5 (1987) to 20.6 (2001) per 1000 person years under 18 years old (P < 0.01). In both years, the incidence was significantly higher in summer, in rural areas and in the southern region of the Netherlands, compared with winter, urban areas and northern region, respectively. Socioeconomic status was not associated with the incidence rate. From 1987 to 2001, there was a trend towards treatment with a topical antibiotic (from 43% to 64%), especially fusidic acid cream and mupirocin cream. Treatment with oral antibiotics (from 31% to 14%) and antiseptics (from 11% to 3%) was prescribed less often. CONCLUSIONS: We have shown an increased incidence of impetigo in the past decade, which may be the result of an increased tendency to seek help, or increased antibiotic resistance and virulence of Staphylococcus aureus. Further microbiological research on the marked regional difference in incidence may contribute to understanding the factors that determine the spread of impetigo. Trends in prescribing for impetigo generally follow evidence-based knowledge on the effectiveness of different therapies, rather than the national practice guideline. http://repub.eur.nl/res/pub/10393/ 2005-01-01T00:00:00Z This study aimed to assess the incidence of unintentional injuries presented in general practice, and to identify children at risk from experiencing an unintentional injury. We used the data of all 0-17-year-old children from a representative survey in 96 Dutch general practices in 2001. We computed incidence rates and multilevel multivariate regression analysis in different age strata and identified patient and family characteristics associated with an elevated injury risk. Nine thousand four hundred and eighty-four new injury episodes were identified from 105 353 new health problems presented in general practice, giving an overall incidence rate of 115 per 1000 person years (95% confidence interval [CI] = 113 to 118). Sex and residence in rural areas are strong predictors of injury in all age strata. Also, in children aged 0-4 years, a higher number of siblings is associated with elevated injury risk (> or =3 siblings odds ratio [OR] = 1.57, 95% CI = 1.19 to 2.08) and in the 12-17-year-olds, ethnic background and socioeconomic class are associated with experiencing an injury (non-western children OR = 0.67, 95% CI = 0.54 to 0.81; low socioeconomic class OR = 1.39, 95% CI = 1.22 to 1.58). Unintentional injury is a significant health problem in children in general practice, accounting for 9% of all new health problems in children. In all age groups, boys in rural areas are especially at risk to experience an injury. http://repub.eur.nl/res/pub/8518/ 2005-01-01T00:00:00Z BACKGROUND: In addition to clinical measures in the evaluation of paediatric interventions, health related quality of life (HRQoL) is an important outcome. The TAPQOL (TNO-AZL Preschool children Quality of Life) was developed to measure HRQoL in preschool children. It is a generic instrument consisting of 12 scales that cover the domains physical, social, cognitive, and emotional functioning. AIMS: To evaluate the feasibility, score distribution, internal consistency, test-retest reliability, and discriminative and concurrent validity of the TAPQOL multi-item scales in preschool children, aged 2-48 months. Also to evaluate the feasibility, reliability, and validity separately for infants (2-12 months old) and toddlers (12-48 months old). METHODS: Parents of a random general population sample of 500 preschool children were sent a questionnaire by mail. A random subgroup of 159 parents who participated received a retest after two weeks. RESULTS: The response rate was 83% at the test and 75% at the retest. There were few missing answers. Six scales showed ceiling effects. Nine scales had Cronbach's alphas >0.70. In general, score distributions and Cronbach's alphas were comparable for infants and toddlers. Test-retest showed no significant differences in mean scale scores; two scales had intra-class correlations <0.50. Five scales showed significant differences between children with no conditions versus children with two or more parent reported chronic conditions. CONCLUSION: Results showed that the TAPQOL is a feasible instrument to measure HRQoL and support the reliability and discriminative validity of the majority of its scales for infants as well as toddlers. http://repub.eur.nl/res/pub/13585/ 2004-12-01T00:00:00Z This study aimed to detect the effect of influenza vaccination on quality of life, symptomatology and spirometry in asthmatic children. A randomised double-blind placebo-controlled trial in 696 (296 in 1999-2000 and 400 in 2000-2001) asthmatic children aged 6-18 yrs, which were vaccinated with either vaccine or placebo, was performed. Children participated for only one influenza season. They recorded symptoms in a diary and reported when symptom scores reached a predefined severity level. If this occurred research nurses visited them twice, first to take a pharyngeal swab and spirometry, and a week later to assess quality of life over the past illness week. Compared with placebo, vaccination improved health-related quality of life in the weeks of illness related to influenza-positive swabs. However, no effect was found for respiratory symptoms recorded in the diaries during those weeks. Similarly, no differences were found for quality of life in all weeks of illness or for respiratory symptoms throughout the seasons. Influenza vaccination was found to have a moderately beneficial effect on quality of life in influenza-positive weeks of illness in children with asthma. http://repub.eur.nl/res/pub/3944/ 2004-11-15T00:00:00Z Background: The risks of influenza vaccination in asthmatic children are still being discussed. Especially, the risk that influenza vaccination may exacerbate asthma is an issue in this debate. Methods: We conducted a randomised double-blind placebo-controlled trial in 696 children 6–18 years of age with asthma recruited in general practice during two influenza seasons, 1999–2000 and 2000–2001. Children participated for only one season. During the first week after vaccination, participants recorded local, influenza like and asthma symptoms as well as use of medication, health care use and absenteeism. Results: Except for cough during the day in the first season, favouring placebo, there were no differences indicating that vaccination exacerbates asthma. Conclusions: Influenza vaccination does not seem to exacerbate asthma. http://repub.eur.nl/res/pub/10367/ 2004-01-01T00:00:00Z BACKGROUND: Although children are frequently referred to specialists, detailed information on referral patterns of them is scarce. Even less information is available on how referral patterns evolve over time. AIMS: To examine current referral patterns for children aged 0-17 years and compare these with referral patterns reported for 1987.Design of study: Data were analysed from two national cross-sectional surveys, performed in 2001 (91 general practices) and in 1987 (103 general practices).SETTING: Dutch general practice.METHOD: All new referrals to specialists were assessed by age, sex, International Classification of Primary Care (ICPC) category, specialty referred to, and specific episodes of disease. Referral measures were quantified as new referrals per 1000 person-years and per 100 new episodes, a measure of likelihood of a young person with a specific diagnosis to be referred. Rates in 2001 were compared with those from 1987. RESULTS: Referral rates decreased from 138 per 1000 person-years in 1987, to 84 per 1000 person-years in 2001. Age differences in referral rates were similar in both surveys. Compared with 1987, more boys than girls were referred to specialists. The overall likelihood of a condition being referred decreased from 8.0 per 100 episodes in 1987 to 6.5 per 100 episodes in 2001. Reasons for referral had also changed by 2001, particularly for the ear, nose, and throat (ENT) specialist and ophthalmologist. Moreover, referral rates for acute otitis media, refractive disorders, and vision problems decreased two- to fourfold in 2001. CONCLUSION: Presently, Dutch general practitioners tend to manage more health problems themselves and refer less young people to specialists. http://repub.eur.nl/res/pub/13268/ 2004-01-01T00:00:00Z There is little evidence that influenza vaccination reduces asthma exacerbations. We determined whether influenza vaccination is more effective than placebo in 6-18-year-old children with asthma. We performed a randomized, double-blind, placebo-controlled trial. Parenteral vaccination with inactivated influenza vaccine or placebo took place approximately November 1, and children were followed until April 1 of the next year. Airway symptoms were reported in a diary. When symptom scores reached a predefined level, a pharyngeal swab was taken. Primary outcome was the number of asthma exacerbations associated with virologically proven influenza infection. Three hundred forty-nine children were assigned placebo, and 347 were assigned vaccine. Pharyngeal swabs positive for influenza were related to 42 asthma exacerbations, 24 in the vaccine group and 18 in the placebo group, a difference of 33% favoring placebo (31% after adjustment for confounders; 95% confidence interval, -34% to 161%). Influenza-related asthma exacerbations were of similar severity in both groups; they lasted 3.1 days shorter in the vaccine group (95% confidence interval, -6.2 to 0.002 days, p = 0.06). We conclude that influenza vaccination did not result in a significant reduction of the number, severity, or duration of asthma exacerbations caused by influenza. Additional studies are warranted to justify routine influenza vaccination of children with asthma. http://repub.eur.nl/res/pub/10189/ 2003-01-01T00:00:00Z Nonbullous impetigo is a common skin infection in children and is frequently caused by Staphylococcus aureus. Staphylococcal toxins and especially exfoliative toxin A are known mediators of bullous impetigo in children. It is not known whether this is also true for nonbullous impetigo. We set out to analyze clonality among clinical isolates of S. aureus from children with nonbullous impetigo living in a restricted geographical area in The Netherlands. We investigated whether staphylococcal nasal carriage and the nature of the staphylococcal strains were associated with the severity and course of impetigo. Bacterial isolates were obtained from the noses and wounds of children suffering from impetigo. Strains were genetically characterized by pulsed-field gel electrophoresis-mediated typing and binary typing, which was also used to assess toxin gene content. In addition, a detailed clinical questionnaire was filled in by each of the participating patients. Staphylococcal nasal carriage seems to predispose the patients to the development of impetigo, and 34% of infections diagnosed in the Rotterdam area are caused by one clonal type of S. aureus. The S. aureus strains harbor the exfoliative toxin B (ETB) gene as a specific virulence factor. In particular, the numbers (P = 0.002) and sizes (P < 0.001) of the lesions were increased in patients infected with an ETB-positive strain. Additional predictors of disease severity and development could be identified. The presence of a staphylococcal plasmid encoding multiple antibiotic resistance traits, as detected by binary typing, was associated with a reduction in the cure rate. Our results recognize that a combination of staphylococcal virulence and resistance genes rather than a single gene determines the development and course of nonbullous impetigo. The identification of these microbial genetic markers, which are predictive of the severity and the course of the disease, will facilitate guided individualized antimicrobial therapy in the future. http://repub.eur.nl/res/pub/8270/ 2002-01-01T00:00:00Z OBJECTIVE: To test the hypothesis that fusidic acid would not increase the treatment effect of disinfecting with povidone-iodine alone in children with impetigo. DESIGN: Randomised placebo controlled trial. SETTING: General practices in Greater Rotterdam. PARTICIPANTS: 184 children aged 0-12 years with impetigo. MAIN OUTCOME MEASURES: Clinical cure and bacterial cure after one week. RESULTS: After one week of treatment 55% of the patients in the fusidic acid group were clinically cured compared with 13% in the placebo group (odds ratio 12.6, 95% confidence interval 5.0 to 31.5, number needed to treat 2.3). After two weeks and four weeks the differences in cure rates between the two groups had become smaller. More children in the placebo group were non-compliant (12 v 5) and received extra antibiotic treatment (11 v 3), and more children in the placebo group reported adverse effects (19 v 7). Staphylococcus aureus was found in 96% of the positive cultures; no strains were resistant to fusidic acid. CONCLUSIONS: Fusidic acid is much more effective than placebo (when both are given in combination with povidone-iodine shampoo) in the treatment of impetigo. Because of the low rate of cure and high rate of adverse events in the placebo group, the value of povidone-iodine in impetigo can be questioned. http://repub.eur.nl/res/pub/9907/ 2002-01-01T00:00:00Z The aim of the study was to determine whether children with chronic benign pain are in contact with their general practitioner (GP) more frequently than those without chronic benign pain. A random sample of children and adolescents aged between 0 and 18 years of age was drawn from the records of ten general practices. According to their responses to a pain questionnaire, subjects were assigned to the chronic benign pain group (n = 95) if they had pain of more than three months' duration, or to the control group (n = 105) if they had pain of less than three months' duration or no pain at all. All the subjects had an average GP consultation rate of 2.6 contacts per year. No significant age and sex differences were found. Chronic benign pain in childhood and adolescence is not related to increased use of healthcare services, suggesting that somatisation does not play a major role in children with chronic benign pain. http://repub.eur.nl/res/pub/9619/ 2001-01-01T00:00:00Z OBJECTIVE: To study chronic pain not caused by somatic disease in adolescents and the effect of pain on the quality of life of the adolescents and their families. METHODS: One hundred twenty-eight youngsters (12-18 years) who had reported chronic pain kept a 3-week diary of their pain and completed a questionnaire on quality of life. Their mothers completed a questionnaire on the impact of their youngster's pain on the family. RESULTS: The most prevalent pains were limb pain, headache, abdominal, and back pain. The pain increased during the day, with the highest frequency around dinner time and the highest intensity around bedtime. Girls reported more intense and more frequent pain than boys. The higher the intensity and frequency of the pain, the lower the self-reported quality of life of the female or male adolescent, especially regarding psychological functioning (e.g. feeling less at ease), physical status (a greater incidence of other somatic complaints), and functional status (more impediments to leisure and daily activities). Chronic pain also had a negative impact on family life. The mothers reported restrictions, particularly in social life, and problems dealing with the stress of the adolescent's pain. CONCLUSIONS: Chronic pain, not caused by somatic disease, was present to a higher degree in girls; the pain increased during the day and had a negative impact on quality of life of the adolescents and the family. There is a need for future research aimed at identifying risk factors for chronic pain and pain-associated quality of life in children and adolescents. http://repub.eur.nl/res/pub/22431/ 1999-01-01T00:00:00Z Objective: To answer the following question: Are children with asthma known to their GP? Methods: Parents of all 464 children, 1-3 years of age and registered with five general practices, received a postal questionnaire asking about asthma symptoms of the child, and past and present asthma medication. Thus, children were classified as having no, mild, moderate or severe asthma. The GPs' records were checked for recorded asthma symptoms, medication and asthma-related diagnoses. The presence of these items was compared with asthma severity. Results: Eighty-seven percent of parents responded to the questionnaire (mean age of children 30.1 months). For all classes of severity, 75% of children with asthma were known to their GP. Although all children with severe asthma were known to their GP, the proportion of asthmatic children known to their GP fell with decreasing severity. Symptoms and medication were recorded more often than asthma-related diagnoses. Conclusions: Most preschool children with asthma are known to their GP. The diagnosis is recorded less often than asthma symptoms and medication. http://repub.eur.nl/res/pub/22427/ 1997-10-01T00:00:00Z Abstract BACKGROUND: Inhalation therapy with sodium cromoglycate is recommended as the first-line prophylactic treatment for moderate asthma in children. The availability of spacer devices with face-masks has extended the applicability of metered-dose inhalers to younger children. We studied the feasibility and effects of this therapy compared with placebo in children aged 1-4 years. METHODS: 218 children aged 1-4 years with moderate asthma were recruited through 151 general practitioners between March, 1995, and March, 1996. They were randomly assigned sodium cromoglycate (10 mg three times daily) or placebo, given by inhaler with spacer device and face-mask for 5 months. Rescue medication (ipratropium plus fenoterol aerosol) was available during the baseline period of 1 month and the intervention period. Parents completed a daily symptom-score list. The primary outcome measure was the proportion of symptom-free days in months 2 to 5. Analysis was by both intention to treat and on treatment. FINDINGS: 167 (77%) children completed the trial. 131 (78%) of these children used at least 80% of the recommended dose. Of the 51 children who stopped prematurely, 23 had difficulties with inhaled treatment. The mean proportion of symptom-free days for both groups was greater for the treatment period than for the baseline period (95% CI for mean difference 5.1 to 17.5 cromoglycate, 11.9 to 23.3 placebo). However there were no differences between the sodium cromoglycate and placebo groups in the proportion of symptom-free days (mean 65.7 [SD 25.3] vs 64.3 [24.5]%; 95% CI for difference -8.46 to 5.70) or in any other outcome measure. INTERPRETATION: Our study in a general practice setting shows that inhalation therapy with a spacer device and face-mask is feasible in a majority of children below the age of 4 years. However, long-term prophylactic therapy with inhaled sodium cromoglycate is not more effective than placebo in this age-group. http://repub.eur.nl/res/pub/8677/ 1997-01-01T00:00:00Z BACKGROUND: Insight into referral patterns provides general practitioners (GPs) and specialists with a frame of reference for their own work and enables assessment of the need for secondary care. Only approximate information is available. AIM: To determine how often, to which specialties and for what conditions children in different age groups are referred, as well as how often a condition is referred given the incidence in general practice. METHOD: From data of the Dutch National Survey of Morbidity and Interventions in General Practice, 63,753 new referrals (acute and non-acute) were analysed for children (0-14 years) from 103 participating practices (161 GPs) who registered. Practices were divided into four groups. Each group of practices participated for three consecutive months covering a whole year altogether. We calculated referral rates per 1000 children per year and referability rates per 100 episodes, which quantifies the a priori chance of a condition being referred for specialist care. RESULTS: The referral rate varied by age from 231 for children under 1 year old to 119 for those aged 10-14 years (mean 159). The specialties mainly involved were ENT, paediatrics, surgery, ophthalmology, dermatology and orthopaedics. Referrals in the first year of life were most frequently to paediatricians (123); among older children the referral rate to paediatricians decreased (mean 36). Referrals to ENT specialists were seen particularly in the age groups 1-4 (71) and 5-9 (53). For surgery, the referral rate increased by age from 19 to 34. Differences between boys and girls were small, except for surgery. The highest referral rates were for problems in the International Classification of Primary Care (ICPC) chapters: respiratory (28); musculoskeletal (25); ear (24) and eye (21). Referability rates were, in general, low for conditions referred to paediatrics and dermatology and high for surgery and ophthalmology. The variation in problems presented to each specialty is indicated by the proportion of all referrals constituted by the 10 most frequently referred diagnoses: from 35% for paediatrics to 81% for ENT; for ophthalmology, five diagnoses accounted for 83% of all referrals. CONCLUSIONS: The need for specialist care in childhood is clarified with detailed information for different age categories, specialties involved and variation in morbidity presented to specialists, as well as the proneness of conditions to be referred. http://repub.eur.nl/res/pub/23807/ 1994-08-31T00:00:00Z [s er een reden tot zorg over de wijze waarop de medische zorg voor kinderen in het Nederlandse gezondheidszorgsysteem is verankerd? Ogenschijnlijk niet! Vrijwel nergens ter wereld zijn de cijfers die een maat vormen voor de gezondheidstoestand van kinderen gunstiger. Zou het toch nog beter kunnen2 De zorg voor het zieke kind is in ons land primair de taak van de huisarts, dit in tegenstelling tot de situatie in veel andere landen waar zowel de curatieve als de preventieve zorg veelal door de kinderarts wordt verleend. Specialistische zorg, ook die van de kinderarts, wordt gegeven na verwijzing en de preventieve zorg is in handen van de jeugdgezondheidszorg. Zijn er punten waarop de zorg door de huisarts te kort schiet, op welke wijze zou de kinderarts kunnen bijdragen aan een verbetering van de zorg en is de wisselwerking tussen de circuits waarin de zorg wordt verleend optimaal? Voor de afdelingen huisartsgeneeskunde en kindergeneeskunde van de Erasmus Universiteit Rotterdam was dit begin jaren tachtig een discussiepunt. In 1986 werden door het Ministerie van Onderwijs en Wetenschappen gelden beschikbaar gesteld voor projecten, gericht op onderzoek dat een bijdrage levert aan de versterking van de extramurale gezondheidszorg. Uit het Vernieuwingsfonds Extramurale Vakken/Toponderzoek Eerstelijn werden gelden toegekend aan de afdelingen Huisartsgeneeskunde en Kindergeneeskunde van de Erasmus Universiteit Rotterdam om onderzoek te verrichten naar de samen~ werking tussen huisarts en kinderarts. De doelstelling van het onderzoek was na te gaan of er knelpunten zijn in de wiize waarop de zorg voor zieke kinderen door huisarts en kinderarts wordt gerealiseerd en op welke punten de samenwerking tussen huisarts en kinderarts niet optimaal is. Indien problemen gesignaleerd werden zou worden nagegaan of de werkwijze van en de interacties tussen huisarts en kinderarts door interventies verbeterd konden worden, er van uitgaande dat dit zou bijdragen tot de verbetering van de zorg voor het zieke kind. http://repub.eur.nl/res/pub/8622/ 1994-01-01T00:00:00Z BACKGROUND: While molluscum contagiosum is considered to be a frequently encountered disease, few data on its incidence are known. AIM: The objective of this study was to describe the incidence of molluscum contagiosum in Dutch general practice and to assess the importance of venereal molluscum contagiosum. METHOD: Data were taken from the national survey of morbidity and interventions in general practice, drawn from 103 practices across the Netherlands, with a study population of 332300. RESULTS: The infection appeared to be common in childhood (cumulative incidence 17% in those aged under 15 years); the adult, sexually transmitted, form was rare. Incidence was higher between January and June than between July and December. Cases were unequally divided between recording practices, which is though to have been caused by the occurrence of small epidemics. CONCLUSION: The incidence of molluscum contagiosum in Dutch general practice was found to be 2.4 per 1000 person years. Molluscum contagiosum should still be considered as a mainly paediatric disease.