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For non-scrotal testes a distinction can be made between retractile testes (completely descended and normally developed but sometimes situated subcutaneously in the groin area), retained testes (testes cannot be brought into the scrotum or this can only be achieved using light manual pressure) and ectopic testes (lying outside of the descent trajectory). - It is estimated that 0.7-0.8% of all boys have as yet undescended testes. - The first few days after the birth are the most suitable for testing and registration, as then the cremaster reflex is absent. Registration should take place in both the youth healthcare file and in the 'growth book' for the parents. - Retractile testes do not require treatment. There is no consensus concerning the treatment of (possible) acquired nonscrotal testes. For undescended testes the management depends on previous testes localisations. For ectopic testes and testes that have never been scrotal, a referral for surgical treatment should be made prior to the second birthday. - Orchidopexy (a better description is orchidofuniculolysis followed by orchidopexy) is only justified in the case of testes which have never descended. - In the case of a clear indication, the general practitioner should make a prompt referral (before the second birthday) and in other cases assurance should be provided and an expectant policy adopted until puberty.

In dit artikel worden de standpunten van in het veld werkzame mondhyginisten en tandartsen ten aanzien van de directe toegankelijkheid van de mondhyginist weergegeven. Een directe toegankelijkheid van de mondhyginist wordt door een groot deel van de mondhyginisten wenselijk geacht. De meeste tandartsen staan er echter sceptisch tegenover. Er bestaan verschillende meningen over welke soort verrichtingen uitgevoerd zouden kunnen worden, welke leeftijdsgroepen van patinten in aanmerking zouden komen, hoe de kwaliteit gewaarborgd kan worden, over de afbakening en verantwoordelijkheden van het professionele handelen en over de te volgen communicatielijnen.Meer inzicht in deze problematiek kan worden verkregen tijdens en na het uitvoeren van proefprojecten.Het zal geen probleem zijn om mondhyginisten te vinden die willen meewerken aan een proefproject.Wat de tandartsen betreft zal dit lastiger zijn.

Cetotheriidae are a group of small baleen whales (Mysticeti) that evolved alongside modern rorquals. They once enjoyed a nearly global distribution, but then largely went extinct during the Plio-Pleistocene. After languishing as a wastebasket taxon for more than a century, the concept of Cetotheriidae is now well established. Nevertheless, the clade remains notable for its variability, and its scope remains in flux. In particular, the recent referral of several traditional cetotheriids to a new and seemingly unrelated family, Tranatocetidae, has created major phylogenetic uncertainty. Here, we describe a new species of Tranatocetus, the type of Tranatocetidae, from the Late Miocene of the Netherlands. Tranatocetus maregermanicum sp. nov. clarifies several of the traits previously ascribed to this genus, and reveals distinctive auditory and mandibular morphologies suggesting cetotheriid affinities. This interpretation is supported by a large phylogenetic analysis, which mingles cetotheriids and tranatocetids within a unified clade. As a result, we suggest that both groups should be reintegrated into the single family Cetotheriidae. © Copyright 2019 Marx et al.

The Youth Health Care guideline 'Early screening for hearing impairment, ages 0-19 years' draws the attention of all parties involved to the case finding of, notably, perceptive hearing loss; it helps workers in the Youth Health Care argue their referrals and improve the next steps in the process. Referrals always aim at ruling out perceptive hearing impairment. It is essential to diagnose and subsequently treat children with perceptive hearing impairment. It is important to keep track of the process after the referral. Screening methods are the Ewing test, the 'Compacte Amsterdamse paedo- audiometrische screener' (CAPAS) test and audiograms. Each age category has groups at risk for hearing impairment. Problems in neonates are a low specificity of the Ewing/CAPAS tests, treatment of middle car disease without ruling out perceptive hearing impairment and absence of interdisciplinary agreements regarding the steps to be taken and the necessary feedback. Children with perceptive hearing loss should be diagnosed before 18 months of age. In the near future neonatal screening may detect congenital perceptive hearing impairment, but hearing impairment may still develop after the screening. Alertness with respect to hearing impairment will remain necessary in every consultation of a child.

The number of referrals under strict adherence to the Dutch consensus guidelines for short stature was estimated using longitudinal data from 970 children (0-10 years). Results showed that over 38% of all children would have to be referred one or more times. There is therefore a clear need to revise the current guidelines.

Objective: To determine the effect of the implementation of a shared care guideline for the lumbosacral radicular syndrome (LRS) on unnecessary early referrals and the duration of the total diagnostic procedure. Design: Introduction of shared care guideline in November 2005. Pre-test in 2005 (April to October), a first post-test in 2006 (April to October) and a second post-test in 2007 (April to October). Setting and Intervention: The introduction of a shared care guideline derived from national guidelines for GPs and several medical/paramedical specialists in two Dutch regions. Three hundred and sixty GPs, 550 physiotherapists and two hospitals (9 neurologists and 18 radiologists) were involved. The essential component of the guideline was a trade-off: if the GP complied with the conservative management approach in the first 6 weeks, the hospital guaranteed a priority appointment with the neurologist after 6 weeks, if still required. Main Outcome Measures: The neurologists in both hospitals registered whether a patient had been unnecessarily referred during the first 6 weeks. The duration of the total diagnostic procedure was defined as the number of days between referral by the GP and the consultation when the neurologist made the final diagnosis. Results: The percentage of patients being unnecessarily referred within 6 weeks fell significantly from 15% in 2005 to 9% in 2006 and 8% in 2007. The duration of the total diagnostic procedure also fell significantly in both the long and short terms. Conclusions: The introduction of a shared care guideline for all care providers in a region reduces the number of unnecessary early referrals for patients with LRS. © The Author 2010. Published by Oxford University Press in association with the International Society for Quality in Health Care.

The objective of this study was to investigate whether universal neonatal hearing screening could be integrated in the youth health care program. The screening was performed by nurses of the well baby clinics. A three stage transient evoked otoacoustic emission screening was performed in three different screening settings in order to study the most effective set up regarding participation, refer rates, and costs. In one setting parents visited the well baby clinic, and in two settings babies were screened at home (either in combination with the screening for metabolic diseases or during an intake visit). Screening was performed on 3114 healthy newborns. The setting where universal neonatal hearing screening is integrated with the screening for metabolic diseases, proved to be most efficient and effective. The participation rate of 88.9% was highest in this setting and the overall refer rate (1.4%) was the lowest. The implementation of universal neonatal hearing screening by the well baby clinic nurses was judged to be possible. The results of this study formed the basis for nationwide implementation. © 2009 British Society of Audiology, International Society of Audiology, and Nordic Audiological Society.

Background/Aims: Growth monitoring is almost universally performed, but few data are available on which referral criteria and diagnostic work-up are used worldwide for children with short stature. Methods: A short questionnaire, containing questions on auxological screening and on diagnostic criteria for short stature, was sent to all members of the European Society of Paediatric Endocrinology (ESPE) and to several pediatric endocrinologists outside Europe. Results: Responses were received from 36 countries. In 27 (75%) a child health care program existed and in 14 (39%) there was a protocol for referral of children with growth retardation. Height for age was mostly used as a referral criterion. Sixteen countries (45%) reported having a guideline in secondary health care for diagnostic work-up. Although all countries agreed on having biochemical, radiological and/or genetic tests in the diagnostic work-up, there was a wide variety of recommended tests. Conclusions: There is little consensus on referral criteria and diagnostic work-up of children with short stature among industrialized countries. There is a need to establish evidence-based guidelines. © Freund Publishing House Ltd., London.

The main goal of this guideline for preventive child health care (PCHC) is to improve early detection of disorders that induce short stature. Based on research, evidence-based referral criteria for children aged 0-10 years with a short stature were formulated. These criteria are important for all professionals working with children, such as PCHC, general practitioners and paediatricians. Previous referral criteria dated 1997 and titled 'Diagnostics of short stature in children' had a very low specificity and were therefore considerably revised. They should no longer be applied. The guideline also provides information on the cause of short stature, psychosocial aspects and the use of growth hormone.

Objectives: To assess the degree to which preventive child health professionals (CHPs) identify and manage psychosocial problems among preschool children in the general population and to determine the association with parent-reported behavioral and emotional problems, sociodemographic factors, and mental health history of children. Design: The CHPs examined the child and interviewed the parents and child during their routine health assessments. The Child Behavior Checklist (CBCL) was completed by the parents. Setting: Sixteen child health care services across the Netherlands that routinely provided well-child care to nearly all preschool children. Patients: Of 2354 children aged 21 months to 4 years who were eligible for a routine health assessment, 2229 (94.7%) participated. Main Outcome Measures: Identification and management of psychosocial problems by CHPs. Results: In 9.4% of all children, CHPs identified psychosocial problems. Two in 5 of the CHP-identified children were referred for additional diagnosis and treatment. Identification of psychosocial problems and subsequent referral were much more likely in children with a clinical CBCL total problems score than in others (identification: 29% vs 7%; odds ratio [95% confidence interval], 5.40 [3.45-8.47]; referral: 15% vs 3%; odds ratio [95% confidence interval], 6.50 [3.69-11.46]). Conclusions: The CHPs frequently identify psychosocial problems in preschool children, although less than among school-aged children, but they miss many cases of parent-reported problems as measured by a clinical CBCL score. This general population study shows substantial room for improvement in the early identification of psychosocial problems.

The Dutch Child Health Care guideline on the early detection of congenital heart disease was developed according to the principles for evidence-based guideline development and contains recommendations for the conduct of the examination during routine check-ups and for referral criteria. Most congenital heart diseases can be detected in the first year of life if physicians and nurses work according to this guideline. Important early times for screening are the home visit to infants at the age of two weeks by the child health nurse and the routine check-up of infants at the age of four weeks by the child health care physician. A routine cardiac screening is carried out in every child by the nurse and the physician at times specified in the basic list of professional responsibilities. A more extensive examination is carried out when indicated. Routine cardiac check-ups are recommended until the age of four, after which they should be done only when indicated on medical grounds. A feasibility study showed that physicians and nurses can apply the guideline effectively, provided that they take part in prior specific training.

Aims: Violence and economic hardship cause many people to go to industrialized countries, often without obtaining a residence permit. The aim of this study is to gain insight into the factors that determine the occurrence of contacts in primary health care with such illegal immigrants. Methods: Data were analysed on contacts with illegal immigrants from a national survey among Dutch general practitioners (GPs) (n=1,148; response: 62%). Results: GPs reported that they have on average 0.74 patient contacts with an illegal immigrant per week (95% CI: 0.56-0.92). This probably includes some over-reporting. Contacts are more likely in practices and communities that comprise more non-Dutch-born people and more (patients with) typically urban health problems. Working experience and demography of the GP are not independently associated with the occurrence of contacts. Conclusions: Contacts of Dutch GPs with illegal immigrants mostly occur in the deprived areas of the big cities. © Taylor & Francis 2001.

Objectives A novel triage approach to routine assessments was introduced to improve the efficiency of Preventive Child Healthcare (PCH): PCH assistants carried out pre-assessments of all children and sent the children with suspected health problems to follow-up assessments conducted by a physician or nurse. This two-step approach differed from the usual approach, in which physicians or nurses assessed all children. This study was aimed to examine the impact of triage and task shifting on care for children at risk identified by PCH or parents and schools. Design and participants An observational prospective cohort design was used, with an analysis of the basic registration data from the preventive health assessments for 1897 children aged 5 to 6, and 10 to 11, years from a sample of 41 schools stratified by socioeconomic status, region of PCH service and urbanisation. Setting A comparison was made between two PCH services in the Netherlands that used the triage approach and two PCH services that provided the usual approach. Main outcome measures The primary outcome measures were the referral rates to either additional PCH assessments or external services. The secondary outcome measures were the rates of PCH assessments requested by, for example, parents and schools. Results Overall, a higher referral rate to additional PCH assessments was found for the triage approach than for the usual approach (OR 1.3, 95% CI 1.0 to 1.6), mainly in the age group of 5 to 6 years (OR 1.9, 95% CI 1.3 to 2.7). We found a lower rate of referral to external services in the triage approach (OR 0.4, 95% CI 0.3 to 0.7) and a higher referral rate to PCH assessments on request (OR=4.6, 95% CI 3.0 to 7.0). Conclusions The triage approach provides extra opportunities to deliver PCH assessments and PCH assessments on request for children at risk. Further research is needed into the cost benefits of the triage approach.

Background: During the last decade, a rapid increase of birth locations for low-risk births, other than conventional obstetric units, has been seen in the Netherlands. Internationally some of such locations are called birth centres. The varying international definitions for birth centres are not directly applicable for use within the Dutch obstetric system. A standard definition for a birth centre in the Netherlands is lacking. This study aimed to develop a definition of birth centres for use in the Netherlands, to identify these centres and to describe their characteristics. Methods: International definitions of birth centres were analysed to find common descriptions. In July 2013 the Dutch Birth Centre Questionnaire was sent to 46 selected Dutch birth locations that might qualify as birth centre. Questions included: location, reason for establishment, women served, philosophies, facilities that support physiological birth, hotel-facilities, management, environment and transfer procedures in case of referral. Birth centres were visited to confirm the findings from the Dutch Birth Centre Questionnaire and to measure distance and time in case of referral to obstetric care. Results: From all 46 birth locations the questionnaires were received. Based on this information a Dutch definition of a birth centre was constructed. This definition reads: "Birth centres are midwifery-managed locations that offer care to low risk women during labour and birth. They have a homelike environment and provide facilities to support physiological birth. Community midwives take primary professional responsibility for care. In case of referral the obstetric caregiver takes over the professional responsibility of care." Of the 46 selected birth locations 23 fulfilled this definition. Three types of birth centres were distinguished based on their location in relation to the nearest obstetric unit: freestanding (n = 3), alongside (n = 14) and on-site (n = 6). Transfer in case of referral was necessary for all freestanding and alongside birth centres. Birth centres varied in their reason for establishment and their characteristics.

Background. Triage in Preventive Child Health Care (PCH) assessments could further the efficient use of human resources and budgets and therefore make extra care possible for children with specific needs. We assessed the costs of routine PCH assessments with and without triage for children aged 5/6 years and 10/11 years. In a triage approach, PCH assistants conduct pre-assessments to identify children requiring follow-up assessments by a physician or nurse. In the usual approach, all children are assessed by a physician and an assistant (children aged 5/6 years) or a nurse (children aged 10/11 years). Methods. All the direct costs of conducting routine PCH assessments with the triage and usual approach were assessed using a bottom-up micro-costing approach. In four PCH services in the Netherlands, two using triage and two the usual approach, professionals completed questionnaires about time spent on assessments, including time related to non-attendance at assessments, the referral of children and administration. Results. The projected costs for PCH professionals working on PCH assessments amounted to €5.2 million per cohort of 100,000 children aged 5/6 years in the triage approach, and €7.6 million in the usual approach. The projected costs in both approaches for children aged 10/11 years were about €4 million per 100,000 children. Conclusion. The triage approach to PCH resulted in a projected cost reduction of about one-third, compared with usual practice, for routine assessments by physicians of children aged 5/6 years. There are minimal cost savings in the group of children aged 10/11 years when nurses are involved and so other considerations such as workforce shortages would be required to justify a change to a triage approach. Further research is needed to investigate the differences in costs of care after the completion of the routine assessments.

Background: Digital health interventions can fill gaps in mental healthcare provision. However, autonomous e-mental health (AEMH) systems also present challenges for effective risk management. To balance autonomy and safety, AEMH systems need to detect risk situations and act on these appropriately. One option is sending automatic alerts to carers, but such 'auto-referral' could lead to missed cases or false alerts. Requiring users to actively self-refer offers an alternative, but this can also be risky as it relies on their motivation to do so. This study set out with two objectives. Firstly, to develop guidelines for risk detection and auto-referral systems. Secondly, to understand how persuasive techniques, mediated by a virtual agent, can facilitate self-referral. Methods: In a formative phase, interviews with experts, alongside a literature review, were used to develop a risk detection protocol. Two referral protocols were developed - one involving auto-referral, the other motivating users to self-refer. This latter was tested via crowd-sourcing (n = 160). Participants were asked to imagine they had sleeping problems with differing severity and user stance on seeking help. They then chatted with a virtual agent, who either directly facilitated referral, tried to persuade the user, or accepted that they did not want help. After the conversation, participants rated their intention to self-refer, to chat with the agent again, and their feeling of being heard by the agent. Results: Whether the virtual agent facilitated, persuaded or accepted, influenced all of these measures. Users who were initially negative or doubtful about self-referral could be persuaded. For users who were initially positive about seeking human care, this persuasion did not affect their intentions, indicating that a simply facilitating referral without persuasion was sufficient. Conclusion: This paper presents a protocol that elucidates the steps and decisions involved in risk detection, something that is relevant for all types of AEMH systems. In the case of self-referral, our study shows that a virtual agent can increase users' intention to self-refer. Moreover, the strategy of the agent influenced the intentions of the user afterwards. This highlights the importance of a personalised approach to promote the user's access to appropriate care. © 2019 The Author(s).

Background: The aim of the current study is to investigate the effectiveness of an intervention that provides health-related quality of life (HRQOL) scores of the patient (the QLIC-ON PROfile) to the pediatric oncologist. Procedure: Children with cancer participated in a sequential cohort intervention study: intervention N=94, control N=99. Primary outcomes of effectiveness were communication about HRQOL domains (t-test, Mann-Whitney U-test) and identification of HRQOL problems (chi-squared test). Secondary outcomes were satisfaction (multilevel analysis), referrals (chi-squared test), and HRQOL (multilevel analysis). Results: The QLIC-ON PROfile increased discussion of emotional functioning (control M=32.9 vs. intervention M=47.4, P<0.05) and psychosocial functioning (M=56.9 vs. M=63.8, P<0.05). Additionally more emotional problems remained unidentified in the control compared to the intervention group, for example, anger (control 26% vs. intervention 3%, P<0.01), fear (14% vs. 0%, P<0.01), and sadness (26% vs. 0%, P<0.001). The intervention had no effect on satisfaction and referrals, but did improve HRQOL of patients 5-7 years of age with respect to self-esteem (P<0.05), family activities (P<0.05), and psychosocial functioning (P<0.01). Conclusions: We conclude that a PRO is a helpful tool for systematic monitoring HRQOL of children with cancer, without lengthening the duration of the consultation. It is recommended to be implemented in clinical practice. © 2011 Wiley Periodicals, Inc.