Prevalence and predictors of health service use among Iraqi asylum seekers in the Netherlands Background A long asylum procedure is associated with higher prevalence rates of psychiatric disorders , lower quality of life , higher disability and more physical health problems . Additional knowledge about health seeking behavior is necessary to guide governments and health professionals in their policies . Introduction Mental health service use differs among populations and geographical areas -LSB- 3 , 15 , 25 -RSB- . Refugees and asylum seekers have high prevalence rates of psychiatric disorders -LSB- 6 , 12 -RSB- and adequate use of health services is important . Literature on this issue is growing , but still limited -LSB- 8 , 9 , 16 -RSB- . Health policies , including accessibility of service for asylum seekers differ between European Union countries -LSB- 19 -RSB- . In the Netherlands refugees have direct access to the general practitioner , while asylum seekers can only enter the curative health care system after a screening by a nurse or doctor in the asylum seeker center . This system has been criticized -LSB- 18 -RSB- , but others claim that these professionals , involved in triage after receiving training in cultural competence , may prevent inadequate referrals . Health service use , according to the Anderson behavioral model -LSB- 1 , 2 -RSB- , is a function of three sets of variables : predisposition , enablement and need . Predisposition includes demographic factors such as age , gender , religion , cultural factors , social network , and support . Enabling factors facilitate service use and include individual social functioning , availability of services , and costs . The third set , i.e. the need variables , consists of health related factors . Both objective -LRB- type and severity of a health problem -RRB- , and subjective health indicators -LRB- disability and perceived health -RRB- belong to the need variables . McCracken et al. -LSB- 15 -RSB- used the above model in a community survey on depression in five European countries , and found that severity of depression , lower perceived health status , social dysfunctioning , and low level of social support were significant predictors of use . Kamperman et al. -LSB- 11 -RSB- used the model in a study among migrants in Amsterdam and found that there were migrant-specific mechanisms in health care consumption . Higher levels of acculturation and lower level of cultural traditionalism increased the use of mental health care facilities . In these health service use studies , a variety of potential predictors , such as psychopathology , physical diseases , physical , and mental well-being , have been included . But disability and quality of life were not included . Nor is there a study that compared groups from the same country of origin , that differ in length of stay in a host country . In a national community study among Iraqi asylum seekers -LRB- n = 294 -RRB- in the Netherlands -LSB- 12 -- 14 -RSB- we measured prevalence rates of psychiatric disorders , quality of life , disability , and physical health problems in relationship with pre - and post-migrations stressors . The study focuses on the risks of a long asylum procedure and showed that asylum seekers who stayed more than 2 years in the Netherlands had significantly higher overall prevalence rates of psychiatric disorders -LRB- 66.2 % -RRB- , than those who arrived recently -LRB- 42.0 % -RRB- . A long asylum procedure was an important independent risk factor for a psychiatric disorder with an odds ratio of 2.16 -LRB- CI 1.15 -- 4.08 -RRB- . This ratio was higher than the odds ratio for premigration stressors , such as exposure to human rights violations . In addition the ` long stay ' group had significantly lower quality of life , higher disability , and higher levels of physical health complaints . In the Anderson model these health indicators can be considered as need factors . The aim of this paper is to examine patterns and predictors of health service use and their relationship with length of stay . The research questions are : -LRB- a -RRB- what is the prevalence of service use of Iraqi asylum seekers in the Netherlands , -LRB- b -RRB- is a long asylum procedure associated with a higher prevalence of service use , -LRB- c -RRB- what is the relationship between psychopathology and service use , and -LRB- d -RRB- which predisposing and other need variables predict service use . We hypothesize that a long asylum procedure is associated with a higher prevalence of service use and that higher levels of psychopathology are related to higher levels of service use . Methods A comprehensive description of used methods is provided in a previous article -LSB- 12 -RSB- . A summary is given below . From the entire population of adult Iraqi asylum seekers , two groups were selected based on their length of stay in the Netherlands . Personal data on these groups was obtained from the Agency for the Reception of Asylum Seekers -LRB- COA -RRB- . Group 1 was selected on the criterion that persons had been living in the Netherlands for less than 6 months -LRB- between September 2000 and November 2001 -RRB- . From the randomly selected 362 respondents , data could be used from 143 interviews . Group 2 was selected on the criterion that they were living in the Netherlands for at least 2 years . On the chosen date of May 31st , 1999 , the COA found that 2,352 Iraqi asylum seekers fulfilled this criterion . From the randomly selected 474 respondents , data could be used from 151 interviews . The questionnaire about service use -- in the 2 months prior to the interview -- included regular services as well as alternative services . The studied regular services are : out-patient services : preventive healthcare -LRB- nurse/doctor in center -RRB- , primary healthcare -LRB- general practitioner -RRB- , generic healthcare -LRB- medical specialist , non-psychiatric -RRB- , social care -LRB- social worker -RRB- , psychiatric services -LRB- mental health professional -RRB- ; in-patient services : hospital admission physical health , hospital admission mental health ; use of drugs -LRB- any drugs , hypnotics , anxiolytics and analgetics -RRB- . Examples of drug names were given to be sure the drugs were put in the right category . As mentioned above , in the Netherlands medical staff is present in all asylum seekers centers . They perform health assessments of recently arrived asylum seekers , facilitate entry into primary health care , and refer to the general or mental health services . Their services can be classified as gateway services -LSB- 7 -RSB- . The studied alternative services are : use of religious helpers or rituals , and herb-doctors or herbs . Respondents ' predisposition to service use was measured by age , gender , religion , ethnicity , and length of stay -LRB- membership Group 1 or Group 2 -RRB- . Enabling factors were not measured : regular health services for asylum seekers are available and accessible in the Netherlands without financial obstacles . Need factors include : psychiatric disorders , physical health , quality of life , and disability , while post-migration living problems -LRB- PMLP -RRB- were added as a special set of need variables . Psychiatric disorders were measured with the WHO-CIDI , version 2.1 -LSB- 28 -RSB- and cluster diagnoses were used in the analyses . Physical health was assessed with 22 items , dealing with : perceived physical health , physical handicaps , chronic physical diseases -LRB- e.g. lung disease , epilepsy , diabetes -RRB- , and chronic physical complaints -LRB- e.g. stomach problems , joint problems , headache more than 3 months -RRB- . Quality of life -LRB- Qol -RRB- was assessed with the WHOQOL-BREF -LSB- 22 -RSB- . The first two single questions i.e. : ` How would you rate your quality of life ? ' -LRB- ` overall Qol ' -RRB- and ` How satisfied are you with your health ? ' -LRB- ` Qol perceived general health ' -RRB- were used in the current study . Disability -LRB- Brief Disability Questionnaire , VonKorff -LSB- 26 -RSB- was measured in two dimensions : total disability -LRB- total of score of 11 items on physical and social role impairments -RRB- , and the total number of days with serious impairment in the last month -LRB- BDQ-days -RRB- . Post-Migration Living Problems -LRB- PMLP -RRB- were assessed with a checklist , adapted from Silove et al. -LSB- 21 -RSB- . The 24 items were clustered , based on a factor analysis -LSB- 13 -RSB- as family issues , discrimination , asylum procedure , socioeconomic living conditions , and religious aspects . The items ` lack of work ' and ` work below level ' loaded on different factors and were analyzed as separate items . The used Iraqi-Arabic composite questionnaire is based on a Palestinian-Arabic version -LSB- 4 , 5 -RSB- and was culturally validated and translated with the help of a focus group . Oral interviews were taken by trained Iraqis . Statistics Differences between the two groups with respect to socio-demographics , psychiatric disorders , service use , and drug consumption were calculated with the χ2-test . Univariate relationships between predisposing and need variables were assessed with a correlation matrix . Ethnicity , religion , and marital status did not show a significant -LRB- P < 0.05 -RRB- correlation with any of the health services . All other variables were entered into multivariate logistic regression analyses as : predisposing variables -LRB- study group , sex and age -RRB- , need variables -LRB- one or more psychiatric disorders , overall quality of life , perceived quality of general health , disability -LRB- 2 items -RRB- , physical health -LRB- 2 items -RRB- , and a special set of need variables : the PMLP -LRB- 7 variables -RRB- . The same independent variables were used in each analysis , in line with the Anderson model . The dependent/outcome variables were : use of preventive service -LRB- nurse/doctor in the center -RRB- , general practitioner , medical specialist -LRB- non-psychiatrist -RRB- , social worker , mental health professional , and use of any drugs . We used a three-step procedure : in the first step each set of variables -LRB- predisposing factors , need factors and PMLP -RRB- was analyzed separately ; in the second step all variables entered one analysis , that way the risk of one variable was corrected for the risks of all other variables . In step one and two , the entire dataset -LRB- n = 294 -RRB- was used . In the third step the analysis was done for Group 1 and Group 2 separately in order to assess the differences of predictors between asylum seekers that had recently arrived -LRB- Group 1 -RRB- and those who had stayed for more than 2 years in the asylum procedure -LRB- Group 2 -RRB- . Adjusted Odds Ratios -LRB- ORs -RRB- , 95 % confidence intervals -LRB- CIs -RRB- , and P values were calculated -LRB- only the ratios with confidence intervals higher or lower than 1 are shown in the tables -RRB- . Differences were considered significant at P < 0.05 . All analyses were performed with SPSS version 10 -LSB- 20 -RSB- . Results Socio-demographics , health and health related variables The two study groups differed on several socio-demographic characteristics -LRB- Table 1 -RRB- . Group 1 contained more subjects younger than 24 years of age , and more females . The average time of stay in the Netherlands of Group 2 was more than 3 years . On the characteristics literacy , social status in Iraq , and psychiatric problems in the family , the two groups did not differ -LRB- not shown in the table , c.f. -LSB- 12 -RSB- . Group 2 had higher scores on prevalence of psychiatric disorders , disability and physical complaints , and lower quality of life score -LRB- Table 1 -RRB- . Except social-religious items , all clustered and non-clustered post-migration living problems were significantly higher in Group 2 . Table 1Socio-demographic , health characteristics and post-migration living problems in at random samples of Iraqi asylum seekers arrived < 6 months -LRB- Group 1 -RRB- versus > 2 years -LRB- Group 2 -RRB- in the Netherlands , 2000 -- 2001VariablesGroup 1 -LRB- n = 143 -RRB- Group 2 -LRB- n = 151 -RRB- Total -LRB- n = 294 -RRB- P-valueStay in months -LRB- mean , SD -RRB- 2.51 -LRB- 1.16 -RRB- 36.77 -LRB- 6.30 -RRB- 20.12 -LRB- 17.76 -RRB- P < 0.0005 , t -LRB- 292 -RRB- = 63.66 Sex -LRB- % -RRB- P < 0.0005 , χ2 -LRB- 1 -RRB- = 27.31 Male49 .778.864.6 Female50 .321.235.4 Age -LRB- % -RRB- P = 0.003 , χ2 -LRB- 4 -RRB- = 16.35 18 -- 24 years21 .79.315.3 25 -- 34 years42 .049.045.6 35 -- 44 years14 .725.820.4 > 45 years21 .715.818.7 One or more psychiatric disorder -LRB- % -RRB- 42.066.254.4 P < 0.0005 , χ2 -LRB- 1 -RRB- = 17.44 Overall quality of life -LRB- mean , SD -RRB- a2 .88 -LRB- 0.99 -RRB- 2.23 -LRB- 1.14 -RRB- 2.55 -LRB- 1.11 -RRB- P < 0.0005 , Z -LRB- 294 -RRB- = − 5.29 Perceived Qol general health -LRB- mean , SD -RRB- b3 .06 -LRB- 1.15 -RRB- 2.74 -LRB- 1.27 -RRB- 2.89 -LRB- 1.22 -RRB- P = 0.017 , Z -LRB- 294 -RRB- = − 2.39 Physical and role disability -LRB- mean , SD -RRB- c17 .31 -LRB- 7.43 -RRB- 19.25 -LRB- 6.77 -RRB- 18.30 -LRB- 7.15 -RRB- P = 0.020 , t -LRB- 292 -RRB- = − 2.34 Days of disability -LRB- mean , SD -RRB- d5 .37 -LRB- 8.24 -RRB- 7.68 -LRB- 9.17 -RRB- 6.56 -LRB- 8.80 -RRB- P = 0.024 , t -LRB- 292 -RRB- = − 2.27 Physical diseases -LRB- mean , SD -RRB- e0 .85 -LRB- 1.18 -RRB- 0.84 -LRB- 0.98 -RRB- 0.85 -LRB- 1.08 -RRB- n.s.Physical complaints -LRB- mean , SD -RRB- e0 .83 -LRB- 1.38 -RRB- 1.62 -LRB- 1.58 -RRB- 1.23 -LRB- 1.54 -RRB- P = 0.0005 , t -LRB- 292 -RRB- = 4.52Post-migration living problems Family related issues -LRB- mean , SD -RRB- f36 .54 -LRB- 26.55 -RRB- 52.81 -LRB- 24.24 -RRB- 44.90 -LRB- 26.62 -RRB- P < 0.0005 , t -LRB- 292 -RRB- = − 5.49 Discrimination -LRB- mean , SD -RRB- f2 .05 -LRB- 7.92 -RRB- 11.17 -LRB- 21.01 -RRB- 6.74 -LRB- 16.65 -RRB- P < 0.0005 , t -LRB- 292 -RRB- = − 4.87 Asylum proc . related issues -LRB- mean , SD -RRB- f48 .58 -LRB- 25.35 -RRB- 60.13 -LRB- 23.23 -RRB- 54.51 -LRB- 24.97 -RRB- P < 0.0005 , t -LRB- 292 -RRB- = − 4.07 Socioeconomic living cond . -LRB- mean , SD -RRB- f22 .35 -LRB- 19.16 -RRB- 32.48 -LRB- 21.08 -RRB- 27.55 -LRB- 20.76 -RRB- P < 0.0005 , t -LRB- 292 -RRB- = − 4.30 Socio-religious aspects -LRB- mean , SD -RRB- f12 .96 -LRB- 17.46 -RRB- 14.48 -LRB- 17.19 -RRB- 13.74 -LRB- 17.31 -RRB- n.s.n.s. : not significant P ≥ 0.05 aScale of 1 -LRB- very bad -RRB- -- 5 -LRB- very good -RRB- bScale of 1 -LRB- very bad -RRB- -- 100 -LRB- very good -RRB- cRange : 11 -LRB- no impairment at all -RRB- -- 33 -LRB- serious impairment -RRB- dRange : 0 -- 31 -LRB- number of days of serious impairment in last months -RRB- eRange : diseases : 0 -- 12 ; complaints : 0 -- 6fRange : 0 -LRB- not worried -RRB- -- 100 -LRB- extremely worried about the issues -RRB- Health service use Table 2 shows the prevalence of service use in the 2 months prior to the interview . Overall , the most frequently used service was the preventive healthcare service , followed by the general practitioner . Sixteen -LRB- 5.4 % -RRB- respondents visited a mental health professional . Group 1 visited the preventive healthcare services in the center more often than Group 2 -LRB- 72.0 % vs. 39.7 % -RRB- and Group 2 visited the mental health services more often than Group 1 -LRB- 9.3 % vs. 1.4 % -RRB- . More than 39 % of the respondents used drugs , 31.0 % used analgetics . Overall drug consumption was higher in Group 2 -LRB- 45.7 % vs. 32.2 % -RRB- . Use of alternative services and treatments was very low , and there was no difference between the two groups : contact religious helper -LRB- 2.7 % -RRB- , use of religious rituals or treatment -LRB- 5.1 % -RRB- , contact with herbal doctor -LRB- 0.7 % -RRB- , use of herbal treatment -LRB- 0.3 % -RRB- . Table 2Health service use and other help seeking behavior in at random samples of Iraqi asylum seekers arrived < 6 months -LRB- Group 1 -RRB- and > 2 years -LRB- Group 2 -RRB- in the Netherlands , 2000 -- 2001Use of services last 2 monthsGroup 1 n = 143 -LRB- % -RRB- Group 2 n = 151 -LRB- % -RRB- Total n = 294 -LRB- % -RRB- P valueUse of any health servicea76 .966.271.4 P = 0.042 , χ2 -LRB- 1 -RRB- = 4.119 bUse of any out-patient -LRB- o-p -RRB- service74 .152.362.9 P < 0.005 , χ2 -LRB- 1 -RRB- = 14.992 bUse of any o-p curative service38 .536.437.4 n.s.Use of preventive o-p service Nurse/doctor in center72 .039.755.4 P < 0005 , χ2 -LRB- 1 -RRB- = 31.004 bUse of o-p curative service General practitioner32 .925.829.3 n.s. Medical specialist in hospital12 .617.915.3 n.s. Social worker5 .66.66.1 n.s. Mental health worker1 .49.35.4 P = 0.003 , χ2 -LRB- 1 -RRB- = 8.846 Use of in-patient service Hospital admission physical health1 .44.02.7 n.s Hospital admission mental health0 .00.70.3 n.sUse of any drugs32 .245.739.1 P = 0.018 , χ2 -LRB- 1 -RRB- = 5.643 Use of anxiolytics10 .522.516.7 P = 0.006 , χ2 -LRB- 1 -RRB- = 7.649 Use of hypnotics11 .921.216.7 P = 0.032 , χ2 -LRB- 1 -RRB- = 4.578 Use of analgetics23 .837.731.0 P = 0.010 , χ2 -LRB- 1 -RRB- = 6.707 n.s. : P > 0.05 aIncludes all regular and alternative services , including drugs , religious rituals/treatment and herbsbGroup 1 more than group 2 , see text Relationship between psychopathology and service use Table 3 shows the univariate relationships between having ` one or more psychiatric disorder ' and service use . Overall , respondents with psychopathology used significantly more services -LRB- 70.0 % vs. 54.5 % -RRB- , both curative and preventive ones . There was no significant difference in use of the services of the general practitioner , this was the case in both groups . Respondents with psychopathology visited a medical specialist -LRB- non-psychiatrist -RRB- much more often in Group 1 , but not in Group 2 -LRB- P > 0.05 -RRB- . Table 3Use of services in respondents with and without one or more psychiatric disorder in Iraqi asylum seekers arrived < 6 months -LRB- Group 1 -RRB- , and > 2 years -LRB- Group 2 -RRB- in the Netherlands , 2000 -- 2001One or more psychiatric disorderGroup 1 n = 143Group 2 n = 151Total n = 294Yes n = 60 , % No n = 83 , % Yes n = 100 , % No n = 51 , % Yes n = 160 , % No n = 143 , % Use of services last 2 months Use of any health servicea88 .368.7 * 76.047.1 * 80.660.4 * Use of any out patient -LRB- o-p -RRB- service86 .765.1 * 60.037.3 * 70.054.5 * Use of any o-p curative service53 .327.7 * 43.023.5 * 46.926.1 * Use of preventive o-p service Nurse/doctor in center83 .363.9 * 47.025.5 * 60.649.3 Use of o-p curative service General practitioner41 .726.529.019.633.823.9 Medical specialist -LRB- non-psychiatrist -RRB- 26.72.4 * 21.011.823.16.0 * Social worker8 .33.610.00.0 * 9.42.2 * Mental health worker1 .71.213.02.0 * 8.81.5 * Use of any drugs45 .022.9 * 58.021.6 * 53.122.4 * Anxiolytics18 .34.8 * 31.05.9 * 26.35.2 * Hypnotics18 .37.2 * 29.05.9 * 25.06.7 * Analgetics31 .718.148.017.6 * 41.917.9 ** P < 0.05 aIncludes all regular and alternative services , including drugs , religious rituals/treatment and herbs The use of drugs in respondents with psychopathology was higher in both groups , compared to those without psychopathology . Almost 60 % of the respondents in Group 2 with psychopathology used drugs , versus 21.6 % of those without psychopathology . Also the use of analgetics was higher , especially in Group 2 -LRB- 48 % vs. 17.6 % -RRB- . Predictors of service use In the ` step 2 ' analyses -LRB- Table 4 -RRB- , with all the independent variables in one analysis , the use of preventive healthcare services was predicted by Group 1 membership , low perceived quality of general health , and physical diseases . Visits to a general practitioner were predicted by age , low perceived quality of general health , and days of disability in the last month . Use of the services of a medical specialist -LRB- non-psychiatrist -RRB- was predicted by having one or more psychiatric disorders , high overall quality of life , low perceived quality of general health and physical diseases . Use of a social worker was predicted by low total disability and days of disability in the last month . Two variables predicted service use of a mental health worker : Group 2 membership , and low perceived quality of general health . Use of any drugs was predicted by age , and low perceived quality of general health . Use of analgetics -LRB- not in table -RRB- was predicted by age , lower perceived quality of general health , and physical diseases . The variables sex , physical complaints , and post-migration living problems -LRB- PMLP -RRB- did not predict any type of service use in the step 2 analyses -LRB- Group 1 and 2 together -RRB- . Table 4Multivariate logistic regression of predisposing and need -LRB- incl . PMLP : post-migration living problems -RRB- variables related to service use of Iraqi asylum seeker in the Netherlands -LRB- N = 294 -RRB- , 2000 -- 2001ServiceNurse/Doctor centerGeneral practitionerMedical spec . -LRB- non-psychiatry -RRB- Social workerMental health workerUse of any drugsORaCI -LRB- 95 % -RRB- ORaCI -LRB- 95 % -RRB- ORaCI -LRB- 95 % -RRB- ORaCI -LRB- 95 % -RRB- ORaCI -LRB- 95 % -RRB- ORaCI -LRB- 95 % -RRB- Predisposing factors Group 2 membershipb0 .180.08 -- 0.375.561.08 -- 28.69 Age -LRB- older age -RRB- 1.031.00 -- 1.051.051.02 -- 1.08 Need factors One or more psychiatric disorder1 .341.18 -- 2.76 Overall Quality of life1 .801.18 -- 2.76 Perceived quality of general health0 .440.30 -- 0.640.510.36 -- 0.730.540.35 -- 0.840.350.17 -- 0.770.490.33 -- 0.71 Disabilityc0 .890.80 -- 0.99 Disability daysd1 .041.001 -- 1.081.071.01 -- 1.15 Physical diseases1 .481.01 -- 2.161.061.02 -- 1.112.071.41 -- 3.05 PMLPaOR : Odds ratios are adjustedbGroup 2 membership > 2 year in asylum procedurecDisability : total score of Brief Disability QuestionnairedDisability days in last month Tables 5 and 6 show the ` step 3 ' analyses for Group 1 -LRB- < 6 months -RRB- and Group 2 -LRB- > 2 years in the Netherlands -RRB- separately . In both groups a lower score on perceived quality of general health predicted almost all types of health services as well as drug use . In Group 1 , but not in Group 2 , use of the services of a medical specialist -LRB- non-psychiatrist -RRB- was also predicted by physical diseases , and by having a psychiatric disorder -LRB- Table 5 -RRB- . In Group 2 , but not in Group 1 , two PMLP -LRB- asylum procedure and socio-economic living conditions -RRB- predicted visits to the nurse/doctor in the center , the general practitioner , and/or a medical specialist -LRB- Table 6 -RRB- . In Group 2 , but not in Group 1 , number of days of disability in the last month and physical complaints predicted the use of analgetics -LRB- not in table -RRB- . Table 5Multivariate logistic regression of predisposing and need -LRB- incl . PMLP : post-migration living problems -RRB- variables related to service use of Iraqi asylum seeker , < 6 months in the Netherlands -LRB- Group 1 : N = 143 -RRB- , 2000 -- 2001ServiceNurse/doctor centerGeneral practitionerMedical spec . -LRB- non-psychiatry -RRB- Mental health workerUse of any drugsORaCI -LRB- 95 % -RRB- ORaCI -LRB- 95 % -RRB- ORaCI -LRB- 95 % -RRB- ORaCI -LRB- 95 % -RRB- Predisposing factors Age -LRB- older age -RRB- 1.061.01 -- 1.10 Need factors One or more psychiatric disorder1 .931.18 -- 3.16 Overall quality of life2 .491.05 -- 3.163.161.29 -- 7.75 Perceived quality of general health0 .250.11 -- 0.560.550.31 -- 0.970.410.18 -- 0.960.290.12 -- 0.74 Disability daysb1 .081.01 -- 1.15 Physical diseases2 .651.33 -- 5.282.711.33 -- 5.54 PLMPaOR : Odds ratios are adjustedbDisability days in last monthTable 6Multivariate logistic regression of predisposing and need -LRB- incl . PMLP : post-migration living problems -RRB- variables related to service use of Iraqi asylum seeker , > 2 years in the Netherlands -LRB- Group 2 : N = 151 -RRB- , 2000 -- 2001ServiceNurse/doctor centerGeneral practitionerMedical spec . -LRB- non-psychiatry -RRB- Mental health workerUse of any drugsORaCI -LRB- 95 % -RRB- ORaCI -LRB- 95 % -RRB- ORaCI -LRB- 95 % -RRB- ORaCI -LRB- 95 % -RRB- ORaCI -LRB- 95 % -RRB- Predisposing factors Age -LRB- older age -RRB- 1.041.00 -- 1.09 Need factors Perceived quality of general health0 .54034 -- 0.870.430.25 -- 0.720.540.31 -- 0.960.410.18 -- 0.880.580.37 -- 0.93 Disabilityb0 .920.86 -- 0.99 Disability daysc1 .071.01 -- 1.13 Physical diseases0 .560.32 -- 0.992.161.26 -- 3.79 PMLP Asylum procedure1 .381.04 -- 1.830.680.51 -- 0.92 Socio-economic l.c. 1.191.02 -- 1.381.231.00 -- 1.50 aOR : Odds ratio 's are adjustedbDisability : total score of Brief Disability QuestionnairecDisability days in last month Discussion The main findings of this study are : There is a high overall service use among Iraqi asylum seekers in the Netherlands . The hypothesis that a long asylum procedure is associated with higher levels of service use , is not confirmed by the results , except for mental health service use and drug use . Psychopathology is related to a higher level of service use -LRB- second hypothesis -RRB- , but when corrected for the influence of other predisposing and need factors , other factors , such as : high role and functional disability , and low perceived quality of general health , are more important predictors . Moreover having one or more psychiatric disorder -LRB- s -RRB- predicts the use of a medical specialist -LRB- non-psychiatrist -RRB- , but does not predict mental health service use . The overall use of mental health service use is very low compared to the high prevalence of psychiatric disorder : over 80 % of the asylum seekers with a psychiatric disorder used any health service , but only 8.8 % visited a mental health service . Next paragraphs will discuss the four research questions . Prevalence of service use , relationship with length of stay The preventive healthcare services are the most frequently visited services in both groups . As explained earlier -LRB- see `` Methods '' -RRB- , in the Netherlands medical staff is present in all asylum seeker centers . Shortly after arrival , all asylum seekers are supposed to get a preventive medical screening by the doctor in the center doing triage for e.g. tuberculosis and AIDS . This probably explains the higher use of this service by Group 1 . Gerritsen et al. -LSB- 9 -RSB- found that 63.7 % of the asylum seekers from Iran , Afghanistan and Somalia reported a visit to the preventive healthcare services in the center . Their average length of stay was 3.4 years , comparable with Group 2 . The rate of the Iraqi group in this study is much lower : 39.7 % , suggesting a difference in use of this service between asylum seekers with different origins . In contradiction to the hypothesis , the use of a general practitioner in Group 2 was not higher compared to Group 1 . The use -LRB- 30 % -RRB- is even lower compared to the general Dutch population , which is 42 % , and even more so compared to immigrants : 51 % -LSB- 27 -RSB- . Also Van Oort et al. -LSB- 24 -RSB- found that asylum seekers visit the general practitioner less often than the general Dutch population : number of contacts per year 3.5 vs. 4.5 . So , despite the higher prevalence of health problems , asylum seekers make less use of the general practitioner . Furthermore , use of a medical specialist is not higher in Group 2 . This is explained by the fact that in the Dutch system a patient can only visit a medical specialist after referral by a general practitioner . Drug consumption is significantly higher in Group 2 -LRB- 45.7 % -RRB- , compared to Group 1 -LRB- 32.2 % -RRB- , confirming the hypothesis . Gerritsen et al. -LSB- 9 -RSB- found an even higher rate -LRB- 57.8 % -RRB- . The high use of analgetics is striking -LRB- see later -RRB- . Use of alternative services is very low . Maybe Iraqi asylum seekers are not interested in these services , but even in case they would be , these services are probably not easily available and accessible . We found no other studies on this issue among Iraqi refugees/asylum seekers . Relationship psychopathology and service use The findings indicate a huge unmet need for mental health care . About 30 % of the asylum seekers with a psychiatric disorder did not visit any service , and more than 90 % of the asylum seekers with a psychiatric disorder did not visit a mental health service -LRB- Table 3 -RRB- . However 60.6 % visited a nurse/doctor in the center and 33.8 % the general practitioner . Both services are important in the pathway to mental health care -LRB- see later -RRB- . We hypothesized that higher levels of psychopathology would be related with higher service use . In the univariate analyses this hypothesis stands , except for use of a general practitioner . Also , there are differences between the groups . The hypothesis is strongly confirmed when we consider drugs use . The high use of analgetics in Group 2 might be explained by the high levels of pain disorders -LRB- 11.3 % -RRB- and physical health complaints -LRB- 66.2 % -RRB- in this group . However other explanations are possible . Van Dijk et al. -LSB- 23 -RSB- did a qualitative study among 22 asylum seekers and concluded that it seems that `` the prescription of paracetamol has become a symbol for the lack of interest of and the rejection by the health care system '' . Their study reports dissatisfaction with the services of the nurse/doctor in the center , as well as with the services of the general practitioner . Predictors of service use After correcting the risks for all other included risk factors in multivariate analyses , low perceived quality of general health was the only significant predictor for mental health service use . Psychopathology , disability , nor physical complaints were significant predictors , while these factors were found to be important predictors in other studies -LRB- e.g. -LSB- 8 , 17 -RSB- -RRB- . Psychopathology , however , was a predictor for higher use of a medical specialist -LRB- non-psychiatrist -RRB- . Our findings lead to the following hypothesis : -LRB- 1 -RRB- asylum seekers present themselves with physical rather than with mental problems -LRB- we know -LSB- 14 -RSB- that the level of physical complaints is high -RRB- , -LRB- 2 -RRB- the staff in the center and the general practitioner do not recognize the mental health problems , and if they do -LRB- 3 -RRB- only a few patient are referred for adequate mental health care . This hypothesis is supported by the findings in the study of Van Oort et al. -LSB- 24 -RSB- . They found that in only 6 % of the cases ` mental health problems ' was recorded as reason of visiting the medical staff in the center , and only 2 % of the referrals to the general practitioners were because of mental health reasons . The general practitioner diagnosed a mental health problem in 10 % of the cases , and of those only 21.4 % were referred to a mental health service -LRB- while 33.3 % was referred to a medical specialist -RRB- . The mismatch between type of health problem and type of health service use seems to be less pronounced in Group 2 : in the analyses per group -LRB- Tables 5 , 6 -RRB- psychopathology did not predict the use of a medical specialist in this group . A curious finding is that overall quality of life has a positive relationship with the use of medical specialist . There might be a parallel with the phenomena that low social support is a risk factor for psychopathology -LSB- 10 -RSB- , but high social support predicts health service use in some studies -LSB- 15 -RSB- . Several post-migration living problems -LRB- PMLP -RRB- predict health service use in Group 2 . Especially worries about socio-economic living conditions increase the need for healthcare . The findings do not support the idea that asylum seekers look for recognition of their health problems in order to get a resident permit : there is no relationship between PMLP and mental health service use and there is a negative relationship with use of a medical specialist . Conclusion This study has shown that Iraqi asylum seekers have a low level of mental health service use , despite the high levels of psychiatric disorders and other health indicators , especially within the group that stayed in the asylum procedure for over 2 years . Moreover , there is a mismatch between the type of health problem and the type of health service use : asylum seekers with a psychiatric disorder make more use of non-mental health service . There is room for improvement of the ` gate way ' preventive services in detection and referrals of patients with mental health problems . The study results suggest that this service is a barrier rather than a facilitator in the pathway to mental health care . The general practitioner should be more involved and consulted . Mental health institutions are recommended to start and/or improve consultation and -LRB- assertive -RRB- care programs .

O O O O O B I O O B I O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O B I O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O B I O O B I O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O B I O O O O O O O O O O O O B I O O O O O O O O O O O O O O O B I O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O B I O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O B I O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O B I O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O B I O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O B I O O O O O O O B I O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O

asylum seekers
service use
drug consumption
psychiatric disorders
iraq


Expert

and

construct

validity

of

the

Simbionix

GI

Mentor

II

endoscopy

simulator

for

colonoscopy

Objectives

The

main

objectives

of

this

study

were

to

establish

expert

validity

-LRB-

a

convincing

realistic

representation

of

colonoscopy

according

to

experts

-RRB-

and

construct

validity

-LRB-

the

ability

to

discriminate

between

different

levels

of

expertise

-RRB-

of

the

Simbionix

GI

Mentor

II

virtual

reality

-LRB-

VR

-RRB-

simulator

for

colonoscopy

tasks

and

to

assess

the

didactic

value

of

the

simulator

as

judged

by

experts

Training

skills

in

endoscopy

for

diagnostic

and

therapeutic

procedures

is

essential

and

requires

a

great

deal

of

hands-on

training

-LSB-

-RSB-

Virtual

reality

-LRB-

VR

-RRB-

simulators

offer

a

promising

option

to

train

these

skills

extensively

prior

to

training

in

real-life

colonoscopy

without

jeopardizing

patients

or

causing

them

unnecessary

discomfort

-LSB-

-RSB-

The

use

of

VR

training

prior

to

performing

real

flexible

endoscopy

on

patients

enables

novice

endoscopists

to

go

through

part

of

their

proficiency

curve

before

submitting

patients

to

their

relatively

insufficient

endoscopy

skills

This

might

not

only

be

advantageous

for

the

patients

undergoing

endoscopy

but

might

also

prevent

complications

and

potential

consequences

resulting

in

medicolegal

litigation

One

of

the

simulators

in

the

field

of

flexible

endoscopy

is

the

GI

Mentor

II

-LRB-

see

Figure

-RRB-

VR

simulators

have

been

used

extensively

in

different

fields

of

expertise

before

applying

these

procedures

to

patients

In

the

United

States

of

America

simulator

training

is

mandated

by

the

Accreditation

Council

for

Graduate

Medical

Education

-LRB-

ACGME

-RRB-

in

laparoscopic

procedures

for

surgical

residents

-LSB-

-RSB-

The

first

step

is

to

validate

the

simulator

construct

properly

and

verify

its

didactic

value

before

implementing

simulators

in

teaching

programmes

or

developing

a

new

curriculum

for

flexible

endoscopy

around

them

Figure

The

GI

Mentor

II

virtual

reality

simulator

the

setup

for

training

in

lower

endoscopy

Some

studies

have

already

been

published

on

this

subject

-LSB-

-RSB-

but

the

presented

outcomes

lacked

power

due

to

their

relatively

small

sample

sizes

In

addition

some

cases

did

not

study

the

validity

of

endoscopy

but

for

example

only

the

EndoBubble

module

a

computer

simulation

skills

test

measuring

how

long

it

takes

a

person

to

pop

balloons

in

a

virtual

tunnel

Objective

The

main

objectives

of

this

study

were

-LRB-

-RRB-

to

establish

the

degree

of

representation

of

real-life

colonoscopy

on

the

Simbionix

GI

Mentor

II

VR

colonoscopy

simulation

as

judged

by

experts

-LRB-

expert

validity

-RRB-

-LRB-

-RRB-

to

determine

whether

the

GI

Mentor

II

simulator

can

distinguish

between

various

degrees

of

expertise

in

endoscopy

judged

by

novice

intermediate

experienced

experienced

and

expert

endoscopists

performing

VR

colonoscopy

-LRB-

construct

validity

-RRB-

and

-LRB-

-RRB-

to

assess

the

didactic

value

of

the

simulator

as

judged

by

experts

Material

and

Methods

Simulator

The

simulator

used

in

this

study

was

the

Simbionix

GI

Mentor

II

-LRB-

Simbionix

Ltd.

Israel

software

version

-RRB-

-LRB-

Figure

-RRB-

The

GI

Mentor

II

can

simulate

upper

GI

tract

endoscopies

such

as

esophagogastroduodenoscopy

endoscopic

retrograde

cholangiopancreatographies

and

endoscopic

ultrasound

The

lower

GI

tract

endoscopies

it

simulates

are

sigmoidoscopy

and

colonoscopy

The

simulator

records

a

range

of

parameters

upon

each

exercise

which

can

be

used

to

assess

performance

objectively

The

endoscope

used

is

a

customized

Pentax

endoscope

Participants

Participants

were

allocated

to

four

groups

to

assess

the

validity

and

didactic

value

of

the

GI

Mentor

II

simulator

The

first

group

the

novices

was

defined

as

participants

without

any

flexible

endoscopy

experience

they

were

all

medical

interns

or

residents

The

second

group

was

intermediate

experienced

with

fewer

than

colonoscopies

performed

before

In

the

third

group

experienced

participants

all

performed

more

than

colonoscopies

but

fewer

than

The

fourth

group

consisted

of

experts

all

of

whom

had

performed

more

than

colonoscopies

These

categories

were

chosen

based

upon

several

other

studies

the

demands

for

Dutch

accreditation

for

colonoscopy

and

the

accreditation

demands

of

the

British

Society

of

Gastroenterology

which

advocates

colonoscopies

under

supervision

during

training

-LSB-

-RSB-

All

persons

were

either

invited

to

participate

within

our

hospital

or

participated

during

a

national

congress

of

the

Dutch

Society

of

Gastroenterology

in

spring

The

groups

consisted

of

at

least

persons

to

ensure

sufficient

statistical

power

-LSB-

-RSB-

A

post

hoc

sample

size

calculation

based

on

the

results

for

time

to

finish

the

EndoBubble

task

showed

a

minimal

sample

of

participants

in

the

novices

group

to

achieve

a

power

of

Originally

the

intermediate

experienced

and

experienced

participants

formed

one

group

but

as

the

expertise

level

and

performance

within

this

group

varied

considerably

this

groups

was

split

A

schematic

setup

of

the

study

design

is

presented

in

Figure

Figure

The

study

design

Questionnaire

All

participants

were

asked

to

fill

out

a

questionnaire

on

demographics

and

their

general

medical

and

endoscopy

experience

It

also

included

the

number

of

endoscopies

performed

annually

and

number

of

years

registered

as

a

skilled

professional

endoscopist

After

the

simulator

run

the

participants

were

asked

to

answer

questions

about

their

appreciation

of

the

realism

of

the

colonoscopy

exercises

performed

Appreciation

was

expressed

on

a

four-point

Likert

scale

-LSB-

-RSB-

varying

from

very

unrealistic

-LRB-

-RRB-

to

very

realistic

-LRB-

-RRB-

Questions

were

asked

about

the

realism

of

imaging

simulator

setup

endoscope

control

and

both

haptic

and

visual

feedback

Experts

were

asked

whether

the

GI

Mentor

II

could

be

used

as

a

teaching

device

for

novice

endoscopists

and

whether

experience

on

the

simulator

could

be

useful

in

practice

Simulation

modules

All

participants

first

performed

the

hand

eye

coordination

task

-LRB-

EndoBubble

level

-RRB-

of

popping

all

balloons

in

the

test

as

quickly

as

possible

without

touching

the

walls

Next

the

participants

performed

VR

case

numbers

and

both

from

colonoscopy

module

These

cases

were

carefully

selected

for

their

discriminative

value

both

cases

are

straightforward

colonoscopies

without

any

abnormalities

such

as

polyps

tumours

or

inflammation

Case

number

is

a

relatively

easy

colonoscopy

to

perform

whereas

case

number

is

more

difficult

requiring

the

endoscopist

to

apply

techniques

such

as

straightening

the

endoscope

during

loop

formation

and

applying

torque

to

the

endoscope

shaft

The

assignment

given

for

the

VR

colonoscopies

was

to

reach

the

cecum

as

quickly

as

possible

with

as

little

patient

discomfort

as

possible

Patient

discomfort

was

defined

as

the

estimated

percentage

of

time

the

virtual

patient

was

in

excessive

pain

and

the

number

of

times

excessive

local

pressure

was

caused

Other

relevant

test

parameters

were

the

percentage

of

time

spent

with

clear

view

and

the

number

of

times

view

of

the

lumen

was

lost

The

task

was

considered

accomplished

when

the

cecum

was

reached

Data

analysis

SPSS

software

was

used

to

perform

descriptive

statistics

and

Kruskal

Wallis

tests

for

statistic

analysis

of

the

data

A

separate

analysis

between

groups

was

performed

using

a

two-tailed

Mann

Whitney

exact

U

test

A

p-value

of

less

than

was

considered

significant

The

data

showed

a

nonparametric

distribution

therefore

the

median

and

range

of

performance

parameters

are

presented

as

primary

values

Results

Participants

Thirty-five

novices

intermediates

experienced

and

expert

endoscopists

participated

in

the

study

The

average

number

of

colonoscopies

performed

annually

by

experts

was

and

their

mean

number

of

years

registered

as

a

gastroenterologist

was

-LRB-

range

years

-RRB-

Construct

validity

Data

output

by

the

simulator

are

presented

in

Tables

and

The

EndoBubble

task

was

completed

faster

by

the

experts

and

experienced

endoscopists

than

by

novices

with

fewer

wall

collisions

These

differences

were

statistically

significant

-LRB-

Kruskal

Wallis

test

-RRB-

-LRB-

Table

-RRB-

Also

the

colonoscopy

tasks

were

completed

faster

-LRB-

p

Kruskal

Wallis

test

-RRB-

with

less

patient

comfort

and

better

visibility

by

experts

and

experienced

endoscopists

-LRB-

Table

-RRB-

Novice

endoscopists

-LRB-

N

-RRB-

reached

the

cecum

in

a

mean

time

of

-LRB-

min

sec

-RRB-

in

colonoscopy

case

intermediate

experienced

-LRB-

N

-RRB-

in

experienced

-LRB-

N

-RRB-

in

and

experts

-LRB-

N

-RRB-

in

Novices

lost

view

of

the

lumen

significantly

more

often

than

the

other

groups

Table

EndoBubble

hand

eye

coordination

taskExperienceTime

to

finish

-LRB-

min

sec

-RRB-

Number

of

times

wall

touchedNovice

N

N

N

N

Asymp

sign

Table

Colonoscopy

module

cases

and

to

reach

cecum

-LRB-

hour

min

sec

-RRB-

of

time

spent

with

clear

viewLost

view

of

lumenExcessive

local

pressure

of

time

patient

was

in

painExcessive

loop

formedCase

N

N

N

N

N

N

N

N

Statistics

colonoscopy

module

cases

and

to

reach

cecum

of

time

spent

with

clear

viewLost

view

of

lumenExcessive

local

pressure

of

time

patient

was

in

painExcessive

loop

formedCase

Asymp

sig

Case

Asymp

sig.0.0000.0730.0000.0000.2320.183Kruskal-Wallis

test

A

separate

analysis

between

groups

using

a

Mann

Whitney

exact

U

test

demonstrated

no

significant

difference

between

the

intermediate

experienced

and

expert

groups

on

all

parameters

They

all

completed

the

task

faster

than

the

novices

-LRB-

see

Table

-RRB-

Table

Differences

between

groups

module

cases

and

to

reach

cecum

of

time

spent

with

clear

viewEost

view

of

lumenExcessive

local

pressure

of

time

patient

was

in

painExcessive

loop

formedCase

vs.

Intermediate

vs.

Experienced

vs.

Intermediate

vs.

Case

vs.

Intermediate

vs.

Experienced

vs.

Intermediate

vs.

Mann

Whitney

two-tailed

test

exact

significance

Expert

validity

The

group

of

expert

endoscopists

rated

the

colonoscopy

simulation

on

a

four-point

Likert

scale

for

overall

realism

Anatomical

representation

was

rated

and

the

simulator

setup

Endoscope

control

scored

Haptic

feedback

was

rated

Didactic

value

Expert

opinion

was

that

the

GI

Mentor

II

simulator

should

be

included

in

the

training

of

novice

endoscopists

-LRB-

on

a

four-point

Likert

scale

-RRB-

and

that

expertise

gained

on

the

simulator

was

considered

applicable

in

a

clinical

curriculum

-LRB-

rated

out

of

-RRB-

The

simulator

was

not

considered

suitable

for

certification

of

trained

endoscopists

-LRB-

rated

out

of

-RRB-

Discussion

This

study

represents

the

largest

and

most

detailed

study

on

the

validity

of

this

type

of

colonoscopy

simulator

so

far

The

data

show

that

the

simulator

can

discriminate

clearly

between

endoscopists

of

different

expertise

levels

performing

different

colonoscopy

tasks

Differences

were

statistically

significant

using

relatively

large

sample

sizes

in

all

three

exercises

the

EndoBubble

task

as

well

as

cases

number

and

The

difference

between

our

study

and

previous

studies

by

others

is

that

we

focused

on

the

basic

aspects

of

navigation

for

colonoscopy

itself

rather

than

on

the

hand

eye

coordination

task

alone

used

for

example

in

the

study

by

Ritter

et

al.

-LSB-

-RSB-

and

that

we

included

more

participants

in

four

separate

groups

with

different

levels

of

expertise

-LSB-

-RSB-

in

this

way

we

were

able

to

demonstrate

that

the

GI

Mentor

II

can

distinguish

between

expertise

levels

up

to

the

level

of

an

intermediate

experienced

endoscopist

who

has

performed

around

colonoscopies

In

a

similar

study

Sedlack

et

al.

-LSB-

-RSB-

describe

a

limited

construct

for

a

different

simulator

-LRB-

AccuTouch

Immersion

Medical

-RRB-

Felsher

et

al.

-LSB-

-RSB-

demonstrated

differences

between

novices

and

experts

in

large

sample

sizes

but

did

not

compare

novices

to

intermediate

levels

of

expertise

In

this

study

we

have

demonstrated

convincing

expert

validity

for

colonoscopy

on

the

GI

Mentor

II

virtual

simulator

This

in

contrast

to

other

studies

focusing

on

the

EndoBubble

task

as

a

validation

study

-LSB-

-RSB-

and

not

dealing

with

the

subject

of

expert

validity

-LSB-

-RSB-

The

colonoscopy

tasks

were

considered

as

accomplished

once

the

participants

reached

the

cecum

Asking

the

participants

to

inspect

the

mucosa

on

the

way

back

through

the

colon

does

not

in

our

opinion

provide

a

proper

representation

of

the

endoscopist

's

skills

in

manoeuvring

through

the

colon

as

other

aspects

besides

the

basic

navigation

skills

of

the

endoscopist

could

influence

the

performance

parameters

provided

by

the

simulator

considerably

in

this

case

This

might

lead

to

very

different

end

times

depending

for

example

on

the

carefulness

of

the

endoscopist

This

study

demonstrates

that

the

GI

Mentor

II

simulator

offers

a

convincing

realistic

representation

of

colonoscopy

according

to

experts

The

overall

assessment

was

good

Expert

opinion

was

that

the

simulator

can

be

used

as

a

teaching

tool

for

novice

endoscopists

The

simulator

's

haptic

feedback

is

doubtful

Inexperienced

residents

can

be

trained

in

the

skills

necessary

in

flexible

endoscopy

such

as

steering

control

straightening

the

endoscope

during

loop

formation

and

applying

torque

up

to

a

certain

level

Conclusion

The

current

study

demonstrates

that

the

GI

Mentor

II

simulator

offers

a

convincing

realistic

representation

of

colonoscopy

according

to

experts

-LRB-

expert

validity

-RRB-

and

that

the

simulator

can

discriminate

up

to

the

level

of

intermediate

experienced

endoscopists

-LRB-

construct

validity

-RRB-

in

colonoscopy

In

the

cases

used

the

simulator

could

not

discriminate

between

intermediate

experienced

and

expert

endoscopists

The

next

step

will

be

a

study

to

determine

whether

novice

endoscopists

can

develop

a

learning

curve

that

will

actually

improve

their

endoscopic

skills

applied

to

real

patients

O O O O O O O O O O B B O B O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O B O O O O O O B O O B O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O B O O B O O O O O O O O O O O O O O O O O B O O O O O B O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O B O O O O B O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O B O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O B O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O B O O O O O O O O O B O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O B O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B B O O O O O O O O B O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O B O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O B O O O O O O O O O O O O O O O B O O O O O O O O O O O O B O O O O 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endoscopy simulator training colonoscopy validation


The analgesic effect of inhalational Entonox for extracorporeal shock wave lithotripsy Extracorporeal shock wave lithotripsy -LRB- ESWL -RRB- is a non-invasive procedure that allows urinary stones to be fragmented using acoustic shock waves . The impact of the shock waves causes transient stinging pain at the entry site as well as deep visceral discomfort , requiring analgesia during the procedure . The objective of this study was to compare the clinical efficacy of Entonox and pethidine for pain relief during outpatient ESWL . We randomized 150 outpatients undergoing elective ESWL into three groups of 50 patients , each group receiving inhalational Entonox , intravenous pethidine , or inhalational compressed air during ESWL . Quantitative evaluation of pain was performed according to a visual analogue scale -LRB- VAS -RRB- , before and after the intervention . Analysis of variance -LRB- ANOVA -RRB- and paired t tests were used to compare VAS scores in the three groups , before and after the intervention . Entonox and pethidine decreased the pain score significantly , while compressed air did not . There was no significant difference between pain relief by Entonox and pethidine . This study demonstrates for the first time that inhalational Entonox is an effective analgesic regimen for ESWL . Entonox can be regarded as an appropriate alternative to analgesics like opioids in relieving pain during ESWL . Introduction Since 1980 , extracorporeal shock wave lithotripsy -LRB- ESWL -RRB- has become the first-line treatment for most urinary stones in adults and children -LSB- 1 -RSB- . However , the vast majority of patients do not tolerate the procedure without analgesia or sedation . Several monitored anesthesia care techniques have been used to provide sedation and analgesia -LSB- 2 -- 5 -RSB- . Some of the analgesic drugs administered for ESWL , however , carry the risk of respiratory depression , delayed discharge , and/or unplanned hospital admission -LSB- 6 -RSB- . Entonox is a mixture of 50 % nitrous oxide and 50 % oxygen . Inhalation produces analgesia without loss of consciousness -LSB- 7 -RSB- . Self-administration of Entonox as an analgesic has been widely used for many years , particularly in obstetric practice -LSB- 8 -RSB- , and by paramedics for prehospital care -LSB- 9 -RSB- . Entonox has a good safety record , with no serious side effects recorded for intermittent use -LSB- 7 -RSB- , and is rapidly cleared from the circulation by exhalation -LSB- 10 -RSB- . The aim of this study was to compare the clinical efficacy of inhalational Entonox and pethidine for pain relief during outpatient ESWL . Methods A total of 150 patients -LRB- 97 men and 53 women -RRB- with stones located in the renal pelvicalyceal system were prospectively randomized to receive Entonox -LRB- prefixed equimolar nitrous oxide and oxygen mixture -RRB- , pethidine , or compressed air for sedoanalgesia during lithotripsy with a third generation electromagnetic lithotripter -LRB- Dornier Compact Delta magneto lithotripter -RRB- . After institutional review board approval , written informed consent was obtained during the anesthesia consultation , which was performed at least 48 h before ESWL . During this consultation , the method of pain assessment was explained to the patients . Patients were asked to rate their pain on a scale from 0 -LRB- no pain -RRB- to 10 -LRB- worst possible pain -RRB- . Patients were included in the study if they were older than 15 years of age , had pelvicalyceal stones , and understood the pain scoring . Patients were excluded from the trial if they had any of the following : -LRB- 1 -RRB- serum creatinine > 200 μmol/l ; -LRB- 2 -RRB- history of chronic use of analgesics and/or sedatives ; -LRB- 3 -RRB- allergy to any of the study medications ; or -LRB- 4 -RRB- history of middle ear surgery within the previous month . Just before entering the lithotripsy room , the patients were randomly assigned to one of the three treatment groups -LRB- Entonox , pethidine , 1 mg/kg intravenously over 10 min , or compressed air , each to be provided if the patient asked for pain relief during ESWL -RRB- by opening a sealed envelope . All patients were assessed by a single physician who was blinded to the patient group assignment . All patients received no premedication and they were told not to eat or drink for at least 4 h prior to the procedure . The control group received compressed air , followed by Entonox gas if pain relief was considered inadequate by the patient . Pain was assessed before and 2 min after receiving pain medication by using a visual analogue scale -LRB- VAS -RRB- with two anchor points , zero denoting no pain and ten for the worst pain the patient had ever experienced . Statistical analysis Data are expressed as mean -LRB- ± SD -RRB- and numbers -LRB- percentages -RRB- . The paired t test was used to analyze VAS score before and after medication . Comparison of means -LRB- VAS decrease -RRB- in the three groups was performed using one-way ANOVA . Comparison of percentages was performed using Chi-square analysis . All statistical analyses were performed using SPSS ® software , version 9.0 , for Windows . Results throughout the text and tables are presented as mean ± SD unless otherwise specified , and statistical significance was defined as P < 0.05 . Results The three study groups were comparable with respect to demographic data , history of urinary calculi and ESWL , and location of calculi . There were no statistically significant differences between the three groups -LRB- Table 1 -RRB- . All patients in the three groups required analgesia . Rescue medication in the form of pethidine was administered in only one case in the Entonox group after recording VAS scores because the analgesia was inadequate . Table 1Demographic data and ESWL variables in three different groupsGroupsEntonoxPethidineControlAge -LRB- years -RRB- 43.76 ± 11.8945 ± 13.4643.9 ± 14.21 Weight -LRB- kg -RRB- 75 ± 278 ± 379 ± 2Height -LRB- cm -RRB- 165 ± 10167 ± 12164 ± 8Gender -LRB- M/F -RRB- -LRB- n -RRB- 30/2034/1633 / 17Stone location -LRB- % -RRB- Renal807884 Ureteral202015 Both021Number of shocks delivered2 ,010 ± 3202,000 ± 5602,500 ± 450Maximum voltage -LRB- kV -RRB- used4 .04 ± 1.154.14 ± 0.754.51 ± 1.00 Past history of urinary calculi -LRB- % -RRB- 707276Past history of ESWL -LRB- % -RRB- 424636Data are expressed as mean ± SD , numbers -LRB- n -RRB- , or percentages -LRB- % -RRB- No ESWL procedure had to be prematurely terminated because of inadequate analgesia . A patient in the Entonox group had mild nausea that subsided spontaneously . The other patients did not develop any complications . Mean ± SD of VAS scores before and after intervention are shown in Table 2 . Statistical analysis showed significant decrease -LRB- Table 2 -RRB- in pain severity in patients receiving Entonox or pethidine . In contrast , patients receiving compressed air had no such change . Table 2Mean ± SD of VAS scores and P-value of comparing scores before and after Entonox , pethidine , and compressed air administration in different groupsVAS scoresEntonoxPethidineCompressed airEntonox in the compressed air groupBefore administration5 .76 ± 1.926.04 ± 1.543.6 ± 1.14.96 ± 1.42 After administration3 .73 ± 2.134.11 ± 1.693.48 ± 1.33.8 ± 1.74P-value0.0010 .0010.4260.001 In control group , after testing with compressed air , we used Entonox . As can be seen in this group , like Entonox group , VAS score decreased significantly While VAS scores after receiving either Entonox or pethidine were significantly different from those in the control group -LRB- P = 0.001 -RRB- after receiving compressed air , statistical comparison showed no significant difference between post-Entonox or post-pethidine VAS scores -LRB- P = 0.5 -RRB- , suggesting that inhalational Entonox may be as effective as intravenous pethidine in alleviating ESWL-associated pain . No significant difference was found in VAS scores of male and female patients in each group -LRB- Fig. 1 -RRB- . Fig. 1VAS scores in different groups before and after administration of Entonox , pethidine , and compressed air Discussion Extracorporeal shock wave lithotripsy -LRB- ESWL -RRB- has become a valuable asset to the urologist and greatly benefits stone patients . In a short period of time , ESWL has completely changed the management of urinary stone disease and has almost entirely supplanted open surgical and most endourologic approaches -LSB- 11 -RSB- . Today , third-generation mobile electromagnetic lithotripters yield an average of 80 % stone-free rate for kidney and ureteral calculi -LSB- 12 -RSB- . As ESWL is frequently carried out on an outpatient basis , it is crucial to provide adequate analgesia with minimal adverse effects -LSB- 13 -RSB- . Chaussy and Thuroff -LSB- 14 -RSB- demonstrated that analgesia requirements in ESWL depend on lithotripter , stone location , age , gender , and number of shock waves . The pathogenesis of pain in ESWL is still not clearly known . Whether it is due to cutaneous or deep visceral afferent stimulation is debatable -LSB- 15 -RSB- . The pain is presumably due to cavitation-mediated stimulation of nerve fibers . The intensity of pain perceived during ESWL depends on the energy level of shock waves passing through the tissues -LSB- 16 -RSB- . Although the development of new generation lithotripters has decreased pain during ESWL , some form of sedation and anesthesia may still be required to provide adequate patient comfort and effective treatment -LSB- 15 -RSB- . Any technique for alleviating ESWL-associated discomfort/anxiety should ideally be reliable in its effect , of rapid onset and short duration of action , free of adverse events , cost-effective , and easily administered -LSB- 17 -RSB- . Opioids are the most commonly used analgesics during ESWL -LSB- 18 -RSB- . Despite their effectiveness , their use may be complicated by central nervous system -LRB- CNS -RRB- or respiratory depression , circulatory failure , or gastrointestinal problems -LSB- 19 -RSB- . Several studies have compared different local and systemic analgesia regimens for pain relief during ESWL , but this , to our knowledge , is the first randomized clinical trial to evaluate the efficacy of Entonox in the treatment of ESWL-associated pain . Nitrous oxide has been used for pain relief during childbirth since the 1930s and was initially delivered at a concentration of 50 % in air , producing an effective analgesic mixture . In 1961 , Mike Tunstall premixed 50 % nitrous oxide with oxygen , and called it Entonox , which was stored as a compressed gas mixture in cylinders . Since then , the convenience of Entonox has made it a successful and popular analgesic for labour -LSB- 20 -RSB- . Entonox has also proved effective in providing pain relief in other specialties -LSB- 21 , 22 -RSB- . Our randomized clinical trial demonstrated that Entonox and pethidine were equally effective in providing analgesia during ESWL and that they were superior to compressed air . Entonox fulfills many of the criteria for an ideal analgesic during ESWL -LSB- 17 -RSB- and , compared to intravenously administered pethidine , provided comparable analgesia with less CNS , circulatory , and respiratory depression or nausea and vomiting . Entonox provides rapid and effective analgesia without heavy sedation and leads to adequate patient relaxation and cooperation . The effect of Entonox was of short duration , allowing the patients to leave the ESWL unit without the need for a long recovery period -LSB- 23 -RSB- . Entonox appeared to be associated with few , minor , and short-lived adverse effects such as nausea and vomiting , dizziness , dry mouth -LRB- breathing dry gas -RRB- , buzzing in the ears , and rarely , pins and needles or numbness , dreams or drowsiness , ranging from 0 to 30 % -LSB- 24 -RSB- . Nitrous oxide -- oxygen inhalation may thus provide a valuable alternative to conventional analgesia regimens during ESWL . In addition to short-acting parenteral sedative narcotics , e.g. , alfentanil , midazolam , and propofol , topical agents such as EMLA cream , lidocaine , prilocaine and piroxicam have been used to minimize pain during SWL -LSB- 25 -RSB- . Further studies are , therefore , warranted to compare the efficacy and safety of Entonox with those of other analgesic regimens . Conclusions Entonox can provide easy , rapid , and adequate pain relief for patients undergoing ESWL , and is associated with few and minimal side effects .

O O O O O B O B I I I B I I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O B I O O O O O O O O O O O O O O O O O O O O O O B O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O O B I O B O B O O O O O O O O O O B O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O B I I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O B O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O B I I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O B O O O O O O B I O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O B O O O O O O O O B I O O O O O O O O O O O O O O O

entonox
extracorporeal shock wave lithotripsy
pain relief
pethidine