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[The role of physicians in the case of death, and professional secrecy in the Netherlands, Belgium, Germany, England and the US].

The role of physicians in issuing a death certificate in the Netherlands differs from that in neighbouring countries and the US; there is also a difference in the degree to which professional secrecy plays a role in this respect. In the Netherlands, England and the US the external examination of the dead body is performed primarily by the attending physician, whereas in Belgium and Germany this may be performed by any physician. Competences and tasks of government-appointed officials such as the medical examiner, forensic pathologist and coroner differ widely. In some countries many data concerning the deceased, the findings of the post-mortem examination, the post-mortal symptoms, the cause of death and the manner of death must be recorded on the death certificate, whilst in other countries, including the Netherlands, hardly any data are recorded. It is recommended that Dutch death certificates should state the points to be covered during a post-mortem as well as explicitly stating the circumstances in which the medical examiner should be called in.

Belgium↗

[Similarities and differences between the euthanasia laws in Belgium and the Netherlands].

Recently, a law on euthanasia has been adopted in both the Netherlands and Belgium. In both countries euthanasia has been legalized under strict conditions and after confirmation with a notification procedure. Although both laws are similar, the Belgian law is more extensive on the requirements of prudent practice. On the other hand, in Dutch society the norm-setting on euthanasia has been more widely developed through jurisprudence. Nevertheless, we expect that the implementation of the new law and the notification procedure in Belgium will be more difficult than in the Netherlands. In order to promote, safeguard and guarantee the quality of the euthanasia practice, the present euthanasia notification procedure in the Netherlands is supplemented with feedback to the physicians. The strict anonymous procedure in the Belgian notification procedure prevents this possibility. Therefore, Belgian physicians will not be supported by the notification procedure to improve their knowledge and skills in euthanasia.

Belgium↗

[High mortality due to infectious diseases and unnatural causes of death among asylum seekers in the Netherlands, 1998-1999].

OBJECTIVE: Description of causes of death among asylum seekers in the Netherlands compared to the Dutch standard population and identification of preventive measures to avoid preventable death. METHODS: An analysis of the causes of death of asylum seekers accommodated in housing facilities of the Central Organ Asylum seekers (COA) for the period 1998-1999 was performed. The primary cause of death was attributed using the International Classification of Diseases (ICD-10) and grouped according to the most important causes of death list issued by Statistics Netherlands. After stratification for gender and age standardised mortality ratios (SMR) were computed. RESULTS: In 82% of the observed deaths amongst asylum seekers a description of the cause and circumstances of death could be obtained. During the 2-year study period 156 asylum seekers died (of which 49 due to an unnatural cause of death and 15 due to infectious diseases). Fourteen stillbirths were registered in an index population of 37,688 in 1998 and 54,110 in 1999. The crude mortality rate was 1.95 per 1000 for male asylum seekers and 1.25 per 1000 for female asylum seekers. Compared to the Dutch standard population, the SMR was 1.23 (95%-CI: 1.01-1.42) for male asylum seekers and 0.85 (0.59-1.11) for female asylum seekers. The elevated mortality in male asylum seekers was due to the high mortality for infectious diseases with an SMR of 4.1 (1.3-6.9) and unnatural death with an SMR of 2.5 (1.7-3.2). More specifically, drowning had an SMR of 11.1 (2.3-20.7), murder and manslaughter 7.3 (2.5-12.0) and suicide 2.8 (1.5-4.1). AIDS accounted for half of the mortality due to infectious diseases. CONCLUSION: In 1998-1999, drowning, murder, manslaughter and suicide contributed significantly to an elevated mortality rate amongst male asylum seekers in the Netherlands. Some of these unnatural deaths could be avoided by implementing preventive measures.

Adolescent↗

[Interculturalisation of medical education in the Netherlands].

The number of immigrants within the Netherlands is rapidly increasing. Towards the year 2010 two million first- or second-generation allochthonous persons will be living in the Netherlands. Their origin is extremely diverse. One district of Rotterdam contains more than 100 different nationalities. Medical education should prepare for these changes in the patient population. Education on import diseases as well as on communication via interpreters is necessary. The characteristics of the Dutch healthcare system (partnership between physician and patient, limited use of drug therapy, emphasis on lifestyle advice, and a central role of primary care) should remain the hallmark of medical education. The rapid influx of second-generation, non-western medical students to the medical faculties should be used to realise internal changes to the medical education system, so that it is adapted to the different medical needs of all persons in the Netherlands.

Cultural Diversity↗

[The efficacy of smoking cessation methods available in the Netherlands: a systematic review based on Cochrane data].

OBJECTIVE: To obtain an overview of data from the Cochrane Library on smoking-cessation methods and aids available in the Netherlands. DESIGN: Systematic literature review. METHOD: Common smoking-cessation methods in the Netherlands in 1999 and 2000 were selected from previous research. Data from relevant Cochrane reviews about these cessation methods were collected, after which the efficacy was calculated as a pooled odds ratio and the effectiveness as a percentage of 12 months' continuous abstinence. RESULTS: The following methods were found to be more efficacious than placebo: tailored written advice, individual counselling, telephonic counselling, group courses, all forms of nicotine-replacement therapy, bupropion and nortriptyline. Acupuncture was not superior to placebo. It was not possible to draw any unequivocal conclusions about hypnotherapy. No randomised studies were found with respect to the 'Allen Carr method'. Rates of 12 months' continuous abstinence were as follows for those methods with proven efficacy: tailored advice: 7%, individual counselling: 16%, telephonic counselling: 7.5%, nicotine gum: 17%, nicotine patch: 13%, nicotine inhaler: 17%, nicotine tablets: 20%, bupropion: 17%, and nortriptyline: 24%. The success rates for nicotine tablets and nortriptyline were based on only 2 and 1 study respectively. CONCLUSION: Several effective smoking-cessation methods are available in the Netherlands. In trials the long-term effectiveness of these methods was between 7-24%.

Humans↗

[HIV-infection and AIDS in the Netherlands: prevalence and incidence, 1987-2001].

OBJECTIVE: To describe the results of HIV-surveillance activities in the Netherlands between 1987 and 2001. DESIGN: Descriptive. METHOD: Data were obtained from HIV-surveillance at STI-clinics, laboratory-surveillance in the region Arnhem, surveillance among injecting drug users, the AIDS-notification, STI-registration and the Amsterdam cohort studies on HIV/AIDS. RESULTS: In the Netherlands, the highest HIV-prevalences were found among injecting drug users (1-26%) and homo- and bisexual men (0-17%). In these high-risk populations, an increase in HIV-prevalence and--incidence, respectively, was found among injecting drug users in Heerlen and homosexual men (> 35 years of age) in Amsterdam. The HIV-prevalence was lower among heterosexuals in the Netherlands (0-2%). However, in certain local populations an increase was seen. In both Amsterdam and Rotterdam, the HIV-prevalence was higher in individuals tested anonymously than in those tested by name. CONCLUSION: Local increases in HIV-infections have been observed recently, in both high- and medium-risk populations.

Acquired Immunodeficiency Syndrome↗

[Cardiovascular risk factors for Surinamese in the Netherlands: a literature review].

OBJECTIVE: To obtain an overview of the prevalence of cardiovascular risk factors in Surinamese (Hindustani and Creoles) individuals in the Netherlands and the implications of this for secondary prevention. DESIGN: Literature study. METHOD: A Medline literature search was carried out for the period 1985-2001 with the keywords 'cardiovascular risk factor' or 'cardiovascular risk factors', and 'Surinamese'. In addition to this, so-called grey literature was searched and the reference lists of articles found were also checked. A total of 7 studies were selected. RESULTS: Smoking is less frequent among Surinamese individuals in the Netherlands compared to the indigenous population, especially in women. The prevalence of both hypertension and diabetes is higher among the Surinamese. Data on dyslipidaemia are almost absent; it is only known that hypercholesterolaemia is less prevalent among the Surinamese. Ethnicity is not included in the risk cards used in the secondary treatment of cardiovascular diseases. CONCLUSION: The lack of research with respect to the cardiovascular risk profile of Surinamese (Hindustani and Creoles) in the Netherlands indicates an unfavourable profile compared to the indigenous Dutch population. This difference justifies further research into the differentiation of prevention and treatment according to ethnic origin.

Adolescent↗

[The 'Inguinal Hernia' guideline of the Association of Surgeons of the Netherlands].

The 'Inguinal hernia' guideline was written over a period of two years by nine surgeons (including one epidemiologist) from all regions of the Netherlands with demonstrable clinical and scientific expertise in the area of inguinal surgery after a training course on 'The development of evidence-based guidelines'. A draft of the guideline was on the website of the Association of Surgeons of the Netherlands for a period of three months, during which time the members of the society could comment on its contents interactively. The guideline comprises chapters on risk factors and prevention, diagnostics, indications for treatment, treatment, day surgery, antibiotics, thrombosis prophylaxis, training, anaesthesia, postoperative pain control, complications, costs, aftercare, and specific aspects of inguinal hernia in children. For the treatment of adult patients a mesh technique is recommended. The Lichtenstein technique is recommended as the first choice for uncomplicated primary inguinal hernia. Laparo-endoscopic techniques can be used by trained teams for specific indications. Other techniques have not been compared with the current methods of treatment sufficiently. It is recommended that the operations be carried out in daycare and that the use of local anaesthesia should be considered more often. The diagnosis of inguinal hernia in a child is based on the physical examination. It is recommended that the surgeon should not rely solely on the history but confirm the presence of a hernia personally. The treatment of a paediatric inguinal hernia is always operative. Generally, the younger the child, the more urgent the operation because of the increased risk of incarceration in infants, particularly premature babies. There is no indication for routine exploration of the contralateral groin. If an incarcerated hernia cannot be reduced, emergency operation is necessary and referral to a paediatric surgical centre must be considered. The implementation and effectiveness of the guideline will be measured by taking an inventory of all inguinal hernia operations performed in the Netherlands before and after its publication.

Adult↗

[Doubling of the number of cases of tick bites and lyme borreliosis seen by general practitioners in the Netherlands].

OBJECTIVE: To obtain detailed information about the current geographical distribution and incidence of tick bites and Lyme borreliosis in the Netherlands and to identify regional differences in the ecological risk factors that might be involved. DESIGN: Retrospective questionnaire study. SETTING: All Dutch general practitioner's (GP) practices. METHODS: In April 2002, all GPs in the Netherlands were asked to complete a short questionnaire on the number of cases of tick bites and erythema migrans seen in 2001 and the size of their practice. Associations with possible risk factors were determined at the municipal level. Results were compared with the results of a similar study done in 1995. RESULTS: The response of the GPs was 64.5% (4730/7330). Together, all GPs reported seeing approximately 61,000 patients in 2001 with tick bites and 12,000 patients with erythema migrans. The incidence of erythema migrans was estimated at 73 per 100,000 inhabitants. There were obvious risk areas. At the municipal level, tick bites and erythema migrans were positively associated with the area covered by forest, sandy soil, the number of roe deer and tourism. There was a negative association with the degree of urbanisation. Increases in tourism in areas with many ticks, new forests in urban regions and an increased number of horses were positively associated with the increase in tick bites and erythema migrans since 1994. CONCLUSION: The number of patients with tick bites and erythema migrans seen by GPs in the Netherlands had doubled between 1994 and 2001. This increase may be attributed partly to changes in ecological risk factors and human behaviour. The number of cases of Lyme borreliosis may be reduced by giving prophylactic information annually about ticks and ways to remove them, plus additional education of patients about the recognition of erythema migrans.

Animals↗

[Forty years of discussion about perinatal mortality in the Netherlands].

In the recently published Peristat study, in which perinatal mortality in the countries of the European Union is compared, the figures for The Netherlands are higher than in the other countries. These figures are based partly on civil registration data. In the countries where these civil registration data were compared with clinical records, i.e. The Netherlands, Northern Ireland and Greece, a considerable underregistration was demonstrated. In The Netherlands, prenatal screening for congenital anomalies is less prevalent than in some other European countries and paediatricians are more reluctant to resuscitate seriously immature infants. This may have some influence on perinatal mortality figures, but a more fundamental question is: are the figures from various countries, based on national civil registration and a large number of divergent clinical registration systems, comparable? This question has not been answered satisfactorily.

Data Collection↗

[Aggression towards paediatricians and trainee paediatricians in the Netherlands].

OBJECTIVE: To determine the extent of aggression from the patient or his family to which paediatricians and trainee paediatricians in the Netherlands are exposed. DESIGN: Cross-sectional survey. METHOD: Data were collected using anonymous questionnaires distributed to doctors working in the field ofpaediatrics in the Netherlands during the annual congress of the Paediatric Association of the Netherlands in 2002. RESULTS: A total of 395 usable questionnaires were returned. 78% of the respondents reported that they had, at some time, been confronted with aggression. Verbal aggression was the most common form (75% of the respondents) and was experienced mainly by doctors with little work experience (63% in the preceding year). 20% of the respondents were aware of the existence of training programmes on dealing with aggression in their hospitals, whereas 47% said that they needed such training. CONCLUSION: Aggression in connection with paediatric care was reported by 78% of the respondents, especially verbal aggression directed at doctors with little work experience. Training on how to cope with aggression might be a useful addition to the paediatric curriculum.

Aggression↗

[Medical transportation of Congolese children by the Foundation "Terre des hommes" Netherlands (1989--1998)].

We report the 10 year assessment of collaboration with the Foundation "Terre des hommes" concerning the medical transfer in the Netherlands of 41 children carrying pathologies which couldn't be treated or operated on in Brazzaville. The average age was 3 years and 6 months old (extremes: 2 months - 15 years). 33 non-cyanotic cardiopathies dominated by ventricular septal defect (VSD) (n = 10) and 11 cyanotic cardiopathies among them the tetralogy of Fallot (n = 5) were admitted. The other pathologies were respectively: osseous (n = 3), vesical (n = 2), pulmonary tumoral, ophthalmic in 1 case. The surgery consisted in a complete repair in 19 cases, palliative in 9 cases. Two children proved to be inoperable. Eight other extra-cardiac pathologies had a specific surgery for each case. The average stay in the Netherlands was 1 month 13 days (extremes: 1 - 12 months). The evolution was favourable for 35 children all pathologies included. Four deaths occurred in the Netherlands and 2 in Congo. The organization of the technology transfer would be probably a better choice in the future.

Adolescent↗

[Rubella epidemic in the Netherlands, 2004/'05: awareness of congenital rubella syndrome required].

Rubella is a public health problem due to the teratogenic effects associated with primary rubella infection during pregnancy (congenital rubella syndrome). Following universal rubella vaccination of infants in the Netherlands, the incidence of rubella has declined dramatically. However, since September 2004, an outbreak has occurred among unvaccinated individuals, most of whom declined vaccination based on religious beliefs. In the period 1 September 2004-22 March 2005, 166 cases of rubella were reported, including 12 pregnant women. Monitoring for signs that the epidemic has spread to other populations in the Netherlands is important because this might indicate the need for additional interventions. Awareness among health-care workers of the possible occurrence of congenital rubella syndrome should be raised. The clinical manifestations of congenital rubella syndrome are diverse, can be transient or permanent, and may not present until adolescence or adulthood. All cases of laboratory-confirmed rubella infection and congenital rubella syndrome should be reported to municipal health authorities. There is a possibility that this outbreak will spread abroad. The WHO aims to reduce the incidence of congenital rubella syndrome to < 1/100,000 live births. Health-care workers in the Netherlands should be extra alert to detect and notify rubella in a timely manner.

Disease Outbreaks↗

[Resistance of gonococci in the Netherlands; results of a survey of medical microbiology laboratories].

OBJECTIVE: To collect information about the incidence ofgonorrhoea and gonococcal resistance in the Netherlands. METHOD: A questionnaire was sent to 39 medical microbiology laboratories to obtain information on current diagnostics and the susceptibility testing method, and on the number of positive results and the susceptibility pattern of gonococcal isolates in 2002 and 2003 (up to and including November). RESULTS: 32 laboratories participated in this survey. 13 laboratories used culture alone and 19 laboratories used culture and/or a molecular test. Gonorrhoea was diagnosed 2,666 times in 2002 and 2,190 times in 2003, with an incidence of 33.5 and 27.0 per 100,000 inhabitants, respectively. The rate of resistance to beta-lactam antibiotics (penicillin and amoxicillin) was 12.2% and 10.7% in 2002 and 2003, respectively, and the rates of resistance to tetracycline were 18.5% and 20.6%. An increase in the resistance to quinolones was observed from 6.6% in 2002 to 9.5% in 2003. Resistance to cephalosporins was low (0.5% in 2002 and 1.2% in 2003). Furthermore, regional differences in susceptibility were found within the Netherlands. CONCLUSION: The observed gonococcal incidence and resistance form the basis for a gonorrhoea prevention and treatment programme in the Netherlands.

Anti-Bacterial Agents↗

[An outbreak of multiresistant tuberculosis from Eastern Europe in the Netherlands].

Infectious multiresistant pulmonary tuberculosis was diagnosed in a 24-year-old woman from an Eastern European country who resided in the Netherlands illegally. Her chest X-ray showed extensive cavitating lesions in both lungs. The patient was infectious for a long time and contact investigation revealed 2 other cases of multiresistant tuberculosis, her boyfriend aged 39 and his father, aged 58 years. Transmission from the index case was confirmed by DNA fingerprinting. Seven contacts had a latent tuberculosis infection. All 3 tuberculosis patients were successfully treated, while a number of the infected contacts received preventive treatment. Multiresistant tuberculosis is on the rise in Eastern Europe. It is a serious disease with a high mortality rate despite treatment and has considerable social implications. This outbreak emphasises the necessity of maintaining an efficient tuberculosis control network in low incidence countries, such as the Netherlands. This is the first time an outbreak of multiresistant tuberculosis of this magnitude is described in the Netherlands.

Adult↗

Regional differences in cardiovascular risk factor profile cannot fully explain differences in cardiovascular morbidity in the Netherlands: a comparison of two urban areas.

BACKGROUND: Our objective was to investigate whether a region in the south of the Netherlands (Heerlen/Kerkrade) had a high burden of cardiovascular disease in comparison with a nearby region (Maastricht) and the average Dutch population, respectively. We also wanted to determine if there are interregional differences in cardiovascular risk factor profile. DESIGN: Cross-sectional study. METHODS: Data from a nationwide registry (CBS) were used to analyse cardiovascular mortality in the two regions and the average in the Netherlands. Data from a primary care morbidity registration network (RNH) were used to compare cardiovascular morbidity and cardiovascular risk factors in both regions. A standardisation procedure was carried out for age and sex. Data were analysed using logistic regression analyses. RESULTS: The overall cardiovascular mortality rate was higher in the Heerlen/Kerkrade region (7.8 per thousand) compared with Maastricht (6.1 per thousand, OR=1.3, 95% CI 1.2-1.5) and the average in the Netherlands (5.7 per thousand). Similarly, most cardiovascular morbidity rates for Heerlen/Kerkrade were more elevated compared with the RNH overall and with Maastricht. Prevalence rates of risk factors such as diabetes mellitus (7.2%, OR=1.5, 95% CI 1.3-1.7) and overweight (10.8%, OR= 2.0, 95% CI 1.8-2.2) were significantly higher in the Heerlen/Kerkrade region compared with Maastricht. There were no differences with regard to hypertension (15.2%, OR=1.0, 95% CI 0.9-1.1). CONCLUSION: Heerlen/Kerkrade is indeed a region with a high burden of cardiovascular disease. Differences in morbidity between Heerlen/Kerkrade and Maastricht cannot be fully explained by differences in cardiovascular risk factor profile.

Adult↗

Genotype distribution amongst hepatitis C patients in The Netherlands.

BACKGROUND: The prevalence of the genotypes of the hepatitis C virus (HCV) differs according to geographical location. In the United States and in European countries, the majority of patients are infected with genotype 1, 2 or 3. There is a lack of data on the distribution of HCV genotypes in The Netherlands. METHODS: The current survey determined the distribution of HCV genotypes amongst recently genotyped patients seen by physicians treating hepatitis C in The Netherlands. RESULTS: Almost half of the 351 patients (49.3%) were infected with genotype 1. Genotype 3 was the second most dominant genotype with a prevalence of 29.3%. Genotypes 2 and 4 were found in 9.7 and 10.5% of the patients, respectively. For 61.5% of the patients (n=216), the subtype was available. For genotype 1 the prevalence of subtype 1a and 1b was very similar, while for genotype 3 a large majority of patients were infected with subtype 3a. CONCLUSION: This survey gives the first estimation of the distribution of HCV genotypes amongst unselected HCV patients in The Netherlands.

Epidemiologic Studies↗

Prevalence of urogenital Chlamydia trachomatis infections in the Netherlands suggests selective screening approaches. Results from the PILOT CT Population Study.

Chlamydia trachomatis screening is being considered in the Netherlands, but policy recommendations are hampered by the lack of population-based data. We studied the prevalence of chlamydia infection in 15-29-year-old women and men in a national representative sample of 21,000 inhabitants of rural and urban areas in the Netherlands. Of this sample, 41% responded by sending in urine and an answered questionnaire, while 11% returned a refusal card. The overall prevalence of chlamydia infection was 2.0% (CI: 1.7-2.3); 2.5% (CI: 2.0-3.0) in women and 1.5% (1.1-1.8) in men. Chlamydia prevalence was significantly greater in very highly urbanized areas (3.2%, CI: 2.4-4.0) compared to rural areas (0.6%, CI: 0.1-1.1). In very highly urbanized areas the greatest prevalence was found among 15-19-year-old women (4.3%) and among 25-29-year-old men (4.2%). A risk profile could be determined and a prediction rule was developed. These data suggest that nationwide systematic screening is not indicated in the Netherlands and that targeted approaches are a better option. Roll-out of selective screening is recommended.

Adolescent↗