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Experiences and career intentions of general practice registrars from The Netherlands.

For some years prospective general practitioners (GPs) from the Netherlands have come to Britain to complete their training. Not all report enjoying their time here, and many leave this country after training. The aim of this study was to examine reasons for coming to Britain, experiences, perceptions and career intentions. The sample consisted of 14 general practice registrars working in their practice year in Southern England. Data were collected through in-depth semistructured interviews and analysed by thematic qualitative analysis. The main reasons for training in this country were easier access, a quicker route to specialization and the quality of training provided. Most had positive professional and personal experiences and saw the British system of training GPs as up to date and supportive of their educational and professional needs. They highlighted some of the positive aspects of the British system, such as the emphasis on teamwork and collaboration with other primary care professionals. They did, however, point out problems and conflicts; for instance, they saw the health care system in Britain as more bureaucratic and as providing unequal access for different groups of the population. Despite their fear of litigation, which they saw as one of the drawbacks for British general practitioners, most looked favourably on the option of staying in or returning to this country if possible. All registrars valued their stay in Britain; however, personal circumstances often dictated a return to Holland. Our findings have implications for manpower planning and recruitment for general practice in both Britain and Holland.

Attitude of Health Personnel↗

Medication discussion groups in the Netherlands: five years of experience.

INTRODUCTION: Nation-wide implementation of medication discussion (MD) groups in the Netherlands was designed as a bottom-up approach and has been in progress for five years. This invites a review of what has been achieved in these structured discussions between general practitioners and pharmacists. CONTEXT: Early in 1997 the Dutch Foundation for Effective Use of Medication (DGV) initiated a fact-finding exercise among general practitioners and pharmacists representing MD groups all over the country. OBJECTIVE: Description of the setting up and the operation of medical discussion groups. Comparison of the quality of the consultations between the start of the project (1992) and 1997. METHODS: Two surveys of medical discussion groups in 1992 and 1997, respectively. RESULTS: The quality of the consultations was found to have improved in comparison with an evaluation shortly after the start of the project. CONCLUSION: The overwhelming majority of those interviewed were satisfied with the MD process, which they consider a useful effort. But there is also a wish for increased commitment to guidelines agreed in MD group consultations.

Drug Therapy↗

Medical students' attitudes towards and perception of the basic sciences: a comparison between students in the old and the new curriculum at the University Medical Center Utrecht, The Netherlands.

OBJECTIVES: The attitudes towards the basic sciences of medical students enrolled in either of 2 different curricula at the University of Utrecht Medical School in The Netherlands were investigated. The purpose of this study was threefold: first, to compare students (beginning clerks) in a conventional and an innovative curriculum; second, to compare beginning clerks with advanced clerks; and third to compare the present results with those of 2 previous American and Canadian studies in which the same questionnaire was used. SETTING: Beginning clerks in the old and in the innovative curriculum, and advanced clerks in the old curriculum, rated 9 statements on a 5-point (disagree - agree) Likert scale. The statements assessed students' attitudes toward the basic sciences. RESULTS: The results showed that beginning clerks in our innovative curriculum, unlike those in a conventional curriculum, consider the basic sciences as somewhat less important for medical practice and do not think that as many biomedical facts as possible should be learned before entering clinical practice. On the other hand, students in the innovative curriculum are more excited by the faculty's teaching of the basic sciences. This latter result confirms the findings in a previous Canadian study. No significant differences were found between beginning and advanced clerks in the conventional curriculum. CONCLUSION: Students experience teaching of the basic sciences as more exciting when they are integrated in organ system blocks with clinical bearings, though they are somewhat less positive about the actual importance of these sciences.

Attitude↗

Validity and reliability of the Nursing Minimum Data Set for the Netherlands (NMDSN).

UNLABELLED: The Nursing Minimum Data Set for the Netherlands (NMDSN) describes nursing care based on nursing phenomena, interventions and outcomes. The validity and reliability of its data collection has not been tested yet. PURPOSE: To report about the discriminative validity and the interrater reliability of the NMDSN. DESIGN: Data were collected in an intensive care ward, in a nursing home and in a residential home. The unit of measurement and analysis is the 'patient day'. The analysis for validity consisted of ridits calculations, and their graphical representations. Interrater reliability was measured by percentage agreement and Cohen's kappa. RESULTS: Graphs illustrate the differences on most nursing phenomena and interventions as expected beforehand. The percentage agreements for the residential home vary from 60.4 to 100%, and the kappa statistics from -0.09 to 0.85, indicating a poor to almost perfect interrater reliability. CONCLUSION: Intensive care patients and patients in the nursing home have more problems and need more nursing interventions compared with general hospital patients, while the patients in the residential home have lesser of both. This illustrates the discriminative validity of the NMDSN. The kappa values for various NMDSN variables are sufficient. A similar test in the general hospital is recommended.

Adult↗

Maternity care in The Netherlands: the changing home birth rate.

In 1965 two-thirds of all births in The Netherlands occurred at home. In the next 25 years, that situation became reversed with more than two-thirds of births occurring in hospital and fewer than one-third at home. Several factors have influenced that change, including the introduction of short-stay hospital birth, hospital facilities for independent midwives, increased referral rates from primary to secondary care, changes in the share of the different professionals involved in maternity care, medical technology, and demographic changes. After a decline up to 1978 and a period of relative stability between 1978 and 1988, the home birth rate started to decline further, to the extent that it might destabilize the Dutch maternity care system and the role of midwives in it. The Dutch maternity care system depends heavily on primary caregivers, midwives and general practitioners who are responsible for the care of women with low-risk pregnancies, and on obstetricians who provide care for high-risk pregnancies. Its preservation requires a high level of cooperation among the different caregivers, and a functional selection system to ensure that all women receive the type of care that is best suited to their needs. Preserving the home birth option in the Dutch maternity care system necessitates the maintenance of high training and postgraduate standards for midwives, the continued provision of maternity home care assistants, and giving women with uncomplicated pregnancies enough confidence in themselves and the system to feel safe in choosing a home birth.

Female↗

Diagnosis and epidemiology of Trichinella infections in wildlife in The Netherlands.

Trichinella infections in foxes and wild boars were studied to determine the prevalence of infection in wildlife in the Netherlands. Muscles of 429 forelegs of foxes (Vulpes vulpes) and diaphragms of 11 wild boars (Sus scrofa) were artificially digested. Single larvae of Trichinella were identified at species level using random amplified polymorphic DNA (RAPD-PCR). In addition, an ELISA using ES antigen was used to test serum samples of 458 wild boars. The prevalence of Trichinella in foxes ranged from 3.9% in the the eastern part of the country, 13.1% in the central part of the country and 1.3% in the most western part of the country. Trichinella larvae of foxes were identified as T. britovi. In most samples, identification of larvae did not show reproducible results. The serological prevalence of Trichinella infections in wild boars was 6.8%. Wild boar populations are located in the central and in the southern part of the country. Trichinella larvae of wild boar were identified as T. spiralis. These results show that two Trichinella species are involved in the epidemiology of trichinellosis among wildlife. On the basis of previous reports, the present results suggest that the prevalence of Trichinella infection in wildlife is increasing in the last 20 years.

Animals↗

Osteosarcoma of the pelvis--oncological results of 40 patients registered by The Netherlands Committee on Bone Tumours.

AIM AND METHODS: We reviewed the oncological outcome in 40 consecutive patients with an osteosarcoma of the pelvic region, registered in the files of the Netherlands Committee on Bone Tumours (NCBT) between 1978 and 1995. RESULTS: Six patients had distant metastases at initial presentation (Enneking stage IIIB), 33 patients had stage IIB osteosarcoma and one patient stage IB osteosarcoma. Patients with metastases were treated with chemotherapy (four) or palliative procedures (two). Patients with non-metastatic osteosarcoma were treated with surgical procedures with (14) or without (four) neoadjuvant chemotherapy, chemotherapy without surgical resection (nine), or palliative procedures (seven). The median survival of stage IIB and IIIB osteosarcoma was 14 months (2-175) and 7.5 months (2-16), respectively. Survival in patients with stage IIB osteosarcoma treated with curative procedures was significantly better (P<0.0006) compared with stage IIB patients treated with palliative intent. Two and 5-year survival for patients with curatively treated stage IIB osteosarcoma was 35% and 26%, respectively; distant metastases had developed in 65% of these patients. On univariate analysis, positive prognostic factors for patients with stage IIB osteosarcoma were complaints of 3 months or less before initial presentation, tumour size of 8 cm or less, osteoblastic subtype, surgical resection of the primary tumour and limb salvage procedures. CONCLUSION: In conclusion, the prognosis of pelvic osteosarcoma remained poor despite modern multimodality treatment regimens, including neoadjuvant chemotherapy.

Adolescent↗

The vascular laboratory in practice: a national survey in the Netherlands.

OBJECTIVES: to overview Dutch vascular laboratory practice and specifically the variation in duplex criteria. METHODS: a questionnaire was sent to all vascular laboratories in The Netherlands (n=140). RESULTS: the response rate of the inquiry was 64% (n=89). There is no consensus on interpretation of outcome. In 22% of the clinics (n=20) a diagnostic angiography will be omitted when a percutaneous angioplasty is advised on account of duplex ultrasound. Only 5% (n=4) relies upon duplex ultrasound for operation without diagnostic angiography. In 44% (n=39) a PSV (peak systolic velocity) of 125 cm/s is used to identify a>70% or internal carotid artery stenosis. In 44% (n=39) a PSV of 210 cm/s and 10% (n=9) a PSV > or =150 cm/s is used. For grading a relevant stenosis in the femoro-politeal arteries a PSV ratio > or =2.5 is chosen in 75% (n=67). Criteria used for graft surveillance shows also a wide variation. CONCLUSIONS: a commission for the accreditation of vascular laboratories should be established with the goal of creating standards and performing quality control.

Angiography↗

Are retinol, vitamin C, vitamin E, folate and carotenoids intake associated with bladder cancer risk? Results from the Netherlands Cohort Study.

In the Netherlands Cohort Study among 120 852 subjects aged 55-69 years at baseline (1986), the association between vitamins and carotenoids intake, vitamin supplement use, and bladder cancer incidence was examined. Exposure status was measured with a food-frequency questionnaire. After 6.3 years of follow-up, data from 569 cases and 3123 subcohort members were available for case-cohort analyses. The age-, sex-, and smoking-adjusted relative risks (RRs) for retinol, vitamin E, folate, a-carotene, b-carotene, lutein and zeaxanthin, and lycopene were 1.04, 0.98, 1.03, 0.99, 1.16, 1.11, and 1.08, respectively, comparing highest to lowest quintile of intake. Only vitamin C (RR: 0.81, 95% CI: 0.61-1.07, P-trend = 0.08), and b-cryptoxanthin intake (RR: 0.74, 95% CI: 0.53-1.03, P-trend < 0.01) were inversely associated with bladder cancer risk. The association with vitamin C disappeared after adjustment for b-cryptoxanthin but not vice versa. The RRs for supplemental use of vitamin A, C or E compared to no use were around unity. We conclude that dietary or supplemental intake of vitamin A, vitamin C, vitamin E, and intake of folate, and most carotenoids are not associated with bladder cancer. In this study, only b-cryptoxanthin intake appeared to be inversely associated.

Aged↗

Nationwide breast cancer screening programme fully implemented in The Netherlands.

The period 1990-1997 saw the implementation of a nationwide breast cancer screening programme in the Netherlands, which provided biennial mammography for all women aged 50-69 years (50-75 years at present). The National Evaluation Team monitors the programme annually collecting regional data on screening outcomes; regional cancer registries provide data on interval cancers and on breast cancers in unscreened women by linkage of cancer registry data to data on screened women. Of 4 million women invited, 78.5% attended for screening. Screening resulted in 13.1 referrals, 9.2 biopsies and 6.1 breast cancers detected per 1000 women screened initially (6.9, 4.5 and 3.5 per 1000 in subsequently screened women, respectively). Within the first 2 years following screening 0.95 interval cancers per 1000 women-years were diagnosed. The stage distribution of screen-detected cancers was more favourable than that of interval cancers and of those diagnosed in unscreened women. The results are largely consistent with expectations. Results may nonetheless be further improved, particularly the detection rate in subsequent screens.

Journal Article↗

Screening of nutritional status in The Netherlands.

BACKGROUND AND AIMS: In 2001, the Dutch Dietetic Association conducted a national screening on malnutrition. The goal of this screening was to determine the prevalence of disease-related malnutrition in The Netherlands in all fields of medical care and to investigate the involvement of the dietitian in the treatment of malnutrition. METHODS: Eight thousand five hundred and twenty nine patients were screened of which data of 7606 patients could be analysed. Eighty one per cent (6150) of the patients were hospital patients. Eleven per cent (808) of the patients lived in a nursing home. Seven per cent (533) of the patients were home-care patients, who were measured at home or at the general practitioner's office. The origin of 115 patients (2%) was not registered. Age, height, weight, unintentional weight loss, kind of illness and intervention by a dietitian were registered. Malnutrition was defined as >10% unintentional weight loss during the past 6 months and risk of malnutrition was defined as 5-10% unintentional weight loss during the past 6 months. RESULTS: Twelve per cent (884) of all patients appeared to be malnourished. Thirteen per cent (962) were at risk of malnutrition and 75% (5760) were well nourished. Fifty four per cent of the malnourished patients were referred to a dietitian. Oncological disease was more associated with malnutrition than non-oncological disease (in particular in the head and neck, lung and intestinal areas). Also, non-oncological gastro-intestinal and lung disease patients were often categorised as malnourished. Elderly patients (>75 years) were more at risk of malnutrition. BMI and unintentional weight loss did not correlate well. CONCLUSION: In this national survey conducted by dietitians, including a convenience sample of mainly institutionalised patients, approximately 25% of patients in all medical fields were categorised as moderately or severely malnourished. About half of these patients were seen by a dietitian.

Adolescent↗

Time off work due to scaphoid fractures and other carpal injuries in The Netherlands in the period 1990 to 1993.

This study assessed the epidemiology, treatment, disability and time off work due to carpal injuries in the Netherlands in the period from 1990 to 1993. Most injuries were scaphoid fractures and carpal instabilities were rare. The time off work was considerable (mean, 155 days; median, 105 days; range, 12-1708 days). Patients with non-scaphoid fractures had the shortest time off work, followed by those with scaphoid fractures; patients with carpal instabilities had the longest time off work. Despite the significant time off work, the prognosis for return to work was excellent.

Adult↗

[Effect of competition-oriented reform in the Netherlands health care system on the relationship between primary care physicians, insurance groups and insured patients].

The German health care policy debate is affected by proposals demanding the introduction of competitive elements. Analysis of the effects of regulated competition in the Netherlands health care system shows that actual behavioural changes of the key actors of the system differ considerably from expected changes, although incentives within the system have been substantially changed. Sickness funds are not selectively linked with providers and insured patients do not change their insurance company very often. From the point of view of the original reform targets, this preliminary result is quite disappointing. It can be explained by the fact that the relations between sickness funds, general practitioners and insured persons or patients are within a broader framework of health care. Thus, competition does not seem attractive to either of them. If regulated competition became more dominant, several undesirable effects on the so far well-appreciated primary care may be expected.

Cross-Cultural Comparison↗

[Interreg II--European regional study of chronic respiratory tract diseases in children in the Germany-Netherlands border zone].

AIM OF THE STUDY: In Westelijke Mijnstreek (WM), Midden-Limburg (ML), both The Netherlands, and Kreis Heinsberg (HS), Germany, the relationship between quality of the indoor environment and respiratory symptoms in children was studied, finally resulting in proposals for prevention of respiratory symptoms in the three regions. This paper presents the results of the first part of the study, investigating prevalences of respiratory complaints. METHODS AND RESULTS: A brief questionnaire was used to document prevalences of respiratory complaints, physicians diagnoses and treatment in about 7,000 children 5-6 resp. 7-8 years of age from HS, ML and WM, in 1995 and 1997. Prevalences of respiratory symptoms differed slightly between the regions, but there were differences in physician-diagnosed asthma and bronchitis and treatment of the children. PERSPECTIVES: The brief questionnaire is a useful instrument to get an overview on respiratory symptoms. Since 1995, it is used by several German Municipal Health Services for Public Health Reports.

Air Pollution, Indoor↗

Monitoring therapy with anticoagulants in The Netherlands.

In The Netherlands, the monitoring of outpatients on oral anticoagulant treatment is conducted, in 95% of the cases, by specialized centers, the so-called "trombosediensten." These centers are recognized by the Ministry of Public Health, Welfare and Sports and must satisfy certain standards and requirements. The centers are united in the "Federatie van Nederlandse Trombosediensten" that provides support in quality assessment and is a board for the negotiations with the government and other authorities. An attempt is made to describe the operation, quality assessment, and the results obtained by these centers by using data from the "Federatie" and one of the centers, in particular. The Dutch system provides a relatively cheap and safe method for treatment with oral anticoagulants, based upon centers where all necessary knowledge is concentrated. The system depends highly upon good communication between referring physician, staff, physicians of the centers, and the patients.

Administration, Oral↗

Time-space distribution of extrahepatic biliary atresia in The Netherlands and West Germany.

Extrahepatic biliary atresia (EHBA) is an infrequent disease confined to early infancy. Its aetiology is not clear, but an infectious agent has been implicated. Demonstration of a time-space clustering would support this hypothesis. Therefore, we investigated the time-space distribution of all 89 cases of EHBA born in a 10-year period in the Netherlands. We carried out a similar study in West Germany and analysed 130 cases of EHBA, born between 1969 and 1986, from 4 paediatric surgical centres. Analysis of these cases did not reveal any evidence for clustering in specific years or in a specific period of the year. The places of birth of the patients also were randomly distributed over rural areas, villages and towns. Neither did a method to reveal time-space interaction give any support for clustering. This random distribution of patients with EHBA suggests that EHBA could be pathogenetically a heterogeneous disease.

Biliary Atresia↗

Outcome of periventricular-intraventricular hemorrhage at 2 years of age in 484 very preterm infants admitted to 6 neonatal intensive care units in The Netherlands.

Of 484 newborn infants with a gestational age of less than 32 weeks and admitted to 6 neonatal intensive care units in the Netherlands, 294 survived and were available for follow-up at the corrected age of two years. The total incidence of impaired neurodevelopmental outcome was 23.1%. Sixty-nine children had a periventricular-intraventricular hemorrhage (PIVH) in the neonatal period: 31 grade I, 21 grade II, 12 grade III, 5 grade IV. Children with grade I and II PIVH had significantly more handicaps than children without PIVH (36.5% vs 17.8%, p less than 0.01). This held even true after the data were adjusted for possible confounding factors (odds ratio [OR] 2.1, confidence interval [1.3, 3.3], p less than 0.01). Children with grade III and IV PIVH had also more handicaps than children without PIVH (52.9% vs 17.8%, p less than 0.001); after adjustment for confounding factors the OR was 3.0, confidence interval [1.6, 5.5], p less than 0.01. The difference between children with grade I and II PIVH and children with grade III and IV PIVH was not significant.

Cerebral Hemorrhage↗

Venous thromboembolism in childhood: a prospective two-year registry in The Netherlands.

OBJECTIVE: To study the incidence, signs and symptoms, diagnostic tests, risk factors, therapy, and complications of pediatric venous thromboembolism (VTE) in The Netherlands. METHODS: A prospective 2-year registry of VTE in children aged < or = 18 years. RESULTS: Ninety-nine patients were registered. The annual incidence of VTE was 0.14/10,000 children, 35% of whom were symptom free. Almost half of the patients were newborns. Neonatal VTE was almost exclusively catheter related, located in the upper venous system, and asymptomatic. In older children VTE was catheter related in approximately one third and more often was located in the lower venous system. In 85% of all patients, thrombosis developed while the patient was in the hospital. Diagnosis was usually made by ultrasonography. In 98% of all patients, at least 1 risk factor was present. Congenital prothrombotic disorders were more often present in older children (21%) than in neonates (6%). A variety of treatment modalities were used. Morbidity consisted of bleeding (7%) and recurrent thrombosis (7%). Two children died as result of VTE. CONCLUSION: VTE is mostly diagnosed in hospitalized children, especially sick newborns with central venous catheters and older children with a combination of risk factors. Primary prevention, optimal treatment, and long-term outcome of pediatric symptomatic and asymptomatic VTE need to be studied.

Adolescent↗