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Tuberculosis (TB) still occurs frequently in the Netherlands among immigrants from countries where the disease is highly endemic, despite the mandatory TB screening upon settling in the Netherlands. The TB-ENDPoint study shows that immigrants from populations at risk for TB are prepared to be screened for latent TB infection (LTBI) and to complete preventative treatment. Cost-effectiveness analysis will have to determine whether and in which target groups screening can replace the present X-ray screening for TB. A targeted approach, in which LTBI screening is combined with screening for other infectious diseases such as hepatitis B and C and HIV, could favourably influence cost-effectiveness. Further research into implementation, involving all stakeholders, would be useful to optimize combined screening.

Mary Mallon (1869-1938) was an Irish immigrant who worked as a cook for rich families in New York. She was responsible for several outbreaks of typhoid fever since she was an asymptomatic carrier of Salmonella typhi. Because of the danger and fear for new outbreaks, she was held in quarantine for years, against her will. What factors contributed to this decision? Was it necessary to keep her isolated? And what was the role of public opinion and media? The history of Mary Mallon is a sad and tragic chapter in medical history, from which we can still draw important lessons.

OBJECTIVE Many healthcare professionals are confronted in their practice with migrants who don't have a valid residence permit. With this study, we want to provide more insight in the health problems and healthcare consumption of this group. DESIGN Retrospective file study. METHOD Data were taken from files created by municipal health-service physicians when medically screening people who present to the municipality to apply for 24-hour shelter on the basis of their health condition. Symptoms and disorders were coded according to the International Classification of Primary Care (ICPC), and use of medication according to the Anatomical Therapeutic Chemical Classification (ATC). RESULTS The study population consisted of 356 people, mainly men, 39 years of age on average (range: 18-80 years). Compared with the total population of people without a valid residence permit who presented to the municipality (n = 1010), in the study population both women (25.6%) and people in age categories above 45 years of age (32.0%) were overrepresented. At the time of screening, 45.2% had a regular, stable place of residence. Most people without a valid residence permit (98.6%) reported one or more health problems. Psychological symptoms, such as stress (78.5%), insomnia (69.7%) and feelings of depression, were the most common ones. At the same time, many people without a valid residence permit were receiving medical care (86.8%). CONCLUSION A majority of people without a valid residence permit who present to apply for 24-hour shelter have health problems. Stress and other psychological symptoms are the most common ones. At the same time, a large part is receiving adequate care. This means that barriers to care, at least in Amsterdam, do not seem too high.

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an X-linked enzyme deficiency with a high prevalence in Sub-Saharan countries and countries in the Middle East. Due to increased migration in the past decennium, the prevalence of this disorder has increased in the Netherlands. Here we present three patients with acute haemolysis due to G6PD deficiency: a male neonate with severe hyperbilirubinaemia leading to kernicterus; a 3-year-old girl with a severe acute haemolysis due to an infection; and a 5-year-old boy with acute haemolysis with no clear cause. These cases serve to trigger the awareness of all caregivers of the increased prevalence of this disorder, and of the limited health literacy of many immigrants.

Peritoneal tuberculosis was diagnosed in a 38-year-old man from Curaçao, a 42-year-old Dutch man and a 38-year-old woman from Surinam. All patients had been living in the Netherlands for over a decade at the time of diagnosis. Time to diagnosis and treatment varied between patients. Factors contributing to delayed diagnosis were nonspecific symptoms, failure to consider tuberculosis exposure, consulting of more than one physician and delay in obtaining adequate material for histopathologic and microbiologic tests. These cases show that peritoneal tuberculosis can represent a diagnostic challenge. Considering the rising incidence of tuberculosis in the Netherlands, general practitioners and medical specialists will encounter patients with extrapulmonary tuberculosis more frequently. We recommend that tuberculosis exposure should always be considered by clinicians, even in patients originating from non-endemic countries. In case of suspected peritoneal tuberculosis, laparoscopy with peritoneal biopsy is the diagnostic tool of choice and should be performed without delay.

To investigate underperformance across ethnic minority groups and by first-generation university students in different types of examinations during pre-clinical training.Prospective cohort studyParticipants included Erasmus MC students from the 2008-2013 cohorts (n=2432). Outcome measures were pass/fail on three types of written examinations: 1) theoretical knowledge: clinical problem solving tests (CPSTs) (Year 1-3) and end-of-block tests (Year 1c2-c3), 2) language skills test (Year 1) and 3) writing skills tests (Year 1-3), and OSCEs (Year 2-3). Odds ratios with 95% confidence intervals were estimated by logistic regression analysis for ethnic subgroups (Surinamese/Antillean, Turkish/Moroccan/African, Asian, Western) compared with Dutch students, adjusted for age, gender, pre-university Grade Point Average (pu-GPA), additional socio-demographic variables (first-generation immigrant, urban background, first-generation university student, first language, medical doctor as parent). Similar analyses were conducted for first-generation university students.Compared with Dutch students, the three non-Western ethnic minority groups underperformed in the CPSTs, the language test and the OSCEs. Findings on the end-of-block and writing skills tests, and results for Western minority students were less consistent. Age, gender, pu-GPA and additional socio-demographic variables could explain the ethnicity-related differences in theoretical examinations, but not in language, clinical and writing skills examinations. First-generation university students only underperformed in the language test.Ethnic minority students underperform in pre-clinical training, but there are differences both across ethnic subgroups and between different types of examinations. In designing assessment programs care should be taken to avoid unintended effects of certain types of examinations for certain groups of students.

In het jaar 2015, zo is de verwachting, worden er in het BIG-register meer buitenlandse tandartsen ingeschreven dan dat er jonge Nederlandse tandartsen afstuderen. Voorts verwacht men dat de instroom van buitenlandse tandartsen in Nederland ook in de toekomst nog zal blijven toenemen. Het is van velen van hen onduidelijk wat het niveau van hun kennis en vaardigheden is, of zij zich tijdelijk of blijvend in Nederland vestigen of zij genoeg kennis hebben van zowel de Nederlandse wet - en regelgeving als van de specifieke manier van samenwerken met mondhygiënisten in de Nederlandse mondzorgpraktijken en of zij de Nederlandse taal voldoende beheersen.

We present the case of a 37-year-old psychotic, homeless man from Albania, who sustained multiple fractures after jumping from a third-floor window. The patient was uninsured and did not consent to transfer to a hospital in Albania because of paranoid delusions. Eventually he was hospitalised for nearly 30 weeks in hospital and a nursing home. Various factors of this complex case are considered, such as the co-morbidity of somatic and psychiatric symptoms, the absence of family support and the financial regulations that apply to uninsured patients. Doctors who are presented with similar complex cases are advised to organise frequent multidisciplinary evaluations with all health care workers involved. We encourage searching for creative interventions which serve both the best interests of the individual patient, and - where possible - also minimize the total cost of health care to society.

In 2012, the Dutch Health Council published updated advice on vitamin D supplementation in the population of the Netherlands. Although implementation of the advice has commenced, progress is slow. The bottlenecks in implementation were highlighted at a national expert meeting and ideas formulated for improvements. Implementation is rendered more difficult because of the complex mix of lack of awareness of the advice, the reimbursement system of the health insurance companies and a lack of clarity regarding price and dosage differences of the supplements. Existing contact opportunities with healthcare professionals, such as when the flu vaccination is given, need to be used to provide information so as to improve the implementation. The children's health clinic can be used to inform the whole family about supplementation. In nursing and care homes, vitamin D supplementation should be instituted as standard and seen as an indicator of responsible care. It is important to prioritize target groups. The initial focus must be on the most vulnerable group, the inhabitants of nursing and care homes. The second priority must be given to the elderly living independently and to non-western immigrants.

The Dutch population of first generation Turkish and Moroccan migrants is ageing. Among them hypertension and diabetes mellitus are frequent findings, which will probably cause an increased incidence of dementia. The language barrier, low education and cultural differences make the diagnosis more difficult. To what extent the MMSE can be used as a cognitive screener in this population will be investigated in this retrospective study.Patients received standard diagnostics, a professional translator addressed the language barrier. Correspondence was scored on characteristics of dementia, a procedure was used to diagnose without including the MMSE score. The optimal cut-off was calculated with the Youden Index and Area under the ROC (AUROC).106 patients were included, 61% had no education. Average MMSE-score was 16, with dementia 12, without 19. The AUROC was 0.85, optimal cut-off was 18 with a Youden index of 0.61.By using a professional translator the MMSE can possibly be used as a cognitive screener in this population. However, the cognitive skills addressed by the MMSE require an education and language skills. Developing a test that is independent of education and language barrier will probably be better.

In Western countries, health and social welfare facilities are not easily accessible for elderly immigrants and their needs are sub optimally addressed. A transition is needed towards culturally sensitive services to make cure and care accessible for elderly immigrants. We developed an intervention programme in which ethnic community health workers (CHWs) act as liaisons between immigrant elderly and local health care and social welfare services.In a quasi experimental design, the effectiveness of introduction of CHWs, will be evaluated in three (semi) urban residential areas in the Netherlands within three different migrant groups and compared with a control group. The primary outcome is use of health care and social welfare facilities by the elderly. Secondary outcomes are quality of life and functional impairments. Implementation of the intervention programme will be examined with focus groups and data registration of CHW activities. In this paper design and methodological issues are discussed.This study can contribute to the improvement of care for elderly immigrants by developing culturally sensitive care whereby the elderly immigrants themselves actively participate. To enable a successful transition, proper identification and recruitment of CHWs is required. Once proven effective, the CHW function can be further integrated into the existing local health care and welfare system.

In the next decade the number of non-western elderly immigrants will double in the Netherlands. Because of specific risk factors (hypertension, diabetes), the number of elderly immigrants with dementia will probably increase. Memory clinics are not well prepared for these patients, because health professionals lack knowledge about important obstacles in intercultural dementia diagnostics. They should consider language barriers, cultural differences, low level of education and illiteracy, as well as ignorance about dementia, shame and special care expectations of patients and their families. We give recommendations to improve communication, (neuropsychological) testing and counseling in clinical practice.

Patients with severe mental illness (SMI) generally receive long-term treatment. Interrupting treatment or leaving treatment early can lead to problems with the interpretation of routine outcome monitoring (ROM) data.To describe the link between early drop-out and treatment duration on the one hand, and patient characteristics and scores on a ROM outcome measure, namely the Camberwell Assessment of Need Short Appraisal Schedule (CANSAS), on the other hand.Annual CANSAS assessments of patients in assertive community treatment (ACT).2946 CANSAS assessments were performed on 1041 patients who had been treated by an ACT team for an average of 1.4 years since their first ROM assessment. Patients who remained under treatment by an ACT team were more frequently male, born outside the Netherlands and had a psychotic or addiction disorder more frequently than patients who had left the ACT team treatment early. Patients who remained in ACT had, both at the start of treatment and at their last assessment, more unfulfilled needs than patients who had been treated for a shorter period.For the correct interpretation of ROM data for patients with SMI, one needs to have information about patient characteristics and the treatment duration.

The attitudes of medical students to psychiatry are important for the future care of patients with psychiatric (co)morbidity. Up till now the attitude of medical students to psychiatry has not been investigated in the Netherlands and the Dutch-speaking part of Belgium.To measure the attitude of third year medical students towards psychiatry by means of the ATP-30. This is a validated instrument, used internationally. To determine the extent to which medical students' attitudes were influenced by the psychiatry curriculum and by some sociodemographic determinants and which aspects of a career – according to earlier Dutch research – made students decide to opt for a particular specialism.Our research was of the prospective cohort type; without controls. The design was a pre- and post design.Attitudes to psychiatry were generally positive (n = 262, ATP score: 106.1, sd 10.9, ATP score ≤ 90 was regarded as negative) and improved after students received instruction in psychiatry. Men were less positive than women. Students who previously had positive experiences with the psychiatric services had higher scores. Foreign students, mainly from non-Western countries, had lower scores. After these foreign students had completed their studies in the Netherlands, there was no longer any significant difference between the scores of the two groups.Attitudes to psychiatry are positive within our cohort. Tuition has a positive effect on students' attitudes. The less positive score of the foreign students at the start of their course is probably due to the fact that they were not familiar with psychiatry and psychiatric services.

Patients of non-Western origin quite often fail to complete their course of treatment. The reasons are generally unclear. aim To suggest ways of tackling the problems in transcultural psychiatric practice.A theoretical model is presented, derived from clinical practice. The model provides insight into essentials of transcultural psychiatry. The model is based on the following: two interpretations of the concept of culture, an elaboration of the university-relativity dichotomy and a subdivision of the clinician’s work into three sections. These sections are: building a trusting relationship, making a diagnosis and carrying out treatment suited to the patient’s needs.The psychiatrist’s attitude to his patient varies according to the phase of treatment, sometimes it is more relativistic, at other times it is more universalistic.The compliance of non-Western patients will probably increase when the clinician adopts a more relativistic approach during the phase of building a relationship with the patient and probably also during some parts of the treatment phase so that he can come closer to meeting the patient’s expectations.

Dutch society comprises a growing percentage of non-Western ethnic minority groups. Little is known about pet ownership among these groups. This study explores some aspects of pet ownership, and the position of veterinarians, among the four largest non-Western ethnic minority groups in the Netherlands. Information was gathered through street interviews with people from a Moroccan, Turkish, Surinamese, or Antillean (including Aruban) background. Five hundred people where interviewed, including 41 pet owners. Results showed that people from non-Western ethnic minorities kept pets less often than Dutch people, with fish and birds being the most frequently kept pets. The number of visits to the veterinary clinic was comparable to that of Dutch pet owners; however, reasons given for the last visit were different. People from non-Western ethnic minorities mostly visited a veterinarian if their pet was ill whereas Dutch people visited the veterinarian if their pet needed to be vaccinated. People from non-Western ethnic minorities were positive about veterinarians, considering that they had sufficient knowledge about and concern for their pets. Moreover, veterinarians were trusted and provided understandable information--the respondents felt that they could go to their veterinarian with any question or problem regarding their pets. Although most respondents considered a visit to the veterinarian expensive, they were more than willing to invest in their pet's health.

To describe differences in the risk of drowning of young children (under 10 years) in the Netherlands according to ethnicity and relevant trends since 996.Retrospective.We analysed the causes of death data for all 266 children aged 0 to 10 years who died of drowning between 1996 and 2005. Information for the cause of death was obtained from the cause of death data of Statistics Netherlands. Data about the size and composition of the population at risk (age, sex and ethnicity) were obtained from the municipal population registers.Young children's risk of drowning has decreased by about one-third since 1996. This decrease took place among native Dutch children and children of the major ethnic groups, notably Turkish, Moroccan and Surinamese. However for children of recently immigrated parents of non-Western ethnicity, mainly asylum seekers, the risk of drowning was 4 to 8 times higher than that of native children aged 3 to 10 years.Timely health education directed at newly arrived families with children could be an important measure to help them cope with the hazards of living in a water-rich environment such as the Netherlands. The education should point out the necessity of increased supervision of the youngest children and improved swimming skills for the slightly older ones.