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Callous-unemotional (CU) traits predict behavioral problems in adolescence. But little is known about early modulatory factors. Behavioral Inhibition (BI) in particular has been suggested to protect against the development of CU-traits. This temperamental predisposition is characterized by heightened environmental sensitivity. The current prospective longitudinal study examined whether BI at 15 months of age predicted lower CU-traits across development to age 21. A longitudinal sample of normatively developing children (n = 125) was used. BI was assessed at 15 months using a standard stranger/robot paradigm. CU-traits were assessed at 2, 5, 9, 12, 14, 17, and 21 years with parent, teacher, and self-reports. Developmental pathways across all available data points were examined using Bayesian mixed models and k-means cluster analysis. Infant BI predicted lower CU-traits across development for girls, suggesting that BI buffers the long-term development of CU-traits for girls. CU-traits peaked in early adulthood. Boys scored higher and showed higher increases in CU-traits than girls from childhood onward. There was no gender difference regarding infant BI. Together, the findings demonstrated gender differences in the development of CU-traits, with a protective role of BI for girls. These results shed new light on the developmental trajectories and protective factors of CU-traits and provide starting points for interventions aiming at increasing children's responsiveness to external cues to prevent antisocial traits and conduct problems.

This study aimed to shed light on the prevalence of chronic peer victimisation among Dutch elementary school children and factors associated with (non-)disclosure of such experiences by victims. 5,961 students from 73 schools participated (51.5% male; M[subscript age] = 9.96; 77.7% native Dutch). Results showed that 12.3% of all children were victimised chronically, of which 29.4% did not disclose. Multilevel logistic regressions indicated that girls, older and native Dutch children were more likely to disclose. Moreover, experiencing depressive symptoms prompts disclosing victimisation. Anxiety, high emotion regulation skills, and perceptions of cohesion in the classroom were negatively associated with disclosure. The disclosure was not related to frequency or duration of victimisation, self-perceived social acceptance, self-worth, impulse control, or perceived classroom climate. Our study reveals information on the prevalence of peer victimisation and its disclosure, based on a nationwide study conducted in 2016-2017. It gives important insights into factors associated with disclosing victimisation experiences.

The goal of this study was to advance the conceptualization and measurement of adolescent popularity by exploring the commonly used composite score (popularity minus unpopularity). We used standardized peer nominations from 4,414 early adolescents (ages [approximately equal to] 12-14 years) from three samples collected in two countries. Popularity and unpopularity were strongly related, but not linearly; scatterplots of the two variables resembled an L-shaped right angle. Subsequent analyses indicated that either including popularity as a curvilinear term or including both popularity and unpopularity as separate terms explained significantly more variance in social and behavioral correlates than linear, bivariate analyses using popularity, unpopularity, or composite popularity. These results suggest that researchers studying adolescent popularity should either separate popularity and unpopularity or treat composite popularity as curvilinear.

Current theories of loneliness posit that biases in social information processing play a key role in the development and maintenance of loneliness. However, this assumption has rarely been tested in longitudinal research in adolescence. The current study concentrated on two constructs associated with such biases, that is, fear of negative evaluation and self-esteem. More specifically, we examined whether changes in loneliness were associated with simultaneous changes in fear of negative evaluation and self-esteem. A sample of Dutch adolescents (N = 1,174; 50% female) in Grades 7 to 10 completed well-established measures of loneliness, fear of negative evaluation, and self-esteem on four measurement occasions with yearly intervals. Correlations among both initial levels and rates of change for these three variables were examined using a Parallel Process Model (PPM). Adolescents scoring high on loneliness scored high on fear of negative evaluation, but low on self-esteem. Changes in loneliness were accompanied by changes in the same direction for fear of negative evaluation and in the opposite direction for self-esteem. These findings indicate that fear of negative evaluation and low self-esteem could indeed play a role in the development and maintenance of loneliness. Future research will need to clarify how exactly these variables can hamper re-affiliation efforts and lead to sustained loneliness over time.

This study explored the content and nature of teachers' knowledge and perceptions of their students. The knowledge and perceptions of seven Dutch secondary school teachers regarding the same 33 students in one second-year school class were studied. Each teacher was invited to tell (in 60 s per student) how he/she perceived and what he/she knew about, each individual student. Interview data were analysed using both qualitative and quantitative methods. Results showed within- and between-teacher differences in the content, amount and evaluative nature of their knowledge and perceptions. In addition, there were within- and between-student differences in how their teachers knew and perceived them. The results suggest that teachers' knowledge and perceptions of their students varies per teacher-student combination and substantiate an interpersonal nature of teachers' knowledge and perceptions. To understand the function of teachers' knowledge and perceptions of students for teaching, future research should focus on how different knowledge and perceptions lead to differential educational trajectories for individual or specific groups of students.

This study investigated how teachers' self-efficacy for intervening in social dynamics and teacher-student relationships directly impact students' self-esteem, and indirectly buffer the negative association between both bullying and victimization and students' self-esteem. Teachers play a key role in shaping the peer relations in the classroom, and they might also be able to lessen the negative impact of bullying and victimization on students' self-esteem. Multilevel regression analysis on a sample of 59 Dutch teachers and 1,490 of their 5th grade students indicated that student-reported bullying and victimization were negatively related to students' self-reported self-esteem. Better student-perceived student-teacher relationships were related to higher self-esteem for all students, with additional increases in self-esteem for victims but decreases in the self-esteem of bullies. Teacher-reported self-efficacy was only related to lower self-esteem in bullies. Implications of these results and suggestions for further research are discussed.

This study examined associations between perceived popularity trajectories and changes in proactive and reactive aggression in middle adolescence. The sample included 1,374 adolescents from 5 cohorts who were followed from Grade 7 to Grade 9 (49% males, M[subscript age] = 12.67 years, SD = 0.67). Popularity trajectories were identified based on initial status and changes in status over time, and linear mixed effects models tested group differences in changes of aggression. The results partially confirmed our expectation that changes in popularity were associated with specific developmental patterns of proactive and reactive aggression and also varied as a function of status already achieved. Specifically, adolescents in groups characterized by gains in status increased in proactive aggression, and those in groups characterized by losses in status decreased in proactive aggression. A more nuanced pattern of group differences emerged for reactive aggression. Changes in reactive aggression were only found for groups characterized by changes in unpopular status. Taken together, these findings suggest that proactive aggression has universal benefits for popularity in middle adolescence, whereas reactive aggression has differential costs. Implications and directions for future research are discussed.

In peer nomination research, individuals who do not provide nominations (nonparticipants) are often included on rosters as potential nominees. This can present ethical questions regarding informed consent, but psychometric consequences of excluding nonparticipants from rosters are unknown. In this investigation, Study 1 simulated both random and systematic missingness with a sample of 1,630 Dutch adolescents, comparing the reliability and correlation matrices of nomination measures when nonparticipants were included and excluded as nominees. Study 2 began with a two-school sample that already included systematic nonparticipation (˜19% missingness among 599 7th grade nominees) and examined how findings would differ if students who had not provided nominations were excluded as nominees. Results showed that the impact of including versus excluding nonparticipants as nominees may vary depending on the type of missingness (Study 1) or in different peer groups (Study 2). Both studies demonstrated that the choice of including versus excluding nonparticipants can affect reliability and intercorrelations in peer nomination data, and provide some evidence that excluding nonparticipants as nominees may compromise peer nomination data quality.

The goal of this study was to examine differences in university success between first-year students by analyzing three domains simultaneously: students' academic achievement, critical thinking disposition, and social-emotional adjustment to university life. Participants were 307 students who completed an online questionnaire. Latent class cluster analysis revealed three patterns of success: (1) average-achieving well-adjusted students (64%), (2) high-achieving average-adjusted students (14%), and (3) low-achieving low-adjusted students (22%). Follow-up ANCOVAs indicated that low-achieving low-adjusted students most strongly experienced that their social life hindered their study, whereas average-achieving high-adjusted students experienced the least interference from their study on their social life. These results indicated that student success is a multi-domain concept, with subgroups of first-year students showing specific patterns of success. The results of this study help to understand the feasibility of and tensions between domains of student success and provide suggestions for universities to adjust their support to specific student needs.

Background: We developed an implementation strategy for the insurance medicine guidelines for depression, which we implemented via a post-graduate course for insurance physicians (IPs). In this study we evaluate the physicians' experiences of the implementation strategy by measuring the following aspects: recruitment and reach, dose delivered and dose received, satisfaction and expectations, and perceived barriers. Methods: Insurance physicians conducting client disability assessments for the Dutch Institute for Employee Benefits Schemes were invited to attend a post-graduate course in implementation of the guidelines for depression in which a controlled experiment was embedded. Data were collected from the participating insurance physicians using questionnaires applied directly after the intervention and at three-month follow-up. Results: Of the 797 insurance physicians invited, 42 participated. Reach was 4.7%. The response to the questionnaires was 100%. The participants appraised the implementation strategy with a total score of 7.7 out of 10, and 81% expected to see improvement in their assessments of clients with depression. Physicians were still satisfied with the implementation strategy after three months. Changes in work routines and the time needed to apply the guidelines were perceived as barriers to use of the implementation strategy. Conclusions: The reach of the newly developed implementation strategy for the guidelines for depression was poor: only 42 IPs out of 900 invited actually attended the post-graduate course. However, the results show that the implementation strategy worked well in a controlled setting for all participants. They were satisfied with the course and with the tools provided, both immediately after the training program and after three months.

Missing data are a persistent problem in psychological research. Peer nomination data present a unique missing data problem, because a nominator's nonparticipation results in missing data for other individuals in the study. This study examined the range of effects of systematic nonparticipation on the correlations between peer nomination data when nominators with various levels of popularity and social preference are missing. Results showed that, compared to completely random nominator missingness, systematic missingness of raters based on popularity had a significant impact on the correlations between various peer nomination variables. Systematic missingness based on social preference had a smaller impact. These results demonstrate varying (and potentially large) effects of systematically missing nominators on studies using nomination data. It is important that researchers using peer nomination data explore whether nominators are missing in any sort of systematic way and include these results as part of each study. Future research into the nature of systematic nominator missingness could make it possible to use advanced methodologies, such as multiple imputation, in an attempt to minimize the issues associated with systematic missingness.

This study addressed the moderating role of classroom descriptive norms for overt and relational aggression, social withdrawal, prosocial behavior, and academic reputation in the association of behavior with social preference and popularity in early adolescence. Participants were 1,492 fifth-grade students ([x-bar][subscript age] = 10.6 years, 52.7% boys) from 59 classrooms who completed unlimited peer nominations for status and behavior. Classroom descriptive norms were computed as the average proportion of classroom nominations received for the different social behaviors. Multilevel analyses revealed that the negative association between overt aggression and social preference was attenuated in classrooms with high norms for overt aggression. The negative association between academic reputation and social preference was enhanced in classrooms with high norms for academic reputation. Classroom norms did not moderate the associations between behavior and popularity. The type of behavior and the type of status should be considered when examining classroom descriptive norms and behavior-status associations.

As a part of classroom management, teachers face the question of how and where to seat their students. However, it is far from clear what considerations teachers have when making seating arrangements. Therefore, in this study seating arrangement considerations from 50 teachers in grades 4-6 of elementary school were assessed. In Phase 1, teachers were interviewed about their goals and considerations for classroom seating arrangements. Teachers mentioned between 2 and 19 reasons for placing students at specific places in the classroom, with mostly academic considerations. They mainly preferred arrangements in small groups to promote student cooperation. In Phase 2, teachers completed a questionnaire about seating arrangements. This allowed us to examine individual differences between teachers related to gender, years of experience, and beliefs, and the concurrence between the interview and questionnaire data. Teachers reported multiple and various considerations for seating arrangements. Correlations with their general student-oriented or subject-oriented beliefs and personal characteristics were low. The concurrence between measurement methods also was low. The discussion focused on teacher awareness of classroom seating arrangements as an important part of classroom management and a tool for prevention and intervention.

Many child and youth protection organizations are changing from being bureaucratic to becoming more learning-oriented. In the course of this radical change, many tensions and challenges are experienced. This article addresses the challenges and strategies in normalizing a radical new way of working in a child and youth protection organization in Amsterdam. It focuses specifically on the work of team leaders (middle management) in reflexive team meetings. A qualitative approach was used to understand middle-management strategies employed in team meetings to support the process of normalizing a new method called Intensive Family Case Management (IFCM). Normalization Process Theory (NPT) was used to guide the study. By using the action learning and action research approach, using peer-leader video-reflection during team meetings in a child and youth protection organization in Amsterdam, the processes leading toward normalization were observed and analyzed in depth. Peer team leaders reviewed the videos in focus group discussions (FGDs) to help interpret the data. The results show the various ways in which reflexive team meetings support the normalization process—sense-making, appraisal and engagement—and shed light on the tensions experienced by team leaders, such as shared responsibility versus dominance/control and efficiency versus learning. Some of these tensions concern defaulting to old ways of working, while others reflect the complex nature of change processes in a dynamic system. Ultimately, this study shows the importance of leaders being aware of tensions within teams in a change process and employing a "both/and" strategy to deal with these tensions. [ABSTRACT FROM AUTHOR]

The goal of this study was to examine behavioral norm effects in 2 peer contexts (classroom, school) on adolescent substance use (tobacco, alcohol, cannabis) and aggressive behaviors (bullying, physical fighting). Participants were 5,642 adolescents (M[subscript age] = 14.29 years, SD = 1.26; 49% boys). There were 3 hypotheses. First, behavioral norms in both contexts affect individual behavior. Second, classroom norms have stronger effects on individual behavior than school norms. Third, classroom and school norms interact and exacerbate each other's influence. Results indicated that classroom norms had stronger effects than school norms on individual tobacco and alcohol use. Furthermore, school norms had equal or stronger effects than classroom norms on the 2 indicators of aggressive behaviors. There was no evidence for an interaction between classroom and school norms for any dependent variable. This study demonstrates that the complexity of multiple (nested) peer contexts should be considered to fully understand peer influence processes.

This study examined adolescent personality and problem behaviours as predictors of two types of social status: social preference and popularity. Academic track (college preparatory and vocational) and gender were expected to moderate these associations. The sample included 693 students (49.0% female; M = 15.46 years) attending classrooms in two academic tracks (vocational and college preparatory). Participants completed self-report measures of personality and problem behaviours and peer-reports of preference and popularity. Results of structural path analyses indicated that academic track and gender moderated several associations. Specifically, externalising problems were associated with more popularity for males and less preference for females in college preparatory classrooms. Internalising problems were associated with popularity and preference for adolescents in vocational classrooms. The findings illustrate the complexities associated with predicting the social status of male and female adolescents attending different academic tracks. The salience of status norms and implications for intervention programmes are discussed.

Although the ability to forgive offending peers may be crucial for maintaining long-term friendships in childhood, little is actually known about forgiveness among peers in childhood. In the present research, we examined whether forgiveness among children is related to enhanced psychological well-being. Importantly, we hypothesized that this association should be most pronounced when friendship is strong rather than weak. In a sample of 275 nine- to 13-year-olds who completed self-reported and behavioral measures of forgiveness and various indicators of psychological well-being, the present study revealed that forgiveness among peers was indeed associated with enhanced psychological well-being. In line with predictions, the association with psychological well-being was stronger when it concerned forgiveness toward friends rather than forgiveness toward nonfriends. Implications for the extant literature on forgiveness among children, and interpersonal relationships more broadly, are discussed.

The purpose of this study was to identify and validate subtypes of peer status by integrating preference and popularity into a single framework. Person-oriented analyses were performed among 3,630 children and adolescents of different cohorts in primary and secondary education. In the young age groups (Grade 3/4 to Grade 7), three clusters were found: popular-liked, average, and unpopular-disliked. In the older age group (Grade 8), four clusters were found: popular, liked, average, and unpopular-disliked. Thus, participants differentiated liked peers from popular peers at the age of 14, but not earlier. Distinct behavioral profiles were found for each subtype. Cohort-sequential analyses demonstrated high stability of cluster membership, especially among the high-status groups. Developmental implications and the importance of school transitions are discussed.

In preschool classes, sociometric peer ratings are used to measure children's peer relationships. The current study examined a computerized version of preschool sociometric ratings. The psychometric properties were compared of computerized sociometric ratings and traditional peer ratings for preschoolers. The distributions, inter-item correlations, and reliabilities of sociometric scores were comparable between the computerized assessment and traditional assessment. The computerized assessment provided additional data for further analysis of the peer evaluation process. Therefore, computerized peer ratings are a promising tool for sociometric measurement with preschool children.

During social interaction, the behavior of interacting partners becomes coordinated. Although interpersonal coordination is well-studied in adults, relatively little is known about its development. In this project we explored how 2-, 3-, and 4-year-old children spontaneously coordinated their drumming with a peer. Results showed that all children adapted their drumming to their partner's drumming by starting and stopping their drumming in a coordinated fashion, but only 4-year-olds adapted the rhythmic structure of their drumming to their partner's drumming. In all age groups, children showed similarly stable drumming. Typically, it was 1 of the 2 children who initiated drumming throughout the session. The results of this study offer new insights into the development of interpersonal coordination abilities in early childhood.

Children's peer relationships are frequently assessed with peer nominations. An important methodological issue is whether to collect unlimited or limited nominations. Some researchers have argued that the psychometric differences between both methods are negligible, while others have claimed that one is superior over the other. The current study compared both methods directly in a counterbalanced design among 112 8-12-year-old elementary school children. Overall, both methods revealed comparable results, although some significant and noteworthy differences were found. The use of unlimited nominations was recommended for questions related to social status (preference, popularity). Some method differences varied by gender. Implications for future peer relations research were discussed.

Despite its importance in social development, social understanding has hardly been studied in high-ability children. This study explores differences in social understanding between children in high-ability and regular classrooms, specifically theory of mind (ToM) and perception accuracy, as well as associations between individual characteristics (age, gender, peer acceptance, and cognitive ability) and social understanding. Participants were 671 children in Grades 1 to 6 (55% boys; M age 9.20 years). Children in high-ability classrooms had higher ToM scores in Grades 1 to 3 and were more accurate perceivers of acceptance than children in regular classrooms. No group differences were found for ToM in Grades 4 to 6. ToM was associated with several individual characteristics, in particular age and cognitive ability. Perception accuracy was mainly related to peer acceptance. Suggestions for future research and implications for practitioners are discussed.

This study examined the peer relationships and social behaviors of deaf adolescents in the first 2 years of secondary school. Peer nominations and ratings of peer status and behavior were collected longitudinally with 74 deaf and 271 hearing adolescents from Grade 7 to Grade 8. The predictions of deaf adolescents' peer status in Grade 8 from Grade 7 behaviors differed between mainstream education and special education settings. The behaviors of deaf early adolescents in the beginning of secondary school strongly predicted their peer status a year later. For deaf mainstream students, withdrawn behavior was the most important and negative predictor of peer status. For deaf students in special education settings, prosocial behavior was the most important and positive predictor of peer status.

This study examined the behavioral, personality, and communicative predictors of acceptance and popularity in 608 early adolescents. Data were collected with sociometric methods and ratings in 30 sixth-grade classrooms. Hierarchical regressions were run to predict acceptance and popularity from prosocial, antisocial, and withdrawn behavior, agreeableness and extraversion, and pragmatic communicative skills. Low levels of antisocial behavior positively predicted peer acceptance. Popularity depended on a more complex profile of predictors. Prosocial and antisocial behavior contributed positively to popularity, whereas withdrawn behavior contributed negatively. Extraversion and pragmatic skills also played a role in the prediction of popularity. Extraversion moderated the associations of prosocial and antisocial behavior with popularity. Popularity was highest when high levels of prosocial or antisocial behavior were combined with high levels of extraversion. Pragmatic skills moderated the association of prosocial behavior with popularity. Popularity was highest when prosocial behavior and pragmatic skills were high.

In 2009, one of the major Dutch addiction care organizations initiated a pilot program to explore the possibility of using an existing Cognitive Behavioral Therapy and Motivational Interviewing based treatment program ("Lifestyle Training") to treat internet addiction. The current study evaluates this pilot treatment program by providing a qualitative analysis of the experiences of the therapists with the treatment of 12 self-proclaimed internet addicts. Therapists report that the program, which is ordinarily used for substance dependence and pathological gambling, fits the problem of internet addiction quite well. Interventions mainly focused on controlling and reducing internet use, and involved expanding (real life) social contacts, regaining a proper daily structure, constructive use of free time, and reframing beliefs. Therapists further indicated that the treatment achieved some measure of progress for all of the 12 treated patients, while patients reported satisfaction with the treatment and actual behavioral improvements.

This study examined the associations of popularity, substance use, athletic abilities, physical attractiveness, and physical and relational aggression with likeability by same-gender and cross-gender peers among early adolescents (N = 3,312; M age = 13.60, with 92.7% of the participants in the 12-14 age range). Data collection consisted of peer nominations in 172 classrooms of 34 secondary schools. Taking a goal-framing perspective, it was argued that key to understanding the association between popularity and likeability is the distinction between features that help to "achieve" popularity and features that help to "maintain" popularity. In support of our hypotheses, popularity and substance use, athletic abilities, and physical attractiveness (characteristics that help to become popular) contributed significantly to likeability, whereas physical and relational aggression (characteristics that help to maintain popularity) negatively predicted likeability. These specific nature of these effects depended on the reference group (same-gender vs. other-gender peers) and were further moderated by popularity. (Contains 5 tables.)

This study examined how children's aggression and prosocial behavior are related to the preference and popularity of their best friends. Participants were 1,953 fourth-graders (52.2% boys). Measures included peer nominations of friendship, peer status, overt and relational aggression, and prosocial behavior. A total of 334 reciprocal same-sex best friend dyads were identified. The Actor-Partner Interdependence Model (Kashy & Kenny, 1999) showed that best friends' peer status significantly predicted children's behavior. For boys, best friends' preference was negatively associated with overt aggression, while best friends' popularity was positively associated with overt aggression. For girls, best friends' popularity was positively related to both relational aggression and prosocial behavior. The model also revealed high similarity between friends in both preference and popularity. This study highlighted the distinction between two dimensions of peer status in the study of friendship and peer influence in middle childhood. It also demonstrated how individual, dyad, and group characteristics can be integrated in the study of children's social relationships. (Contains 2 tables and 1 figure.)

This study examined the role of peer acceptance and perceived popularity in bullying and victimization in early adolescent peer groups. Peer acceptance is the degree to which adolescents are well liked by their peers; perceived popularity indicates visibility, dominance, and prestige. It was hypothesized that acceptance negatively predicts bullying, whereas popularity positively predicts bullying, and that both acceptance and popularity negatively predict victimization. Interactions between acceptance and popularity were tested as well. Participants were 1,207 13- to 14-year-old adolescents who completed sociometric assessments in their classrooms. Both bullying and victimization were predicted by the interaction between acceptance and perceived popularity. Bullying was positively associated with popularity, and this association was stronger for adolescents with lower levels of acceptance. Victimization was negatively associated with popularity, and this association was also stronger for adolescents with lower levels of acceptance. Linear and curvilinear main effects and interactions were found; some were further moderated by gender. The discussion focused on the role of individual status and group dynamic factors in the occurrence of aggression among early adolescents. (Contains 4 tables and 5 figures.)

This study examined whether 19-month-old-infants' social understanding was related to their interaction behavior during dyadic cooperation with a peer. Toddlers' ability to predict others' action intentions was examined using a computerized experimental task. The children watched a series of stimulus movies in which an actor expressed her liking or disliking towards two different objects and then announced that she was going to grasp one of them. Toddlers' eye movements were registered, and it was examined whether they showed anticipatory looks to the object the model was going to grasp. During the dyadic cooperation task the toddlers interacted with an unfamiliar peer. Toddlers' interaction performance during cooperation was observed, and affiliative and antagonistic behaviors were coded. Intention understanding was positively correlated with affiliative behaviors, and negatively with antagonistic behaviors during the cooperation task. Measures of cooperation success were not related to toddlers' intention understanding. Toddlers' capability to understand others' intentions was thus closely associated with their peer interaction behavior, but now with their task performance.

The present study was designed to examine early adolescents' stereotypical descriptions of two types of youth who are seen as popular by their peers. Participants were 13- to 14-year-old early adolescents (N = 287). The results indicated that early adolescents distinguished two types of popular peers: a "populistic" (popular but not necessarily well liked) type and a "prosocial-popular" (popular and well liked and accepted) type. These two types differed in terms of academic and interpersonal behaviors. Populistic adolescents were seen as relationally aggressive, stuck up, vulgar, bullies, and academically disengaged. They were also seen as leaders, influential, and arrogant more than were prosocial-popular adolescents. Adolescents in the latter group were seen as affiliative, helpful, and academically engaged. Both types of popular youth were seen as attractive and fashionable. The implications of these findings for future research on high status in the adolescent peer group are discussed. (Contains 2 tables and 2 figures.)

Awareness that high-status adolescents can be targets of aggression has grown in recent years. However, questions remain about the associations of the confluence of victimization and popularity with adjustment. The current study fills this gap by examining the joint and unique effects of victimization and popularity on aggression and alcohol use. Participants were 804 Dutch adolescents (50.2% boys, Mage = 13.65) who were followed for one year. High-status victims were more aggressive and drank more alcohol than lower-status victims. High-status victims were also more proactively and indirectly aggressive and self-reported more bullying than high-status non-victims. Thus, the findings demonstrated a conjoined risk of victimization and popularity for some types of aggression. [ABSTRACT FROM AUTHOR]

Background : Severe hand injuries due to firecrackers are unfortunately common in the Netherlands. These injuries are expected to have long-term functional and psychological sequalae. We performed a study to assess the long-term impact of such injuries on the victims and their parents. Methods: Eight sequential adolescent patients that underwent surgery for firecracker-induced severe hand injuries between September 2012 and March 2015 were included. The patient files were assessed for data on hand function. The impact of the injuries was measured by questionnaires and measure instruments: VAS for pain, CHEQ2.0 and COPM-DLV for activities and participation, PedsQL-4.0 for participation and quality of life, RSES for self-esteem, and DT-P for impact on parents. Results: Seven of the eight patients underwent (partial) hand amputation. Three adolescents still reported pain at a mean of 3.2 years post-trauma. All adolescents required more time than peers performing activities. Seven showed a total of 34 activity and participation problems. One adolescent showed no problems at all. The adolescents showed a mean score of 81 on the PedsQL-4.0, which was not different to healthy adolescents. None had problematic low self-esteem. Six out of eight parents had elevated distress; three parents stated that they still needed psychological support. Conclusions: Severe hand trauma due to firecrackers has an evident impact on hand function and activities in all adolescents. The injuries have a significant long-lasting psychological impact on the parents. Prolonged psychological help is recommended for the adolescents as well as their parents with a more family-centered approach. Level of evidence: Level IV, therapeutic study. [ABSTRACT FROM AUTHOR]

The German and Allied bombing of Rotterdam in the Second World War caused thousands of dead and hundreds of missing, and severely damaged the Dutch port city. The joint destruction of people and their built environment made the ruins and rubble stand metonymically for the dead when they could not be mentioned in the censored press. The contiguity of ruins, rubble, corpses and human remains was not only semantic but also material because of the intermingling and even amalgamation of organic and inorganic remains into anthropomineral debris. The hybrid matter was dumped in rivers and canals to create broad avenues and a modern city centre. This article argues that Rotterdam's semantic and material metonyms of destruction were generated by the contiguity, entanglement, and post-mortem and post-ruination agencies of the dead and the destroyed city centre. This analysis provides insight into the interaction and co-constitution of human and material remains in war. [ABSTRACT FROM AUTHOR]

Whole blood point-of-care PT/INR test devices, e.g. CoaguChek XS, are calibrated by their manufacturers. In the Netherlands, each new lot of test strips for CoaguChek XS is validated by a group of anticoagulant clinics collaborating with a Coagulation Reference Laboratory. In 2017, a new International Standard for recombinant human thromboplastin (coded rTF/16) has been established by the World Health Organization. To assess uncertainty of the validation procedure and the magnitude of the INR bias of a series of consecutive lots of test strips imported in the Netherlands. CoaguChek XS test strip INR results were compared to INRs determined with the new International Standard rTF/16. Comparisons were made with variable numbers of blood samples obtained from patients treated with vitamin K-antagonists. Relationships between CoaguChek XS and rTF/16 results were determined with orthogonal regression analysis. The relationships were used to assess bias and uncertainty of bias. Average bias between CoaguChek XS test results and rTF/16 depends on the INR level. Overall, there was a trend of increasing bias and increasing uncertainty with increasing INR values. Along the sequence of 47 consecutive lots, a temporary fluctuation of bias was observed. At an INR level of 3.0 the average bias was less than 10% in all cases, but at an INR of 4.0 there were 5 lots with average bias between 10 and 15%. Validation of test strips is useful to assess bias but depends on availability of fresh patients' samples and traceability to an accepted Reference Measurement System. • INR bias in CoaguChek XS was assessed versus new International Standard rTF/16. • Mean INR bias in CoaguChek XS test strips was assessed by orthogonal regression. • A method is described to assess the uncertainty of the mean INR bias. • In 5 out of 47 test strip lots, the mean INR bias was 10–15% at INR of 4.0. • In all 47 test strip lots, the mean bias was <10% in the range 2.0–3.0 INR. [ABSTRACT FROM AUTHOR]

Background: Severe maternal iodine deficiency during pregnancy leads to marked intellectual disability in the offspring. Although recent studies showed that even mild-to-moderate maternal iodine deficiency is associated with lower intelligence quotient and attention deficit hyperactivity disorder in offspring, the underlying neurobiological mechanism of these associations remains unknown. The aim of this study was to investigate the association of maternal iodine excretion during pregnancy with offspring brain morphology during pre-adolescence. Methods: This study was embedded within Generation R, a prospective population-based birth cohort in Rotterdam, the Netherlands. We included 990 mother–child pairs with data on urinary iodine concentration (UIC) and creatinine during pregnancy. The UIC was assessed at <18 and/or 18–25 weeks of gestation and offspring brain imaging data were acquired with magnetic resonance imaging (MRI) at age 10 years. We used linear regression to study the association of the iodine-to-creatinine ratio (UI/Creat) with offspring brain MRI outcomes. Results: Maternal UI/Creat during pregnancy was not consistently associated with offspring brain morphology. A low UI/Creat (<150 μg/g) during pregnancy was nominally associated with smaller total gray matter volume, but this did not survive correction for multiple testing. Also, we could not identify a linear association between continuous iodine excretion and offspring brain morphology. Instead, our results suggest a curvilinear association between UI/Creat and brain morphology. In sensitivity analyses using the World Health Organization categorization for UIC values, both low and high UI/Creat were associated with smaller total gray matter volume. Conclusions: The current study provides some but no conclusive evidence for an association of maternal iodine excretion during pregnancy with offspring brain morphology. Our results suggest that the exact definition of the reference group is important because of potential non-linear associations, which could be leveraged in future studies. [ABSTRACT FROM AUTHOR]

Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency (21OHD) is a disorder of adrenal steroid biosynthesis, leading to hypocortisolism, hypoaldosteronism, and hyperandrogenism. Impaired quality of life (QoL) has been demonstrated in women with CAH, but data on men with CAH are scarce. We hypothesized that disease severity and poor treatment control are inversely associated with QoL. In this study, 109 men (16-68 years) with 21OHD were included. The WHOQOL-BREF questionnaire was used to measure self-reported QoL domain scores on a 0-100 scale, where higher scores reflect better QoL. QoL domain scores were compared to published data on healthy and chronically ill reference populations from France, Germany, the Netherlands, and the United Kingdom. Differences in QoL scores among groups of disease severity and treatment control were tested within the study population. Overall, the men with CAH in this study appeared to rate their QoL as good. Median domain scores were 78.6 (IQR: 67.9-85.7) for physical health, 79.2 (IQR: 66.7-87.5) for psychological health, 75.0 (IQR: 58.3-83.3) for social relationships, and 81.3 (IQR: 71.9-90.6) for environment. In general, these scores were similar to WHOQOL-BREF domain scores in healthy references and higher compared to chronically ill reference populations. The domain scores did not differ among genotype groups, but patients with undertreatment or increased 17-hydroxyprogestrone concentrations scored higher on several QoL domains (p<0.05). Patients treated with dexamethasone or prednisone scored higher on the physical health, psychological health, and social relationships domains, but not on the environmental domain. In conclusion, QoL domain scores appeared to be comparable to healthy reference populations and higher compared to patients with a chronic illness. QoL was not influenced by genotype, but undertreatment and use of dexamethasone or prednisone were associated with higher QoL. [ABSTRACT FROM AUTHOR]

Background: Central line-associated bloodstream infections (CLABSI) are a main focus of infection prevention and control initiatives in neonatal care. Standardised surveillance of neonatal CLABSI enables intra- and interfacility comparisons which can contribute to quality improvement. To date, there is no national registration system for CLABSI in neonatal care in the Netherlands and several criteria are used for local monitoring of CLABSI incidence rates. To achieve standardised CLABSI surveillance we conducted a consensus procedure with regard to nationwide neonatal CLABSI surveillance criteria (SC). Methods: A modified Delphi consensus procedure for the development of nationwide neonatal CLABSI SC was performed between January 2016 and January 2017 in the Netherlands. An expert panel was formed by members of the Working Group on Neonatal Infectious Diseases of the Section of Neonatology of the Dutch Paediatric Society. The consensus procedure consisted of three expert panel rounds. Results: The expert panel achieved consensus on Dutch neonatal CLABSI SC. Neonatal CLABSI is defined as a bloodstream infection occurring more than 72 h after birth, associated with an indwelling central venous or arterial line and laboratory confirmed by one or more blood cultures. In addition, the blood culture finding should not be related to an infection at another site and one of the following criteria can be applied: 1. a bacterial or fungal pathogen is identified from one or more blood cultures; 2. the patient has clinical symptoms of sepsis and 2A) a common commensal is identified in two separate blood cultures or 2B) a common commensal is identified by one blood culture and C-reactive protein level is above 10 mg/L in the first 36 h following blood culture collection. Conclusions: The newly developed Dutch neonatal CLABSI SC are concise, specified to the neonatal population and comply with a single blood culture policy in actual neonatal clinical practice. International agreement upon neonatal CLABSI SC is needed to identify best practices for infection prevention and control. [ABSTRACT FROM AUTHOR]

To compare the effectiveness of a biopsychosocial primary care intervention (Back on Track) with primary care physiotherapy as usual in patients with chronic low back pain (CLBP) experiencing low complex psychosocial complaints. A double-blind multicentre pilot-randomised controlled trial. Twenty-five patients (≥18 years) with non-specific CLBP (≥12 weeks) experience low psychosocial complaints and a low to moderate level of disability. The Back on Track intervention (four individual and eight group sessions) versus physiotherapy as usual (maximally 12 individual sessions). Primary outcome: functional disability (Quebec Back Pain Disability Score) at post-treatment and 3 months follow-up. Anxiety, depression, catastrophizing, pain intensity, kinesiophobia, self-efficacy, global perceived effect. Effects were analysed using linear mixed model analysis. No significant differences in functional disability were found between interventions at post-treatment (mean difference 0.10, 95% CI: −12.9 to 13.1) and 3 months follow-up (mean difference −5.4, 95% CI −19.1 to 8.3). Secondary outcomes also showed no significant differences. No differences in effects were found between patients with CLBP experiencing low complex psychosocial complaints who receive the Back on Track intervention compared to patients receiving primary care physiotherapy as usual. Well-powered studies of sufficient methodological quality are needed to detect differences in effects. [ABSTRACT FROM AUTHOR]

Adolescents play video games as a social leisure activity, yet it is unclear whether peer influences play a role in spreading violent video game exposure (VVE) and aggression. It has been suggested that adolescents' aggression increases because of their friend's exposure to violent video games. This study tests this suggestion by using longitudinal social network analyses to investigate selection and socialization of aggression owing to VVE. A total of 796 adolescents from 34 different classrooms were followed from grade 7 to grade 8 (Mage = 12.60 years, 51 percent male adolescents). Exposure to violent video games, physical aggression, and within-classroom friendships were assessed at both time points. Data were analyzed by means of stochastic actor-based modeling in RSiena to estimate the effects of VVE and aggressive behavior on changes in friendships (selection), and the effects of friendships on changes in participants' VVE and aggressive behavior (socialization). Results showed homotypic selection effects, that is, adolescents became friends with peers who were similar in aggression and similar in violent video game exposure. Furthermore, there was a homotypic socialization effect, as friends became more similar in aggression over time. Friends did not become more similar in VVE over time. Violent games played by friends did not increase adolescents' own aggressive behavior. This suggests that concerns about peer influences on violent video games are unwarranted. Future studies on socialization processes of VVE should focus on influences from closest friends and investigate behavior during actual play. [ABSTRACT FROM AUTHOR]

Rationale: Sepsis is characterized by a dysregulated immune response to infection. Norepinephrine, the cornerstone vasopressor used in septic shock, may contribute to immune dysregulation and impact host defense.Objectives: To investigate effects of norepinephrine and the alternative vasopressor vasopressin on the immune response and host defense.Methods: Leukocytes from six to nine donors were stimulated in the presence or absence of norepinephrine and vasopressin. A total of 190 C57BL/6J mice received a continuous infusion of norepinephrine or vasopressin via microosmotic pumps and were challenged with LPS or underwent cecal ligation and puncture. Thirty healthy volunteers were randomized to a 5-hour infusion of norepinephrine, vasopressin, or saline and intravenously challenged with LPS. The relationship between the norepinephrine infusion rate and the use of β-blockers and plasma cytokines was assessed in 195 patients with septic shock.Measurements and Main Results: Norepinephrine attenuated the production of proinflammatory mediators and reactive oxygen species and augmented antiinflammatory IL-10 production both in vitro and in LPS-challenged mice. Norepinephrine infusion during cecal ligation and puncture resulted in increased bacterial dissemination to the spleen, liver, and blood. In LPS-challenged volunteers, norepinephrine enhanced plasma IL-10 concentrations and attenuated the release of the proinflammatory cytokine IFN-γ-induced protein 10. Vasopressin exerted no immunomodulatory effects across these experimental setups. In patients, higher norepinephrine infusion rates were correlated with a more antiinflammatory cytokine balance, whereas β-blocker use was associated with a more proinflammatory cytokine balance.Conclusions: Norepinephrine dysregulates the immune response in mice and humans and compromises host defense. Therefore, it may significantly contribute to sepsis-induced immunoparalysis, whereas vasopressin does not have untoward immunologic effects. [ABSTRACT FROM AUTHOR]

Placement of wood in streams has become a common method to increase ecological value in river and stream restoration and is widely used in natural environments. Water managers, however, are often hesitant to introduce wood in channels that drain agricultural and urban areas because of backwater effect concerns. This study aims to better understand the dependence of wood‐induced backwater effects on cross‐sectional area reduction and on discharge variation. A newly developed, one‐dimensional stationary model demonstrates how a reduction in water level over the wood patch significantly increases directly after wood insertion. The water level drop is found to increase with discharge, up to a maximum level. If the discharge increases beyond this maximum, the water level drop reduces to a value that may represent the situation without wood. This reduction predominately depends on the obstruction ratio, calculated as the area covered by wood in the channel cross section divided by the total cross‐sectional area. The model was calibrated with data from a field study in four lowland streams in the Netherlands. The field study showed that morphologic adjustments in the stream and reorientation of the woody material reduced the water level reduction over the patches in time. The backwater effects can thus be reduced by optimizing the location where wood patches are placed and by manipulating the obstruction ratio. The model can function as a generic tool to achieve a stream design with wood that optimizes the hydrological and ecological potential of streams. [ABSTRACT FROM AUTHOR]

OBJECTIVES To examine the longitudinal association between frequency of moderate physical activity (PA) and overall, physical, psychological, and social frailty among community‐dwelling older adults older than 70 years. Second, we assessed the association between a 12‐month change in frequency of moderate PA and frailty. DESIGN Longitudinal cohort study. SETTING Community settings in Spain, Greece, Croatia, the Netherlands, and the United Kingdom. PARTICIPANTS A total of 1735 participants (61.1% female; mean age = 79.6 years; SD = 5.5 years). MEASUREMENTS The frequency of self‐reported moderate PA was measured and classified into two categories: "regular frequency" and "low frequency." The 12‐month change in frequency of moderate PA between baseline and follow‐up was classified into four categories: "continued regular frequency," "decreased frequency," "continued low frequency," and "increased frequency." The 15‐item Tilburg Frailty Indicator assessed overall, physical, psychological, and social frailty. RESULTS: Participants who undertook moderate PA with a regular frequency at baseline were less frail at 12‐month follow‐up than participants with a low frequency. Participants who undertook moderate PA with a continued regular frequency were least frail at baseline and at 12‐month follow‐up. After controlling for baseline frailty and covariates, compared with participants with a continued regular frequency, participants with a decreased frequency were significantly more overall (B = 1.31; 95% confidence interval [CI] = 0.99‐1.63), physically (B = 0.80; 95% CI = 0.58‐1.03), psychologically (B = 0.43; 95% CI = 0.30‐0.56), and socially frail (B = 0.14; 95% CI = 0.04‐0.23) at 12‐month follow‐up; participants with a continued low frequency were significantly more overall (B = 1.16; 95% CI = 0.84‐1.49), physically (B = 0.73; 95% CI = 0.51‐0.96), psychologically (B = 0.42; 95% CI = 0.29‐0.55), and socially frail (B = 0.13; 95% CI = 0.04‐0.23) at 12‐month follow‐up; the 12‐month follow‐up frailty level of participants who undertook moderate PA with an increased frequency was similar to those with a continued regular frequency. CONCLUSION: Maintaining a regular frequency of PA as well as increasing to a regular frequency of PA are associated with maintaining or improving overall, physical, psychological, and social frailty among European community‐dwelling older adults older than 70 years. J Am Geriatr Soc 68:1484‐1493, 2020. [ABSTRACT FROM AUTHOR]

In Dutch discourses euthanasia has consecutively been viewed as murder, as mercy offered by medical doctors and as a self-chosen right for older people. This seems to reflect decreasing religious authority over death. Therefore, 26 interviews with Dutch adults aged 79–100 were carried out to evaluate the relationship between religion and attitudes towards euthanasia. Qualitative analysis indicates three groups of participants. Participants in the refraining group, wishing not to let the moment of their death be determined by euthanasia, predominantly believed both in God and an afterlife, and had most preference for a religious funeral. Participants in the depending group, wishing to ground euthanasia decisions in medical criteria, were least religious, which illustrates the co-occurrence of medicalisation and secularisation of death. Participants in the self-determining group, asserting that older adults should be allowed to determine themselves if and when they wish to receive euthanasia, were almost as religious as the refraining group, although they believed less in an afterlife. Their less traditional religiosity suggests that the late modern decline of traditional religious frameworks affords both self-determination concerning euthanasia and individual interpretations of religiosity. Moreover, our data suggest a connection between a persistent death wish in older adults and a perceived social death. [ABSTRACT FROM AUTHOR]

Purpose: Osteogenesis imperfecta (OI) is characterized by increased bone fragility and susceptibility for fractures. A few studies described and compared treatment modalities for femur fractures in children with OI. However, no cohort studies on adults with OI have been published. This study on adult OI patients aims to give insight into the incidence of femur fractures and non-unions and its best treatment options to avert non-union. Methods: In this retrospective, descriptive study of the OI expert clinic in The Netherlands, all medical charts of patients 16 years or older were analyzed for femur fracture incidence, non-union rate and treatment modality. Results: Of 216 OI patients, 34 patients suffered a femur fracture with 12 patients having more than 1 femur fracture. For all types of femur fractures, the incidence was 651 fractures per 100,000 person-years annually. In 49 total fractures, 10 fractures resulted in a non-union, mostly shaft fractures of type 4 OI patients. Surgically treated shaft fractures had the best outcomes for non-union. Conclusions: OI adults were prone to developing femur fractures and non-unions. Especially type 4 OI adults, with conservatively treated shaft fractures, were at high risk for non-unions. [ABSTRACT FROM AUTHOR]

Background Studies on the association between frailty and health-related quality of life (HRQoL) are scarce and show contradictory results. This study aimed to evaluate the association between physical, psychological and social frailty and HRQoL among community-dwelling older people. Methods A cross-sectional study was performed with baseline data collected in 2015 from the Urban Health Centers Europe (UHCE) project in five European countries, the United Kingdom, Greece, Croatia, The Netherlands and Spain. A total of 2325 participants were included in the baseline measurements of the Urban Health Centers Europe project; 2167 participants (mean age = 79.7; SD=5.6) were included in the analyses after excluding participants with missing data. The Tilburg Frailty Indicator measured overall frailty as well as physical, psychological and social frailty. The 12-Item Short-Form Health Survey was used to measured physical and mental HRQoL. Results Regarding physical HRQoL, a large difference (d =1.29) between physically and not physically frail participants was observed. Regarding mental HRQoL, a large difference (d =1.20) between psychologically and not psychologically frail participants was observed. In the full model with all three domains of frailty and the covariates to explain physical HRQoL, physical (P <0.001) and social frailty (P <0.001) remained significant. In the full model to explain mental HRQoL, all three domains of frailty remained significant (P <0.001). Conclusion Physical frailty had the strongest association with physical HRQoL, and psychological frailty had the strongest association with mental HRQoL. The associations between social frailty and both physical and mental HRQoL remain significant when controlling for physical and psychological frailty. [ABSTRACT FROM AUTHOR]

Background: In the Netherlands, each new lot of test strips for the CoaguChek XS is validated by a group of collaborating centers. The purpose of this study was to assess the accuracy of the international normalized ratio (INR) measured with consecutive test strip lots and the suitability of frozen plasma pools for accuracy evaluation. Methods: Each year, a particular lot of CoaguChek XS test strips is used as reference lot. The reference lots have been validated with the International Standard for thromboplastin rTF/09, yielding a mathematical relationship (R1) between reference lot INR and International Standard INR. New lots are compared to the reference lot using patients' capillary blood samples, yielding a relationship (R2) between the new lot INR and the reference lot INR. INRs of the blood samples were within the 1.5–4.5 interval. In parallel, three frozen plasmas pools are analyzed with the test strips. The distance of each plasma point to the line of relationship R2 was assessed. Results: Fifty-four test strip lots have been evaluated during 3 years (2014–2016). Mean INR differences between test strip lot and International Standard rTF/09 varied between −0.14 and +0.20 (−4% and +8%, respectively). A positive trend with strip lot sequence number was observed (p<0.001). In several cases, the distance of the frozen plasmas to the whole blood relationship (R2) was greater than the critical value for commutability. Conclusions: Using whole blood, all evaluated test strip lots met the analytical bias criterion of ±10%. Frozen plasma pools behave differently compared to whole blood and are not suitable for assessing absolute accuracy of new CoaguChek XS test strips. [ABSTRACT FROM AUTHOR]

Azole resistance is a major concern for treatment of infections with Aspergillus fumigatus. Environmental resistance selection is a main route for Aspergillus spp. to acquire azole resistance. We investigated the presence of environmental hotspots for resistance selection in the Netherlands on the basis of the ability of A. fumigatus to grow and reproduce in the presence of azole fungicide residues. We identified 3 hotspots: flower bulb waste, green waste material, and wood chippings. We recovered azole-resistant A. fumigatus from these sites; all fungi contained cyp51A tandem repeat-mediated resistance mechanisms identical to those found in clinical isolates. Tebuconazole, epoxiconazole, and prothioconazole were the most frequently found fungicide residues. Stockpiles of plant waste contained the highest levels of azole-resistant A. fumigatus, and active aerobic composting reduced Aspergillus colony counts. Preventing plant waste stockpiling or creating unfavorable conditions for A. fumigatus to grow in stockpiles might reduce environmental resistance burden. [ABSTRACT FROM AUTHOR]

The Lower Meuse Valley crosses the Roer Valley Rift System and provides an outstanding example of well-preserved late glacial and Holocene river terraces. The formation, preservation, and morphology of these terraces vary due to reach-specific conditions, a phenomenon that has been underappreciated in past studies. A detailed palaeogeographic reconstruction of the terrace series over the full length of the Lower Meuse Valley has been performed. This reconstruction provides improved insight into successive morphological responses to combined climatic and tectonic external forcing, as expressed and preserved in different ways along the river. New field data and data obtained from past studies were integrated using a digital mapping method in GIS. Results show that late glacial river terraces with diverse fluvial styles are best preserved in the Lower Meuse Valley downstream sub-reaches (traversing the Venlo Block and Peel Block), while Holocene terrace remnants are well-developed and preserved in the upstream sub-reaches (traversing the Campine Block and Roer Valley Graben). This reach-to-reach spatial variance in river terrace preservation and morphology can be ascribed to tectonically driven variations in river gradient and subsurface lithology, and to river-driven throughput of sediment supply. [ABSTRACT FROM AUTHOR]

Objective: To assess the effect of somatostatin analogs (SSAs) on mortalit y in relation to disease control of acromegaly after pituitary surgery. Design: A retrospective study in two large tertiary referral centers i n The Netherlands. Methods: Overall, 319 patients with acromegaly in whom pituitary surger y was performed as primary therapy between January 1980 and July 2017 were included. Postoperative treatme nt with SSA was prescribed to 174 (55%) patients because of persistent or recurrent disease. Disease control at last visit was assessed by IGF1 standard deviation score (SDS). Adequate disease control was defined as IGF1 SDS ≤2. Univariate determinants of mortality and standardized mortality ratios (SMRs) were calculated for groups with and wit hout SSA at any moment postoperatively and at last visit. Results: In total, 27 deaths were observed. In univariate analysis, det erminants of mortality were inadequate disease control (relative risk (RR): 3.41, P = 0.005), surgery by craniotomy (RR: 3.53, P = 0.013) and glucocorticoid substitution (RR: 2.11, P = 0.047). There was a strong trend toward increased mortality for patients who used SSA (RR: 2.01, P = 0.067) and/or dopamine agonists (RR: 2.54, P = 0.052) at last visit. The SMR of patients with adequate disease control who used SSA at any moment postoperatively (1.07, P = 0.785) and at last visit (1.19; P = 0.600) was not increased. Insufficiently controlled patients had a significantly raised SMR (3.92, P = 0.006). Conclusions: Postoperative use of SSA is not associated with increased mort ality in patients with acromegaly who attain adequate disease control. In contrast, inadequate disease contr ol, primary surgery by craniotomy and glucocorticoid substitution are associated with increased mortality. [ABSTRACT FROM AUTHOR]