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Objective: To describe trends and developments in the total duration of training medical specialists in the Netherlands, including their ages upon completion of the components of medical education: undergraduate medical program, waiting time and further post-graduate specialist training., Design: Population cohort study., Method: From the combined data from Statistics Netherlands and the Registration Committee for Medical Specialists for the period 1986 to 2018 relevant populations were selected and training trajectories were mapped. The population size was 40,604 individuals for undergraduate medical programs, 41,885 for the duration of post-graduate specialist training, 31,915 for the waiting periods and 21666 for the total duration of the trajectory from the start of medical school until registration as a specialist., Results: The median duration of undergraduate medical programs was 7.1 years, which is longer than the nominal duration and this remained unchanged over the observation period. The average waiting time between graduating medical school and postgraduate specialist training has increased from 2010 onwards to 3.7 years in 2018. The average duration of postgraduate specialist training is increasing. The average age at graduation of medical school fell by 1.7 years to 26.1. The average age at the start of post-graduate specialist training decreased, as did the average age at registration as a specialist., Conclusion: The total duration of training of medical specialists is stable. Changes such as "dedicated transition year" and flexible arrangements for postgraduate training have had no discernible influence on the total duration of medical training. Because the average age at start of postgraduate specialist training has decreased, medical specialists are on average younger upon registration.

Background: Statins may restrict the cellular functions required for melanoma growth and metastasis., Objectives: To determine whether long-term statin use commenced before diagnosis of a primary melanoma is associated with reduced risk of melanoma recurrence., Methods: We prospectively followed a cohort of patients newly diagnosed between 2010 and 2014 with localized tumour-stage T1b to T4b melanoma in Queensland, Australia. We used Cox regression analyses to examine associations between long-term statin use and melanoma recurrence for the entire cohort, and then separately by sex and by presence of ulceration, due to evidence of effect modification., Results: Among 700 patients diagnosed with stage T1b to T4b primary melanoma (mean age 62 years, 59% male, 28% with ulcerated tumours), 94 patients (13%) developed melanoma recurrence within 2 years. Long-term statin users (n = 204, 29%) had a significantly lower risk of disease recurrence than nonusers [adjusted hazard ratio (HR adj ) 0·55, 95% confidence Interval (CI) 0·32-0·97] regardless of statin subtype or potency. Compared with nonusers of statins, risk of recurrence was significantly decreased in male statin users (HR adj 0·39, 95% CI 0·19-0·79) but not in female statin users (HR adj 0·82, 95% CI 0·29-2·27) and in statin users with ulcerated (HR adj 0·17, 95% CI 0·05-0·52) but not nonulcerated (HR adj 0·91, 95% CI 0·46-1·81) primary melanoma., Conclusions: Statins commenced before melanoma diagnosis may reduce the risk of melanoma recurrence, especially in men and in those with ulcerated tumours. Clinical trial evaluation of the potential role of statins in improving the prognosis of high-risk melanoma is warranted., (© 2020 British Association of Dermatologists.)

Deinstitutionalization is often described as an organizational shift of moving care from the psychiatric hospital towards the community. This paper analyses deinstitutionalization as a daily care practice by adopting an empirical ethics approach instead. Deinstitutionalization of mental healthcare is seen as an important way of improving the quality of lives of people suffering from severe mental illness. But how is this done in practice and which different goods are strived for by those involved? We examine these questions by giving an ethnographic description of community mental health care in Trieste, a city that underwent a radical process of deinstitutionalization in the 1970s. We show that paying attention to the spatial metaphors used in daily care direct us to different notions of good care in which relationships are central. Addressing the question of how daily care practices of mental healthcare outside the hospital may be constituted and the importance of spatial metaphors used may inform other practices that want to shape community mental health care.

Background: Medical curricula are increasingly internationalized, with international students being mixed with domestic students in small group learning. Small group learning is known to foster competency learning in undergraduate medical education, specifically Communication, Collaboration, Leadership, and Professionalism. However, it is unclear what happens with the learning of competencies when international students are introduced in small groups. This study explores if students in international small groups master the competencies Collaboration, Leadership and Professionalism at the same level as students in domestic groups in an undergraduate medical curriculum., Method: In total, 1215 Students of three academic year cohorts participated in the study. They were divided into four learning communities (LCs), per year cohort, in which tutor groups were the main instructional format. The tutorials of two learning communities were taught in English, with a mix of international and Dutch students. The tutorials of the other two learning communities were taught in Dutch with almost all domestic students. Trained tutors assessed three competencies (Collaboration, Leadership, Professionalism) twice per semester, as 'Not-on-track', 'On-track', or 'Fast-on-track'. By using Chi-square tests, we compared students' competencies performance twice per semester between the four LCs in the first two undergraduate years., Results: The passing rate ('On-track' plus 'Fast-on-track') for the minimum level of competencies did not differ between the mixed and domestic groups. However, students in the mixed groups received more excellent performance evaluations ('Fast-on-track') than the students in the homogenous groups of Dutch students. This higher performance was true for both international and Dutch students of the mixed groups. Prior knowledge, age, gender, and nationality did not explain this phenomenon. The effect could also not be explained by a bias of the tutors., Conclusion: When students are educated in mixed groups of international and Dutch students, they can obtain the same basic competency levels, no matter what mix of students is made. However, students in the mixed international groups outperformed the students in the homogenous Dutch groups in achieving excellent performance scores. Future research should explore if these findings can be explained from differences in motivation, perceived grading or social network interactions.

Background: Concerns are raised about missed, delayed and inappropriate diagnosis of Lyme Borreliosis. Quantitative descriptive studies have demonstrated non-adherence to the guidelines for testing for Lyme Borreliosis. Objectives: To gain insight into the diagnostic practices that general practitioners apply for Lyme Borreliosis, their motives for ordering tests and how they act upon test results. Methods: A qualitative study among 16 general practitioners using semi-structured interviews and thematic content analysis. Results: Five themes were distinguished: (1) recognising localised Lyme Borreliosis and symptoms of disseminated disease, (2) use of the guideline, (3) serological testing in patients with clinically suspect Lyme Borreliosis, (4) serological testing without clinical suspicion of Lyme Borreliosis, and (5) dealing with the limited accuracy of the serological tests. Whereas the national guideline recommends using serological tests for diagnosing, general practitioners also use them for ruling out disseminated Lyme Borreliosis. Reasons for non-adherence to the guideline for testing were to reassure patients with non-specific symptoms or without symptoms who feared to have Lyme disease, confirmation of localised Lyme Borreliosis and routine work-up in patients with continuing unexplained symptoms. Some general practitioners referred all patients who tested positive to medical specialists, where others struggled with the explanation of the results. Conclusion: Both diagnosis and ruling out of disseminated Lyme Borreliosis can be difficult for general practitioners. General practitioners use serological tests to reassure patients and rule out Lyme Borreliosis, thereby deviating from the national guideline. Interpretation of test results in these cases can be difficult.

Background: Global concern about vitamin D deficiency has fuelled debates on photoprotection and the importance of solar exposure to meet vitamin D requirements., Objectives: To review the published evidence to reach a consensus on the influence of photoprotection by sunscreens on vitamin D status, considering other relevant factors., Methods: An international panel of 13 experts in endocrinology, dermatology, photobiology, epidemiology and biological anthropology reviewed the literature prior to a 1-day meeting in June 2017, during which the evidence was discussed. Methods of assessment and determining factors of vitamin D status, and public health perspectives were examined and consequences of sun exposure and the effects of photoprotection were assessed., Results: A serum level of ≥ 50 nmol L -1 25(OH)D is a target for all individuals. Broad-spectrum sunscreens that prevent erythema are unlikely to compromise vitamin D status in healthy populations. Vitamin D screening should be restricted to those at risk of hypovitaminosis, such as patients with photosensitivity disorders, who require rigorous photoprotection. Screening and supplementation are advised for this group., Conclusions: Sunscreen use for daily and recreational photoprotection does not compromise vitamin D synthesis, even when applied under optimal conditions. What's already known about this topic? Knowledge of the relationship between solar exposure behaviour, sunscreen use and vitamin D is important for public health but there is confusion about optimal vitamin D status and the safest way to achieve this. Practical recommendations on the potential impact of daily and/or recreational sunscreens on vitamin D status are lacking for healthy people. What does this study add? Judicious use of daily broad-spectrum sunscreens with high ultraviolet (UV) A protection will not compromise vitamin D status in healthy people. However, photoprotection strategies for patients with photosensitivity disorders that include high sun-protection factor sunscreens with high UVA protection, along with protective clothing and shade-seeking behaviour are likely to compromise vitamin D status. Screening for vitamin D status and supplementation are recommended in patients with photosensitivity disorders., (© 2019 The Authors. British Journal of Dermatology published by John Wiley & Sons Ltd on behalf of British Association of Dermatologists.)

Prevention enthusiasts show great optimism about the potential of health apps to modify peoples' lifestyles through the tracking and quantification of behaviours and bodily signs. Critical sociologists warn for the disciplining effects of self-tracking. In this paper we use an empirical ethics approach to study the characteristics and strivings of the various types of 'ethico-psychological subjects' that emerge in practices of self-quantification by analysing how people and numbers relate in three cases of self-quantification: in prevention discourse, in testimonies from the quantified self (QS) movement and in empirical work we did with people with Diabetes type I and with 'every day self-trackers'. We show that a free subject that needs support to enact its will is crucial to understand the optimism about prevention. In the QS-movement the concern is with a lack of objective and personalised knowledge about imperceptible processes in the body. These subjects are decentered and multiplied when we trace how numbers in their turn act to make sense of people in our empirical study. We conclude that there are many different types of ethico-psychological subjects in practices of self-tracking that need to be explored in order to establish what good these practices of self-quantification might do., (© 2019 The Authors Sociology of Health & Illness published by John Wiley & Sons Ltd on behalf of Foundation for SHIL (SHIL).)

Objectives: Sixty-five per cent of older people have hypertension, but little is known about their preferences and concerns regarding hypertension management. Guidelines on hypertension lack consensus on how to treat older people without previous cardiovascular disease (CVD). This asks for explicit consideration of patient preferences in decision making. Therefore, the aim of this study was to explore older peoples' experiences, preferences, concerns and perceived involvement regarding hypertension management., Design: Qualitative interview study., Setting: Participants were selected from 11 general practitioner (GP) practices in the Netherlands and purposively sampled until data saturation was achieved. Semistructured interviews were conducted, audio recorded and analysed by two researchers using thematic analysis., Participants: Fifteen community dwelling older people aged 74-93 years with hypertension and without previous CVD participated., Results: Interviewees rarely started the conversation about hypertension management with their GP, although they did have concerns. Reasons for not discussing the subject included low priority of hypertension concerns, reliance on GPs or trust in GPs to make the right decision on their behalf. Also, interviewees anticipated regret of reducing medication, fearing vascular incidents. Interviewees would like to discuss tailoring treatment to their needs, deprescription of medication and ways to reduce side effects. They expected GPs to be more transparent on treatment effects., Conclusion: Older people describe having little involvement in hypertension management, although they have several concerns. Since GPs are also known to be hesitant to bring up this subject, we signal a conspiracy of silence about antihypertensive medication. Through breaking this silence, GPs can facilitate shared decision-making on hypertension management and better tailored care., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

This paper articulates dignity as relational engagement in concrete care situations. Dignity is often understood as an abstract principle that represents inherent worth of all human beings. In actual care practices, this principle has to be substantiated in order to gain meaning and inform care activities. We describe three exemplary substantiations of the principle of dignity in care: as a state or characteristic of a situation; as a way to differentiate between socio-cultural positions; or as personal meaning. We continue our analysis by presenting cases on dignity in care related to us in focus groups with medical professionals. Our empirical ethical lens is in this paper is to analyse, not the meaning of dignity, but the way in which it emerges in practices where it is pursued, within relationships between people, technologies, places, regulations, and the values cherished by or embedded in them. We show that professional caregivers recognize in the dignity of the person they care for their own dignity; giving up on the one implies no less than giving up on the other. This 'mirrored experience' of dignity expresses itself in professional's engagement with the situation. The value of this engagement, we argue, lies not primarily in realizing the particular content of the values at stake. We point to the importance of engagement itself, even if the values engaged with cannot be realized to the full, and even if competing versions of dignity are at stake simultaneously. In this way the caregivers provide us with interesting examples of moral actorship in situations of conflicting values.

Background: Sessile serrated adenomas with BRAF mutation progress rapidly to cancer following the development of dysplasia (SSAD). Approximately 75% of SSADs methylate the mismatch repair gene MLH1, develop mismatch repair deficiency and the resultant cancers have a good prognosis. The remaining SSADs and BRAF mutant traditional serrated adenomas (TSA) develop into microsatellite stable cancers with a poor prognosis. The reason for this dichotomy is unknown. In this study, we assessed the genotypic frequency of the MLH1-93 polymorphism rs1800734 in SSADs and TSAs to determine if the uncommon variant A allele predisposes to MLH1 promoter hypermethylation., Methods: We performed genotyping for the MLH1-93 polymorphism, quantitative methylation specific PCR, and MLH1 immunohistochemistry on 124 SSAD, 128 TSA, 203 BRAF mutant CRCs and 147 control subjects with normal colonoscopy., Results: The minor A allele was significantly associated with a dose dependent increase in methylation at the MLH1 promoter in SSADs (p = 0.022). The AA genotype was only observed in SSADs with MLH1 loss. The A allele was also overrepresented in BRAF mutant cancers with MLH1 loss. Only one of the TSAs showed loss of MLH1 and the overall genotype distribution in TSAs did not differ from controls., Conclusions: The MLH1-93 AA genotype is significantly associated with promoter hypermethylation and MLH1 loss in the context of SSADs. BRAF mutant microsatellite stable colorectal cancers with the AA genotype most likely arise in TSAs since the A allele does not predispose to methylation in this context.

A 57-year-old man developed a locked-in state due to a brain stem stroke. He communicated through eye movements. The team suggested treatment should be discontinued, as there was no perspective of improvement. The family was very upset because they experienced sufficient quality of life. We investigated what 'quality of life' means. The literature shows that severely ill and completely care-dependent patients may experience high quality of life; this is called the disability paradox. Patients and families evaluate quality of life by looking for positive things to live for. Some quality-of-life tests, however, understand quality of life as 'functionality'. Healthy people evaluate the situation of people living with handicaps more negatively than the handicapped themselves do. Practitioners may overlook the instability of patients' evaluations: responses and situations may shift. Quality of life as an outcome in clinical trials may be different for individual patients. These insights may improve communication.

Purpose: An evaluation of the alignment between intensive care medicine (ICM) training and practice provides valuable information for the development of ICM training. Therefore this study examines how well recently licensed intensivists feel prepared for practice and whether intensivists from different background specialties attain comparable preparedness rates., Methods: An inventory was developed to cover the tasks that constitute ICM practice. Two hundred five recently licensed Dutch intensivists received a questionnaire in which they could indicate how well their ICM training programme prepared them for these tasks on a 5-point Likert scale., Results: Ninety-one respondents returned the questionnaire (response 45%). Respondents felt excellently prepared for 67 tasks, well prepared for 16 tasks, marginally sufficiently prepared for 6 tasks and insufficiently prepared for 15 tasks. Intensivists from anaesthesiology felt better prepared for IC specific activities (mean 4.25, SD 0.38) than those from internal medicine (mean 4.01, SD 0.40, P=.02).Average scores on tasks related to medical expertise were relatively high while tasks relating to management and leadership, science and professional development scored lower., Conclusions: Although recently licensed intensivists are well prepared for most tasks in ICM, lower preparedness scores on tasks related to leadership and management, science, and professional development call for re-evaluation of the current curriculum., (Copyright © 2017 Elsevier Inc. All rights reserved.)

In the Netherlands, autonomy is a key ideal in visions of care for people with learning disability. This ideal can lead to tension when clients, in the opinion of their caregivers, overuse alcohol or drugs. In this article, we analyze how professional caregivers understand the ideal of autonomy in care for people with learning disability, and articulate the tacit attempts of caregivers to provide "good care," which can be understood as care for relationships. This relational view includes caregivers, care recipients, and their networks and infrastructures in the vision of care.

This article is a written version of the lecture for the IPONS conference in Stockholm. The article starts from the claim that there is no such thing as technology, only different variations of technologies. These technologies, plural, all have their specific workings that we can only learn about by studying these empirically, by analysing the relations between people and their technologies. These relations are always unpredictable, as it is not given beforehand what values the participants pursue. Studying and understanding the workings of healthcare technology is a crucial task for nursing studies, as nurses are often key actors in making these devices work. The article hands the reader some tools to engage in the study of technologies in practice, using an empirical ethics approach., (© 2016 John Wiley & Sons Ltd.)

Textbook examples of adaptive radiation often show rapid morphological changes in response to environmental perturbations. East Africa's Lake Victoria, famous for its stunning adaptive radiation of cichlids, has suffered from human-induced eutrophication over the past decades. This cultural eutrophication is thought to be partly responsible for the dramatically reduced cichlid biodiversity, but climatic variability in itself might also have contributed to the eutrophication which resulted in low oxygen levels and decreased water transparency. To determine how recent environmental changes have influenced the lake and its cichlids over the past 50 years, we gathered environmental and meteorological variables and compared these with gill surface area of four cichlid species. We found that during the period of severe eutrophication and temperature increase (1980s), reduced wind speeds coincided with a reduction in oxygen levels and a decrease in both water temperature and transparency. The gill surface area in three out of the four cichlid species increased during this period which is consistent with adaptive change in response to increased hypoxia. During the 2000s, wind speeds, oxygen levels, water transparency and water temperature increased again, while cichlid gill surface area decreased. Our results imply that climatic changes and especially wind speed and direction might play a crucial role in tropical lake dynamics. The changes in Lake Victoria's water quality coincide with fluctuations in cichlid gill surface area, suggesting that these fish can respond rapidly to environmental perturbations, but also that climatic variability, together with continued eutrophication, might be detrimental to the lake's cichlid biodiversity.

The transformation of an aryloxybutanoic acid ultra high-throughput screening (uHTS) hit into a potent and selective series of G-protein coupled receptor 120 (GPR120) agonists is reported. uHTS hit 1 demonstrated an excellent rodent pharmacokinetic profile and selectivity over the related fatty acid receptor GPR40, but only modest GPR120 potency. Optimization of the "left-hand" aryl group led to compound 6, which demonstrated a GPR120 mechanism-based pharmacodynamic effect in a mouse oral glucose tolerance test (oGTT). Further optimization gave rise to the benzofuran propanoic acid series (exemplified by compound 37), which demonstrated acute mechanism-based pharmacodynamic effects. The combination of in vivo efficacy and attractive rodent pharmacodynamic profiles suggests compounds generated from this series may afford attractive candidates for the treatment of Type 2 diabetes., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Although people often refer to quality of life and there is a respectable research tradition to establish it, the meaning of the term is unclear. In this article we qualitatively study an intervention of which the quantitative effects are documented as indecisive. We do this in order to learn more about what the meaning of the term quality of life means when it is studied in daily life. With the help of these findings we reflect on the intricacies of objectifying and measuring quality of life using quantitative research designs. Our case is the feeding tube for patients suffering from ALS, a severe motor neuron disease that rapidly and progressively incapacitates patients. We studied how these patients, who lived in the Netherlands, anticipated and lived with a feeding tube in the course of their physical deterioration. Our analysis shows that the quality of life related to the feeding tube has to be understood as a process rather than as an outcome. The feeding tube becomes a different thing as patients move through the various phases of their illness, due to changes in their condition, living circumstances, and concerns and values. There are very different appreciations of the way the feeding tube changes the body's appearance and feel. Some patients refuse it because they feel it disfigures their body, whereas others are indifferent to its appearance. Our conclusion is that these differences are difficult to grasp with a quantitative study designs because 'matters of taste' and values are not distributed in a population in the same ways as physiological responses to medication. Effect studies assume physiological responses to be more or less the same for everyone, with only gradual differences. Our analysis of quality in daily life, however, shows that what a treatment comes to be and how it is valued shows shows generalities for subgroups rather than populations.

Background: GPs play an important role in recognising the symptoms of dementia; however, little is known about how they perceive their actual and future role in diagnosing dementia., Aim: To explore Dutch GPs' perceptions of their current position in diagnosing dementia, their reasons for referral to secondary care, and views on the future diagnostic role of GPs., Design and Setting: A qualitative study among Dutch GPs., Method: Eighteen GPs participated in a semi-structured interview that ranged from 20 to 60 minutes. Interviews were transcribed verbatim and thematic analysis was performed., Results: GPs reported that their role in the diagnostic phase of identifying people with suspected dementia is limited to recognising cognitive problems and deciding whether a patient needs to be referred for further investigation, or whether care could be organised without specialist diagnosis. GPs indicated that they were likely to refer patients if patients/caregivers or dementia case managers requested it, or if they thought it could have consequences for treatment. Typically, GPs do not see the need for referral when their patients are very old and declining slowly. GPs would welcome a more prominent role in diagnosing dementia in their own practice., Conclusion: Diagnosing dementia involves a complex balance between patient and carer preferences, the consequences for treatment and care, and the burden of referral. Dutch GPs favour a stronger involvement in diagnosing dementia provided that both resources and diagnostic algorithms are improved., (© British Journal of General Practice 2016.)

Background: Vitamin D, specifically serum 25(OH)D has been associated with mortality, cancer and multiple other health endpoints in observational studies, but there is a paucity of clinical trial evidence sufficient to determine the safety and effectiveness of population-wide supplementation. We have therefore launched the D-Health Trial, a randomized trial of vitamin D supplementation for prevention of mortality and cancer. Here we report the methods and describe the trial cohort., Methods: The D-Health Trial is a randomized placebo-controlled trial, with planned intervention for 5years and a further 5years of passive follow-up through linkage with health and death registers. Participants aged 65-84years were recruited from the general population of Australia. The intervention is monthly oral doses of 60,000IU of cholecalciferol or matching placebo. The primary outcome is all-cause mortality. Secondary outcomes are total cancer incidence and colorectal cancer incidence., Results: We recruited 21,315 participants to the trial between February 2014 and May 2015. The participants in the two arms of the trial were well-balanced at baseline. Comparison with Australian population statistics shows that the trial participants were less likely to report being in fair or poor health, to be current smokers or to have diabetes than the Australian population. However, the proportion overweight or with health conditions such as arthritis and angina was similar., Conclusions: Observational data cannot be considered sufficient to support interventions delivered at a population level. Large-scale randomized trials such as the D-Health Trial are needed to inform public health policy and practice., (Copyright © 2016 Elsevier Inc. All rights reserved.)

"Citizenship" is a term from political theory. The term has moved from the relationship between the individual and the state toward addressing the position of 'others' in society. Here, I am concerned with people with long-term mental health problems. I explore the possibilities of ethnographically studying this rather more cultural understanding of citizenship with the use of the concept of relational citizenship, attending to people who leave Dutch institutions for mental health care. Relational citizenship assumes that people become citizens through interactions, whereby they create particular relations and social spaces. Rather than studying the citizen as a particular individual, citizenship becomes a matter of sociality. In this article, I consider what social spaces these relationships create and what values and mechanisms keep people together. I argue that the notion of neighborhood as a form of community, although built implicitly or explicitly into mental health care policy, is no longer the most plausible model to understand social spaces.

Introduction: Many training programmes in postgraduate medical education (PGME) have introduced competency frameworks, but the effects of this change on preparedness for practice are unknown. Therefore, we explored how elements of competency-based programmes in PGME (educational innovations, attention to competencies and learning environment) were related to perceived preparedness for practice among new consultants., Methods: A questionnaire was distributed among 330 new consultants. Respondents rated how well their PGME training programme prepared them for practice, the extent to which educational innovations (portfolio, Mini-CEX) were implemented, and how much attention was paid to CanMEDS competencies during feedback and coaching, and they answered questions on the learning environment and general self-efficacy. Multiple regression and mediation analyses were used to analyze data., Results: The response rate was 43 % (143/330). Controlling for self-efficacy and gender, the learning environment was the strongest predictor of preparedness for practice (B = 0.42, p < 0.001), followed by attention to competencies (B = 0.29, p < 0.01). Educational innovations were not directly related to preparedness for practice. The overall model explained 52 % of the variance in preparedness for practice. Attention to competencies mediated the relationship between educational innovations and preparedness for practice. This mediation became stronger at higher learning environment values., Conclusions: The learning environment plays a key role in determining the degree to which competency-based PGME prepares trainees for independent practice.

The increasing use of telecare will profoundly change nursing care. How to understand these changes is, however, far from clear. This is because (i) studies on telecare seldom consider the situation it replaces, and (ii) current concepts and methods used to study the impact of telecare may not allow us to fully grasp these changes. We suggest that an analysis of the changing materiality of care practices is a suitable way to articulate and reflect on possible concerns. It allows us to compare care practices in the same terms before and after telecare has been introduced. To demonstrate this, we study the materiality of the classical care setting, the nursing house call, to map the situation before telecare is introduced. Building on science and technology studies, we apply four categories as heuristics to analyse materiality in care: signs, dis/enablers (or scripted things), tools and practical arrangements. We leave open the question of how material arrangements could or should be matters of concern in nursing care, and instead argue for studies that give insights into the everyday tinkering with the materiality of care that both nurses and patients need to engage in., (© 2015 Foundation for the Sociology of Health & Illness.)

Context: Telecare and telehealth developments have recently attracted much attention in research and service development contexts, where their evaluation has predominantly concerned effectiveness and efficiency. Their social and ethical implications, in contrast, have received little scrutiny., Objective: To develop an ethical framework for telecare systems based on analysis of observations of telecare-in-use and citizens' panel deliberations., Design: Ethnographic study (observation, work shadowing), interviews, older citizens' panels and a participative conference., Setting: Participants' homes, workplaces and familiar community venues in England, Spain, the Netherlands and Norway 2008-2011., Results: Older respondents expressed concerns that telecare might be used to replace face-to-face/hands-on care to cut costs. Citizens' panels strongly advocated ethical and social questions being considered in tandem with technical and policy developments. Older people are too often excluded from telecare system design, and installation is often wrongly seen as a one-off event. Some systems enhance self-care by increasing self-awareness, while others shift agency away from the older person, introducing new forms of dependency., Conclusions: Telecare has care limitations; it is not a solution, but a shift in networks of relations and responsibilities. Telecare cannot be meaningfully evaluated as an entity, but rather in the situated relations people and technologies create together. Characteristics of ethical telecare include on-going user/carer engagement in decision making about systems: in-home system evolution with feedback opportunities built into implementation. System design should be horizontal, 'two-way'/interactive rather than vertical or 'one-way'. An ethical framework for telecare has been developed from these conclusions (Table 1)., (© 2013 John Wiley & Sons Ltd.)

Background: Postgraduate medical education training programs strive to prepare their trainees optimally for independent practice. Several studies have shown, however, that new consultants feel inadequately prepared for practice, and that this increases the risk of stress and burnout., Aim: To analyze across specialties for which tasks and themes new consultants feel inadequately prepared. And, to identify themes that need improved attention in postgraduate medical education programs or after registration., Methods: 330 New consultants from all hospital specialities with accredited training programs who completed their training in the north-eastern educational region of The Netherlands between 2004 and 2010 received a questionnaire which was based on a previously validated generic task inventory., Results: 143 respondents (43%) returned the questionnaire. They felt excellently prepared for 40 tasks, well prepared for 25 tasks, marginally sufficiently prepared for 18 tasks and insufficiently prepared for 8 tasks. Preparedness scores were lowest for tasks concerning management administration and leadership, research, end-of-life care, and patient safety-related communication. Surgical specialists felt better prepared for practice than medical specialists, which could not be explained by differences in general self-efficacy., Conclusion: Although new consultants felt well prepared for medical tasks, the scores of more generic tasks indicate that the alignment between the different phases of the medical education continuum and independent practice needs improvement.

This paper describes the approach of empirical ethics, a form of ethics that integrates non-positivist ethnographic empirical research and philosophy. Empirical ethics as it is discussed here builds on the 'empirical turn' in epistemology. It radicalizes the relational approach that care ethics introduced to think about care between people by drawing in relations between people and technologies as things people relate to. Empirical ethics studies care practices by analysing their intra-normativity, or the ways of living together the actors within these practices strive for or bring about as good practices. Different from care ethics, what care is and if it is good is not defined beforehand. A care practice may be contested by comparing it to alternative practices with different notions of good care. By contrasting practices as different ways of living together that are normatively oriented, suggestions for the best possible care may be argued for. Whether these suggestions will actually be put to practice is, however, again a relational question; new actors need to re-localize suggestions, to make them work in new practices and fit them in with local intra-normativities with their particular routines, material infrastructures, know-how and strivings.

Background: Cardiovascular prevention programmes are increasingly being offered to older people. To achieve the proposed benefits, adherence is crucial. Understanding the reasons for adherence and non-adherence can improve preventive care., Aim: To gain insight into what motivates older people living in the community to partake in a cardiovascular prevention programme, and reasons for subsequent continuation or withdrawal., Design and Setting: Qualitative study of current and former participants of the ongoing ≥6 year PreDIVA (prevention of dementia by intensive vascular care) trial in primary care practices in suburban areas in the Netherlands., Method: Semi-structured interviews were conducted with a purposive sample of 15 participants (aged 76-82 years). Interviews were audiorecorded and analysed by two independent researchers using a thematic approach. Participants were asked about their motivation for participating in the programme, along with the facilitators and barriers to continue doing so., Results: Responders reported that regular check-ups offered a feeling of safety, control, or being looked after, and were an important motivator for participation. For successful continuation, a personal relationship with the nurse and a coaching approach were both essential; the lack of these, along with frequent changes of nursing staff, were considered to be barriers. Participants considered general preventive advice unnecessary or patronising, but practical support was appreciated., Conclusion: To successfully engage older people in long-term, preventive consultations, the approach of the healthcare provider is crucial. Key elements are to offer regular check-ups, use a coaching approach and to build a personal relationship with the patient., (© British Journal of General Practice 2015.)

There are roughly two meanings attached to the concept of dignity: humanitas and dignitas. Humanitas refers to ethical and juridical notions of equality, autonomy and freedom. Much less understood is the meaning of dignitas, which this paper develops as peoples' engagement with aesthetic values and genres, and hence with differences between people. Departing from a critical reading of Georgio Agamben's notion of 'bare life', I will analyze a case where aesthetics are quite literally at stake: women who lost their hair due to cancer treatment. The analysis shows a complicated interplay between varying evaluations of female baldness by the self and others, mediated by (often strongly negative) cultural imaginaries, and aesthetic genres depicting conventional ways of 'looking good'. The paper concludes by arguing for a reconnection of the two notions of dignity, and for a rehabilitation of aesthetics in daily life and care as fundamental values for organizing our societies.

Dignity is a fundamental concept, but its meaning is not clear. This paper attempts to clarify the term by analysing and reconnecting two meanings of dignity: humanitas and dignitas. Humanitas refers to citizen values that protect individuals as equal to one another. Dignitas refers to aesthetic values embedded in genres of sociality that relate to differences between people. The paper explores these values by way of an empirical ethical analysis of practices of washing psychiatric patients in nursing care. Nurses legitimate the washing of reluctant patients with reference to dignity. The analysis shows the intertwinement of humanitas and dignitas that gives dignity its fundamental meaning., (© 2013 John Wiley & Sons Ltd.)

Background: Internationally, postgraduate medical education (PGME) has shifted to competency-based training. To evaluate the effects of this shift on the outcomes of PGME appropriate instruments are needed., Aim: To provide an inventory of tasks specialists perform in practice, which can be used as an instrument to evaluate the outcomes of PGME across disciplines., Methods: Following methodology from job analysis in human resource management, we used document analyses, observations, interviews and questionnaires. Two thousand seven hundred and twenty eight specialists were then asked to indicate how frequently they performed each task in the inventory, and to suggest additional tasks. Face and content validity was evaluated using interviews and the questionnaire. Tasks with similar content were combined in a total of 12 clusters. Internal consistency was evaluated by calculating Cronbach's alpha. Construct validity was determined by examining predefined differences in task performance between medical, surgical and supportive disciplines., Results: Seven hundred and six specialists (36%) returned the questionnaire. The resulting inventory of 91 tasks showed adequate face and content validity. Internal consistency of clusters of tasks was adequate. Significant differences in task performance between medical, surgical and supportive disciplines indicated construct validity., Conclusion: We established a comprehensive, generic and valid inventory of tasks of specialists which appears to be applicable across medical, surgical and supportive disciplines.

Purpose: To examine the impact of social networks and a two-day faculty development course on clinical supervisors' adoption of an educational innovation., Method: During 2007-2010, 571 residents and 613 clinical supervisors in four specialties in the Netherlands were invited to complete a Web-based questionnaire. Residents rated their clinical supervisors' adoption of an educational innovation, the use of structured and constructive (S&C) feedback. Clinical supervisors self-assessed their adoption of this innovation and rated their communication intensity with other clinical supervisors in their department. For each supervisor, a centrality score was calculated, representing the extent to which the supervisor was connected to departmental colleagues. The authors analyzed the effects of supervisor centrality and participation in a two-day Teach-the-Teacher course on the degree of innovation adoption using hierarchical linear modeling, adjusting for age, gender, and attitude toward the S&C feedback innovation., Results: Respondents included 370 (60%) supervisors and 357 (63%) residents. Although Teach-the-Teacher course participation (n=172; 46.5%) was significantly related to supervisors' self-assessments of adoption (P=.001), it had no effect on residents' assessments of supervisors' adoption (P=.371). Supervisor centrality was significantly related to innovation adoption in both residents' assessments (P=.023) and supervisors' self-assessments (P=.024)., Conclusions: A clinical supervisor's social network may be as important as faculty development course participation in determining whether the supervisor adopts an educational innovation. Faculty development initiatives should use faculty members' social networks to improve the adoption of educational innovations and help build and maintain communities of practice.

Telecare is advocated in most European countries with great, if not grandiose, promises: improving healthcare, lowering costs, solving workforce shortage. This paper does not so much question these specific promises, but rather the 'register of promising' as such, by comparing the promises with actual processes of incorporating technologies in healthcare practices. The case we study is the use of webcams in follow-up care from a Dutch rehabilitation clinic for people with severe chronic obstructive pulmonary disease (COPD). This process shows many changes and contingencies, and corresponding shifts in goals and aims. The conclusion is that when innovative technologies such as telecare are actually put to work, 'the same' technology will perform differently. In order to function at all, technology has to be tamed, it has to be tinkered with to fit the practices of the users. The technology, however, is not meekly put to use (tamed), but is unleashed as well, affecting care practices in unforeseen ways. The untenability of pre-given promises and the fluidity of locally evolving goals has important implications for the way in which innovations are promoted, as well as for the way innovative technologies may be evaluated., (© 2010 The Authors. Sociology of Health & Illness © 2010 Foundation for the Sociology of Health & Illness/Blackwell Publishing Ltd.)

Background/objective: Experimental studies suggest that dietary factors may influence skin cancer risk, but there have been few human studies of diet and basal cell carcinoma (BCC), the most common type of skin cancer. The objective was to prospectively investigate the association between food intake and incidence of BCC skin cancers., Subjects/methods: At baseline in 1992, 1056 adults in a subtropical Australian community completed a validated food-frequency questionnaire from which we estimated the intake of 15 food groups, selected based on hypothesized associations in the literature. Between 1992 and 2002, incident, histologically confirmed BCCs were recorded in terms of number of persons newly affected by BCC, as well as BCC tumor counts., Results: Intakes of the food groups were not associated with the incidence of persons affected by BCC. However, there was a borderline positive association between intake of eggs and incidence of BCC tumors (highest vs lowest tertile adjusted relative risk (RR) 1.5; 95% confidence interval (CI): 1.0-2.2; P for trend = 0.06). A borderline inverse association with potato intake (highest vs lowest tertile RR 0.7; 95% CI: 0.4-1.0, P for trend = 0.06) disappeared after exclusion of three subjects with more than 10 BCCs., Conclusion: Despite some suggestive evidence that egg and potato consumption may be associated with BCC tumor incidence, there are no plausible grounds for considering these as truly causal rather than chance associations. This study provides little evidence for a role of food intake in BCC prevention.

Nurses and ethicists worry that the implementation of care at a distance or telecare will impoverish patient care by taking out 'the heart' of the clinical work. This means that telecare is feared to induce the neglect of patients, and to possibly hinder the development of a personal relation between nurse and patient. This study aims to analyse whether these worries are warranted by analysing Dutch care practices using telemonitoring in care for chronic patients in the Netherlands. How do clinical practices of nursing change when telecare devices are introduced and what this means for notions and norms of good nursing? The paper concludes that at this point the practices studied do not warrant the fear of negligence and compromised relations. Quite the contrary; in the practices studied, telecare lead to more frequent and more specialised contacts between nurses and patients. The paper concludes by reflecting on the ethical implications of these changes.

An LC-MS/MS method for simultaneous determination of hippuric acid (HA) and benzoic acid (BA) in monkey urine after direct injection was developed. Since HA and BA are endogenous compounds in urine, surrogate standards ((13)C(6)-hippuric and (13)C(6)-benzoic acid) were employed to generate calibration curves. l-Phenylalanine-ring-D5 served as an internal standard. Multiple reaction monitoring in the negative ionization mode with an APCI source was used for detection of all components in the assay. The developed method is intended for determination of HA and BA in the range of 0.25-250 and 0.1-100microg/ml, respectively. Weighted (1/x) quadratic regression (r(2)>0.99) was used to generate calibration curves. Precision and accuracy of the method were assessed by analyzing 3 quality control samples (concentrations at low, medium, and high range of calibration curve) prepared in monkey urine. Stability for 48h at room temperature and after 3 freeze-thaw cycles was also evaluated. The proposed method was successfully utilized for analysis of urine samples from female monkeys following the administration of everninomicin alone and in combination with gentamicin. The concentrations of endogenous HA and BA were calculated based on the peak area ratio of the analyte to the internal standard using a regression equation for corresponding surrogate standard., (Copyright (c) 2010 Elsevier B.V. All rights reserved.)

Most models of patient-physician communication take decision-making as a central concept. However, we found that often the treatment course of metastatic cancer patients is not easy to describe in straightforward terms used in decision-making models but is instead frequently more erratic. Our aim was to analyse these processes as trajectories. We used a longitudinal case study of 13 patients with metastatic colorectal and pancreatic cancer for whom palliative chemotherapy was a treatment option, and analysed 65 semi-structured interviews. We analysed three characteristics of the treatment course that contributed to the 'erraticness' of the course: (1) The treatment (with or without chemotherapy) contained many options; (2) these options were not stable entities to be decided upon, but changed identity over the course of treatment, and (3) contrary to the closure (option X means no option Y, Z, etc.) a decision implies, the treatment course was a continuous process in which options instead remained open. When the treatment course is characterised by these many and changeable options that do not result in closure, the shared decision-making model should take these into account. More attention needs to be paid to the erratic character of the process in which the doctor has to provide continuous information that is related to the changing situation of the patient; also, flexibility in dealing with protocols is warranted, as is vigilance about the overall direction of the process.

Background/objectives: Dairy foods contain various nutrients that may affect health. We investigated whether intake of dairy products or related nutrients is associated with mortality due to cardiovascular disease (CVD), cancer and all causes., Subjects/methods: We carried out a 16-year prospective study among a community-based sample of 1529 adult Australians aged 25-78 years at baseline. Habitual intakes of dairy products (total, high/low-fat dairy, milk, yoghurt and full-fat cheese), calcium and vitamin D were estimated as mean reported intake using validated food frequency questionnaires (FFQs) self-administered in 1992, 1994 and 1996. National Death Index data were used to ascertain mortality and cause of death between 1992 and 2007. Hazard ratios (HRs) were calculated using Cox regression analysis., Results: During an average follow-up time of 14.4 years, 177 participants died, including 61 deaths due to CVD and 58 deaths due to cancer. There was no consistent and significant association between total dairy intake and total or cause-specific mortality. However, compared with those with the lowest intake of full-fat dairy, participants with the highest intake (median intake 339 g/day) had reduced death due to CVD (HR: 0.31; 95% confidence interval (CI): 0.12-0.79; P for trend=0.04) after adjustment for calcium intake and other confounders. Intakes of low-fat dairy, specific dairy foods, calcium and vitamin D showed no consistent associations., Conclusions: Overall intake of dairy products was not associated with mortality. A possible beneficial association between intake of full-fat dairy and cardiovascular mortality needs further assessment and confirmation.

Improvements and innovation in health service organization and delivery have become more and more important due to the gap between knowledge and practice, rising costs, medical errors, and the organization of health care systems. Since training and education is widely used to convey and distribute innovative initiatives, we examined the effect that following an intensive Teach-the-Teacher training had on the dissemination of a new structured competency-based feedback technique of assessing clinical competencies among medical specialists in the Netherlands. We compared this with the effect of the structure of the social network of medical specialists, specifically the network tie strength (strong ties versus weak ties). We measured dissemination of the feedback technique by using a questionnaire filled in by Obstetrics & Gynecology and Pediatrics residents (n=63). Data on network tie strength was gathered with a structured questionnaire given to medical specialists (n=81). Social network analysis was used to compose the required network coefficients. We found a strong effect for network tie strength and no effect for the Teach-the-Teacher training course on the dissemination of the new structured feedback technique. This paper shows the potential that social networks have for disseminating innovations in health service delivery and organization. Further research is needed into the role and structure of social networks on the diffusion of innovations between departments and the various types of innovations involved., (Copyright (c) 2010 Elsevier Ltd. All rights reserved.)

Background: Dairy consumption in childhood may have long-term effects on cardiovascular mortality through influencing the development of risk factors or programming effects., Objective: To investigate whether dairy and calcium consumption in childhood is associated with adult mortality due to coronary heart disease (CHD), stroke and all causes., Methods: In 1937-9, 4999 children in England and Scotland participated in a study of family food consumption, assessed from 7-day household food inventories. Cause of death was ascertained between 1948 and 2005 in 4374 traced cohort members with complete data. Per capita household intake estimates for dairy products and calcium were used as proxies for individual intake., Results: No strong evidence that a family diet in childhood high in dairy products was associated with CHD or stroke mortality was found. However, childhood calcium intake was inversely associated with stroke mortality (multivariable adjusted hazard ratio (HR) for highest versus lowest calcium group: 0.41; 95% confidence interval (CI) 0.16 to 1.05; p for trend = 0.04), but not CHD mortality. All-cause mortality was lowest in those with the highest family dairy (HR = 0.77; 95% CI 0.61 to 0.98; p for trend = 0.04) and calcium intake (HR = 0.77, 95% CI 0.60 to 0.98; p for trend = 0.05)., Conclusions: Children whose family diet in the 1930s was high in calcium were at reduced risk of death from stroke. Furthermore, childhood diets rich in dairy or calcium were associated with lower all-cause mortality in adulthood. Replication in other study populations is needed to determine whether residual confounding explains part of these findings.

Objective: To investigate the association between total alcohol intake and intake of different types of alcoholic beverages in relation to the risk of basal cell (BCC) and squamous cell (SCC) carcinoma of the skin., Design: Prospective cohort study., Setting: Follow-up data from a community-based skin cancer study in Australia., Subjects: Randomly selected sample of 1360 adult residents of the township of Nambour who completed a food frequency questionnaire in 1992 and were monitored for BCC and SCC until 31 December 2002., Results: No significant association was found between overall BCC or SCC risk and total alcohol intake, or intake of beer, white wine, red wine or sherry and port. However, among those with a prior skin cancer history, there was a significant doubling of risk of SCC for above-median consumption of sherry and port (multivariable adjusted relative risk 2.46, 95% confidence interval 1.06-5.72) compared with abstainers., Conclusions: There are no associations between first occurrence of skin cancers and alcoholic beverage consumption. People with a history of skin cancer who consume above-average quantities of sherry or port may be at a raised risk of SCC, although replication of these findings in different study populations is needed to confirm this possible role of specific alcoholic beverages in secondary keratinocytic skin cancer risk.

Participation in the community and citizenship for patients are common ideals that inspire improvements in mental health care. But what is meant by citizenship? Here an analysis is made of washing practices in psychiatric nursing in long-term mental health institutions. Four repertoires of washing are described, each oriented towards a specific notion of citizenship. In the first repertoire, washing is part of individual privacy; the patient is "enacted" as an individual whose authenticity should be respected in order to equip him or her for participation in the community. In the second repertoire, washing is a basic skill; the patient must learn to take care of her body in order to become an independent citizen. In the third repertoire washing is a precondition to citizenship; patients are to be helped to develop their potentials so that they can find their way in the community. In the fourth repertoire, washing is one opportunity among others to develop social relations; the extent and quality of these relations define a citizen. This analysis opens up not the question if, but which type of citizenship should be promoted.

The "patient perspective" serves as an analytical tool to present patients as knowing subjects in research, rather than as objects known by medicine. This paper analyses problems encountered with the concept of the patient perspective as applied to long-term mental health care. One problem is that "having a perspective" requires a perception of oneself as an individual and the ability to represent one's individual situation in language; this excludes from research patients who do not express themselves verbally. Another problem is that the idea of "talk" as a representation of the world ignores the fact that talk is also performative in the world: it requires, at least, the ability to deal with an interview situation. To think up alternative ways of including patients as subjects in research, I develop an approach that takes this performativity as a starting point. Analysing practical situations and activities, I argue that patients enact appreciations, making known what they like or dislike by verbal or non-verbal means in a given material environment, in situations that are co-produced by others. Thus, subjectivity is linked to situations and interactions, rather than just to individual characteristics; to "patient positions;" rather than "patient perspectives".

Purpose: Students often act as subjects during practical and clinical skills training sessions. This routine seems to be quite acceptable for them but may present side-effects. Disorders, sometimes of a serious nature, have been discovered in medical students during clinical skills training. Because the incidence of and sequels to medical problems discovered in medical students during study-related activities are unknown, we carried out an explorative study., Methods: An anonymous questionnaire was administered to 1132 students (85%) in our medical school., Results: A total of 740 students (65% response rate) returned the questionnaire. Of them 124 (16.8% of respondents) reported 139 incidents. The estimated incidence was 1.5% per year. In 63 cases (45%) the diagnosis of a consulted doctor was known. Pathology (e.g. a ventricular septal defect) was revealed in 30 students (21%), a normal physiological variation (e.g. a functional cardiac murmur) in 22 (16%) and no abnormality was found in 11 (8%). Most of the incidents (65%) occurred during clinical skills training. The incidents were experienced negatively by 35% of the students., Conclusion: Based on these findings, we estimate the incidence of medical problems discovered in medical students during study-related activities to be 1.5%. This and the moral and legal implications emphasise that every medical school should realise the possibility of consequences. In our opinion, this realisation should result, minimally, in the development of a protocol for students and faculty that outlines procedures for handling such incidents. Information should also be provided explaining these possible side-effects of medical education.

Integrating mental health care into residential homes for the elderly is a potentially effective model to address the complex care needs of older chronically mentally ill people. Because no research was available on the implementation of such integrated care in practice, six programs already operating in the Netherlands were analyzed. At the administrative level, three types of cooperative arrangements existed: a psychiatric hospital renting a unit in a residential home for the elderly, a psychiatric hospital stationing mental health professionals in a residential home on a permanent basis, and a residential home employing its own psychiatrically trained staff. At the operational level, contrasting views emerged on the relation-ship between physical and mental health care; these were delivered separately or in integrated form. In either case, the employees trained as elder care workers or as psychiatric nurses had difficulties understanding each other because they held different ideas about good-quality care. These care visions can be characterized as the care-giving approach (care workers) versus the problem-oriented and the rehabilitation approaches (nurses). At the housing level, two models existed: mentally ill patients having apartments in a separate unit (concentrated housing) or located throughout the facility (dispersed housing). The most promising model appears to be the one in which a psychiatric hospital assigns mental health professionals to work in a residential home, where they remain administratively and operationally distinct from the standard residential services. Whether or not the psychiatric residents should be housed in separate units could not be decided based on this study.

Four diterpenes were isolated from the stem bark of Mitrephora celebica through bioassay-guided fractionation. Ent-trachyloban-19-oic acid (1) and ent-kaur-16-en-19-oic acid (2) were identified as the compounds responsible for the antimicrobial activity of the plant against methicillin-resistant Staphylococcus aureus and Mycobacterium smegmatis. 8(14),15-pimaradien-18-oic acid (3) and 7,15-pimaradien-18-oic acid (4) were isolated from the same fraction and were inactive against the microorganisms.

Background: Despite the fact that visual function has an important role in the quality of life in later years, very few studies have measured visual acuity in population based nationwide samples of British elderly people. Such measurements were carried out in the context of the national diet and nutrition survey of people aged 65 years or over (NDNS)., Methods: NDNS participants, who were living in 80 different randomly selected postcode areas of mainland Britain, were visited at their home by a nurse who measured visual acuity at 3 metres, using the Glasgow acuity card (GAC) method. In addition, a brief questionnaire related to ocular health was administered., Results: Visual acuity was measured in 1362 NDNS participants who were not classified as mentally impaired. Visual impairment (using the WHO low vision criteria) was measured in 195 (14.3%) subjects. Prevalence of visual impairment increased significantly with age (65-74 years 3.1%; 75-84 years 11.6%; 85+ years 35.5%, p<0.001 for trend). Impaired vision was more common in subjects living in a nursing home (odds ratio adjusted for age 2.59 (95% CI 2.23 to 2. 96)) and in women (odds ratio adjusted for age 1.55 (95% CI 1.21 to 1.89)). 132 (9.7%) subjects had previously undergone cataract surgery and another 157 (11.5%) had been told that they currently had cataract. Vision improved 0.2 log units or more (at least one Snellen line) with the aid of a pinhole occluder in 289 subjects (21. 2%)., Conclusion: Results of this nationwide, community based study confirm that problems with poor distance visual acuity exist in a substantial part of the elderly community, particularly in women and people living in nursing homes.