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Purpose In this study, the authors assessed the influence of masking level (29% or 71% sentence perception) and test modality on the processing load during language perception as reflected by the pupil response. In addition, the authors administered a delayed cued stimulus recall test to examine whether processing load affected the encoding of the stimuli in memory. Method Participants performed speech and text reception threshold tests, during which the pupil response was measured. In the cued recall test, the first half of correctly perceived sentences was presented, and participants were asked to complete the sentences. Reading and listening span tests of working memory capacity were presented as well. Results Regardless of test modality, the pupil response indicated higher processing load in the 29% condition than in the 71% correct condition. Cued recall was better for the 29% condition. Conclusions The consistent effect of masking level on the pupil response during listening and reading support the validity of the pupil response as a measure of processing load during language perception. The absent relation between pupil response and cued recall may suggest that cued recall is not directly related to processing load, as reflected by the pupil response.

This qualitative study explores (1) how members of the Dutch Association for People with Bipolar Disorder explain the affliction of bipolar disorder; (2) the relationship between genetic, environmental and personal factors in these explanations and (3) the relationship between illness explanations, self-management and identity. A total of 40 participants took part in seven different focus group discussions. The results demonstrate that there are two different explanatory idioms, each one centred around an opposing concept, that is, susceptibility and disease. Individuals who construct explanations around the concept of ‘disease’ attach more importance to ‘genes and chemicals’ than to environmental components in the onset of the disorder, whereas individuals adhering to the central concept of ‘susceptibility’ tend to do this much less. Compared with individuals using the ‘susceptibility’ idiom, those who use a ‘disease’ idiom tend to observe fewer possibilities for self-management and are less inclined to construct normalcy through a quest for personal growth. Stories of suffering seem more integral to the ‘disease’ idiom than to the ‘susceptibility’ idiom. The ‘disease’ idiom seems less integrated in a contemporary surveillance psychiatric discourse than the ‘susceptibility’ idiom; however, both vocabularies can offer normative constraints.

Item does not contain fulltext OBJECTIVES: Although the course of single diseases can be studied using traditional epidemiologic techniques, these methods cannot capture the complex joint evolutionary course of multiple disorders. In this study, multilevel temporal Bayesian networks were adopted to study the course of multimorbidity in the expectation that this would yield new clinical insight. STUDY DESIGN AND SETTING: Clinical data of patients were extracted from 90 general practice registries in the Netherlands. One and half million patient-years were used for analysis. The simultaneous progression of six chronic cardiovascular conditions was investigated, correcting for both patient and practice-related variables. RESULTS: Cumulative incidence rates of one or more new morbidities rapidly increase with the number of morbidities present at baseline, ranging up to 47% and 76% for 3- and 5-year follow-ups, respectively. Hypertension and lipid disorders, as health risk factors, increase the cumulative incidence rates of both individual and multiple disorders. Moreover, in their presence, the observed cumulative incidence rates of combinations of cardiovascular disorders, that is, multimorbidity differs significantly from the expected rates. CONCLUSION: There are clear synergies between health risks and chronic diseases when multimorbidity within a patient progresses over time. The method used here supports a more comprehensive analysis of such synergies compared with what can be obtained by traditional statistics.

Businesses increasingly offer their services electronically via the Web. Take for example an Internet Service Provider. An ISP offers a variety of services, including raw bandwidth, IP connectivity, and Domain Name resolution. Although in some cases a single service already satisfies a customer need, in many situations a customer need is so complex that a bundle of services is needed to satisfy the need, as with the ISP example. In principle, each service in a bundle can be provisioned by a different supplier. This paper proposes an ontology, e3service , that can be used to formally capture customer needs, services, and multisupplier service bundles of these. In addition, this paper contributes a process called PCM2 to reason with the ontology. First, a customer need is identified for which desired consequences are elicited. Then, the desired set of consequences is matched with consequences associated with services. The matching process results in a service bundle, satisfying the customer need, containing services that each can be provided by different suppliers. PCM2 is inspired by a family of formal reasoning methods called Propose-Critique-Modify (PCM). However, whereas PCM methods emphasize solution generation from a given set of requirements, our reasoning process treats the space of requirements as a first class citizen. Hence PCM2 : the requirements space and solution space are equally important. How the reasoning and matching process practically works, is illustrated by an industry strength case study in the healthcare domain.

Objective To test the effect of 800 μg of misoprostol orally on the prevention of manual removal of retained placenta. Design Multicenter, double-blinded, placebo-controlled, randomized trial. Setting One university and one non-university teaching hospital in the Netherlands. Sample 99 women with retained placenta (longer than 60 min after childbirth) in the absence of postpartum hemorrhage. Methods Eligible women were administered either 800 μg of misoprostol or placebo orally. Main outcome measures Number of manual removals of retained placenta and amount of blood loss. Results Manual removal of retained placenta was performed in 50% of the women who received misoprostol and in 55% who received placebo (relative risk 0.91, 95% confidence interval 0.62-1.34). No difference in the amount of blood loss (970 vs. 1120 mL; p = 0.34) was observed between the two groups. Conclusions Administration of 800 μg of oral misoprostol, one hour after childbirth, does not seem to reduce the number of manual removals of retained placentas. The time elapsing results in the delivery of 50% of the retained placentas at the expense of an increased risk of postpartum hemorrhage. © 2013 The Authors Acta Obstetricia et Gynecologica Scandinavica © 2013 Nordic Federation of Societies of Obstetrics and Gynecology.

Contains fulltext : 117640.pdf (Publisher’s version ) (Open Access) OBJECTIVES: To test the hypothesis that low risk women at the onset of labour with planned home birth have a higher rate of severe acute maternal morbidity than women with planned hospital birth, and to compare the rate of postpartum haemorrhage and manual removal of placenta. DESIGN: Cohort study using a linked dataset. SETTING: Information on all cases of severe acute maternal morbidity in the Netherlands collected by the national study into ethnic determinants of maternal morbidity in the netherlands (LEMMoN study), 1 August 2004 to 1 August 2006, merged with data from the Netherlands perinatal register of all births occurring during the same period. PARTICIPANTS: 146 752 low risk women in primary care at the onset of labour. MAIN OUTCOME MEASURES: Severe acute maternal morbidity (admission to an intensive care unit, eclampsia, blood transfusion of four or more packed cells, and other serious events), postpartum haemorrhage, and manual removal of placenta. RESULTS: Overall, 92 333 (62.9%) women had a planned home birth and 54 419 (37.1%) a planned hospital birth. The rate of severe acute maternal morbidity among planned primary care births was 2.0 per 1000 births. For nulliparous women the rate for planned home versus planned hospital birth was 2.3 versus 3.1 per 1000 births (adjusted odds ratio 0.77, 95% confidence interval 0.56 to 1.06), relative risk reduction 25.7% (95% confidence interval -0.1% to 53.5%), the rate of postpartum haemorrhage was 43.1 versus 43.3 (0.92, 0.85 to 1.00 and 0.5%, -6.8% to 7.9%), and the rate of manual removal of placenta was 29.0 versus 29.8 (0.91, 0.83 to 1.00 and 2.8%, -6.1% to 11.8%). For parous women the rate of severe acute maternal morbidity for planned home versus planned hospital birth was 1.0 versus 2.3 per 1000 births (0.43, 0.29 to 0.63 and 58.3%, 33.2% to 87.5%), the rate of postpartum haemorrhage was 19.6 versus 37.6 (0.50, 0.46 to 0.55 and 47.9%, 41.2% to 54.7%), and the rate of manual removal of placenta was 8.5 versus 19.6 (0.41, 0.36 to 0.47 and 56.9%, 47.9% to 66.3%). CONCLUSIONS: Low risk women in primary care at the onset of labour with planned home birth had lower rates of severe acute maternal morbidity, postpartum haemorrhage, and manual removal of placenta than those with planned hospital birth. For parous women these differences were statistically significant. Absolute risks were small in both groups. There was no evidence that planned home birth among low risk women leads to an increased risk of severe adverse maternal outcomes in a maternity care system with well trained midwives and a good referral and transportation system.

Limited integration of contextual factors in maternal care contributes to slow progress towards achieving MDG5 in sub-Sahara Africa. In Ngorongoro, rural Tanzania, the maternal mortality ratio is high with 642 maternal deaths/100,000 live births. Skilled birth attendants (SBAs) assist only 7% of deliveries. This study, undertaken from 2009 to 2011, used Participatory Action Research involving local stakeholders (Maasai women and men, traditional birth attendants (TBAs), hospital staff) to examine reasons for low utilization of SBAs and moreover to develop proposals how to integrate contextual factors and local needs in the health care system. Interviews, observations and literature study were also conducted. Thaddeus and Maine’s Three Delays model is used to structure the analysis. Delaying factors in decision making at home: negative perceptions by the community on availability and quality of care in the hospital; discontinuity of care by TBAs; food and financial insecurity; desired nearness to cattle and family; limited recognition of maternal deaths; limited male health education and suboptimal birth preparedness. Delaying factors in reaching the hospital: vehicle and road limitations. Delaying factors in receiving hospital care: limited (human) resources and limited knowledge sharing at the hospital. Community members and health workers proposed: increasing food/financial security; tailoring male health education; combining TBA/SBA care to provide continuous, culturally appropriate labour support; creating separate maternity wards; increasing the number and training of staff; ensuring continuous availability of Emergency Obstetric Care. Applying solutions to increase hospital utilization seems complex as collaborative actions by multiple actors and institutions are needed to create both a needs based and clinically sound continuum of maternal care. To follow-up this process of integrating local solutions into the maternal care system, we suggest to adapt the WHO Strategic Approach—a top-down framework for the implementation of innovations—to fit this bottom-up approach.

Purpose. Health-care providers invest substantial resources to establish and implement hospital quality management systems. Nevertheless, few tools are available to assess implementation efforts and their effect on quality and safety outcomes. This review aims to (i) identify instruments to assess the implementation of hospital quality management systems, (ii) describe their measurement properties and (iii) assess the effects of quality management on quality improvement and quality of care outcomes. Data sources. We performed a systematic literature search from 1990 to 2011 in PubMed, CINAHL, EMBASE, Cochrane Library and Web of Science. In addition, we used snowball strategies, screened the reference lists of eligible papers, reviewed grey literature and contacted experts in the field. Study selection and data extraction. Two reviewers screened eligible papers based on pre-defined inclusion and exclusion criteria and all authors extracted data. Eligible papers are described in terms of general characteristics (settings, type and level of respondents, mode of data collection), methodological properties (sampling strategy, item derivation, conceptualization of quality management, assessment of reliability and validity, scoring) and application/implementation (accounting for context, organizational adaptations, sensitivity to change, deployment and effect size). Results. Eighteen papers were deemed eligible for inclusion. While some common domains emerged in measurement conceptualization, substantial differences in scope persist. The instruments’ measurement properties were insufficiently described and only few instruments assessed links between the implementation of quality management systems (QMS) and improvement strategies or outcomes. Conclusions. There is currently no well-established measure to assess the implementation and effectiveness of quality management systems. Future research should address this gap.

Background: Little is known about the quantity and reasons for use of palliative sedation in general practice. Aim: To gain more insight into the trends of and reasons for palliative sedation in Dutch general practice. Design and setting: Dynamic cohort study using registrations and questionnaire data of Dutch GPs. Method: Data collected in the years from 2005 until 2011 in the Dutch Sentinel General Practice Network were analysed. Trends and reasons for use of palliative sedation were analysed using multilevel analyses to control for clustering of observations within general practices. Results: From 2005–2011, 183 cases were reported from 56 general practices. The incidence of palliative sedation fluctuated between 33.7 per 100 000 patients in 2006 and 15.2 in 2011. No rise or decline during the period was observed. Palliative sedation was applied in 5.7% of all deaths and most frequently used in younger patients with cancer. The mean number of refractory symptoms was 2.6 (SD 1.2); pain (69.4%), dyspnoea (53.0%), and fear (39.3%). Patient involvement in decision making before the start of palliative sedation (87.4%) was less frequently present in patients suffering from cardiovascular or chronic obstructive pulmonary disease and in older patients compared to patients with cancer (P

Aims and objectives: This paper is a report of a study of experiences of people with Cystic Fibrosis (CF) with their hospital admission. It evaluates how they perceive their treatment and care and the impact on their social life (school or work). Background: In The Netherlands, people with CF are hospitalized in seven CF centers. In general, hospitalization may raise several challenges concerning the patient’s psychosocial well-being, before, during and after the admission. The admission of people with CF is complicated, because of segregated treatment and care that aims to prevent hospital-based cross-infection. Design: This article reports on a qualitative study. Methods: Data were collected during 2009 and 2010. Nineteen people with CF admitted for more than 5 days in one of the seven Dutch CF-centres participated. Results and conclusions: The findings are organized into five contexts with subthemes: Before admission & Arrival (1); Treatment & Care (2); Room & Stay (3); Discharge (4); Social & Societal context (5). The findings show that patients express a need for enhancing the quality of some treatments, like intravenous injections and patients express normative expectations of professionals that directly relate to their psychosocial well-being, e.g. they want to be ‘seen’ and treated as human beings and not solely as patients. They desire segregation policies to be consistent, whilst simultaneously they prefer flexible segregation guidelines. In general, respondents are satisfied with hospital facilities. The study reports on challenges concerning continuation of school and work during the admission. The paper is relevant to every hospital where people are being nursed in isolation.

In deze klinische les illustreren we de meerwaarde en werkwijze van de POH-ouderenzorg, een verpleegkundige die de huisarts ondersteunt bij de uitvoering van chronische en preventieve zorg voor ouderen, een belangrijke taak. Zij neemt geen taken van de huisarts over, maar is complementair aan diens werk en expertise en versterkt en ondersteunt deze: er is sprake van supplementatie van zorg. Het gaat om een proactieve en gestructureerde aanpak via de inzet van een verpleegkundige (POH-ouderenzorg), die niet alleen reageert op klachten, maar die ook actief problemen signaleert en deze tijdig aanpakt via een geintegreerd zorgaanbod-op-maat. Daarbij stimuleert zij de actieve inbreng van de oudere zelf, zodat de zorg aansluit bij de doelen en de levenswijze van de oudere.

Objectives To compare actual treatments with preferences for starting or forgoing treatment of older adults at the end of life. Design Mortality follow-back study of relatives of deceased older adults. Preferences and actual treatment were studied for each of four treatments: starting or forgoing resuscitation (do not resuscitate), artificial nutrition and hydration (ANH), antibiotics, and artificial respiration. Setting Older adults in the Netherlands. Participants Proxies of deceased members (in 2006-2009) of two cohorts representative of the older Dutch population (n = 168) and of people with an advance directive (n = 184). Measurements Relationship between preferred and actual treatment. Results In most individuals who preferred receiving treatment, this preference was followed (n = 2/2, resuscitation; 23/26, ANH; 33/38, antibiotics; 23/24, AR). In approximately half of the individuals who preferred that a treatment be forgone, the preference was followed (n = 6/13, resuscitation; 11/18, ANH; 3/5, antibiotics), except for artificial respiration (n = 1/8). The majority of people for whom no preference was known received treatment (n = 5/9, resuscitation; 19/33, ANH; 15/20, antibiotics; 8/13, artificial respiration). People with a known preference for receiving a specific treatment had a seven times higher chance of preference being followed than people with a known preference for forgoing that treatment. People with a known preference for forgoing a treatment had a six times higher chance of treatment being forgone than people having no known preference. Conclusion Although concordance between preferred and actual treatment is high in older adults who prefer treatment and lower in people who prefer no treatment, making preferences for forgoing treatment known is useful because it increases the chance of treatments being forgone in those who wish so. © 2013, The American Geriatrics Society.

Objective Pharmacological treatment of older adults with cognitive impairment represents a challenge for prescribing physicians, and polypharmacy is common in these complex patients. The aim of the current study is to assess prevalence and factors related to polypharmacy in a sample of nursing home (nursing home) residents with advanced cognitive impairment. Methods We conducted a cross-sectional analysis of 1449 nursing home residents with advanced cognitive impairment participating to the Services and Health for Elderly in Long Term Care (SHELTER) project, a study collecting information on residents admitted to 57 nursing home in eight countries. Data were collected using the International Resident Assessment Instrument (InterRAI) for long-term care facilities. Polypharmacy status was categorized into three groups: nonpolypharmacy (zero to four drugs), polypharmacy (five to nine drugs), and excessive polypharmacy (≥10 drugs). Results Polypharmacy was observed in 735 residents (50.7%) and excessive polypharmacy was seen in 245 (16.9%). Compared with nonpolypharmacy, excessive polypharmacy was associated directly with ischemic heart disease (odds ratio [OR], 3.68; 95% confidence interval [CI], 2.01–6.74), diabetes mellitus (OR, 2.66; 95% CI; 1.46–4.84), Parkinson's disease (OR, 2.84; 95% CI, 1.36–5.85), gastrointestinal symptoms (OR, 1.20; 95% CI, 1.43–3.39), pain (OR, 3.12; 95% CI, 1.99–4.89), dyspnea (OR, 2.57; 95% CI, 1.31–5.07), and recent hospitalization (OR, 2.56; 95% CI, 1.36–5.85). An inverse relation with excessive polypharmacy was shown for age (OR, 0.74; 95% CI, 0.59–0.93), activities of daily living disability (OR, 0.79; 95% CI, 0.63–0.99) and presence of a geriatrician on the nursing home staff (OR, 0.36; 95% CI, 0.20–0.64). Conclusion Polypharmacy and excessive polypharmacy are common among nursing home residents with advanced cognitive impairment. Determinants of polypharmacy status includes not only comorbidities, but also specific symptoms, age, and functional status. A geriatrician in the facility is associated with lower prevalence of excessive polypharmacy.

Objective To determine the change in adverse event (AE) rates and preventable AE rates over time, identify certain patient risk groups and discuss factors influencing the outcome. Design Longitudinal retrospective patient record review study. Setting and participants A random sample of 21 hospitals in The Netherlands in 2004, and 20 hospitals in 2008. In each hospital, 400 patient admissions were included in 2004, and 200 in 2008. Main outcome measures AEs and preventable AEs. Results Multilevel analyses of 11 883 patient records (7.887 in 2004, 3.996 in 2008) showed that the rate of patients experiencing an AE increased from 4.1% (95% CI 3.3% to 5.1%) in 2004 to 6.2% (95% CI 5.0% to 7.6%) in 2008. The preventable AE rate remained relatively stable at 1.8% (95% CI 1.3% to 2.4%) in 2004 and 1.6% (95% CI 1.2% to 2.3%) in 2008. The risk of experiencing a preventable AE was increasingly higher for patients admitted to a surgical unit (OR 1.54 (95% CI 1.10 to 2.16) in 2004 and 3.32 (95% CI 2.17 to 5.07)) in 2008. More than 50% of all AEs were related to surgery. Indications were found that differences in the risk of experiencing a preventable AE between hospital departments were larger in 2008 than in 2004, while differences between hospitals themselves were smaller. Conclusions Patient harm related to healthcare is a persistent problem that is hard to influence. Measuring AEs over time stresses the continuing urgency, and also identifies possible areas for improvement.

Patients with chronic obstructive pulmonary disease (COPD) are at increased risk of cardiovascular disease. Electrocardiography (ECG) carries information about cardiac disease and prognosis, but studies comparing ECG characteristics between patients with and without COPD are lacking. We related ECG characteristics of patients with COPD, to ECG characteristics of patients without COPD, and determined whether ECG abnormalities are related to COPD severity. A cross-sectional study was conducted within a cohort of 243 COPD patients, aged 65 years or older. All patients underwent extensive examinations, including resting 12-lead ECG and pulmonary function tests. The reference group (n = 293) was a sample from the general population, also aged 65 or older, without COPD. Abnormal ECGs were more prevalent in COPD patients (50%) than in patients without COPD (36%, p = 0.054). Conduction abnormalities were the most common ECG abnormality in COPD patients (28%) being significantly more prevalent than in patients without COPD (11%, p < 0.001). The mean heart rate was higher in COPD patients (72 bpm (SD 14)) compared to controls (65 bpm (SD 13), p < 0.001), and QTc prolongation was less frequent in COPD patients (9% versus 14%, p = 0.01). The prevalence of ECG abnormalities increased with severity of pulmonary obstruction. ECG abnormalities, especially conduction abnormalities are common in COPD patients, and the prevalence of ECG abnormalities increases with severity of COPD. This underlines the importance of an integrated-care approach for COPD patients, paying attention to early detection of unrecognized coexisting cardiac disorders.

Background: Nowadays, palliative care is considered as a care continuum that may start early in the course of the disease. In order to address the evolving needs of patients for palliative care in time, GPs should be aware in good time of the diagnosis and of the imminence of death. The aim of the study was to gain insight into how long before a non-sudden death the diagnosis of the disease ultimately leading to death is made and on what kind of information the diagnosis is based. In addition, we aimed to explore when, and based on what kind of information, GPs become aware that death of a patient will be in the foreseeable future. Methods: A written questionnaire focusing on the GPs' experiences with their last patient who died non-suddenly was sent to a random representative sample of 850 GPs in the Netherlands. Results: The data were analysed of the 297 GPs who responded. 76% of the reported cases were cancer patients and 24% were patients with another non-sudden cause of death. The diagnosis was made only in the last week of life for 15% of the non-cancer patients and 1% of the patients with cancer. GPs were most likely to have been informed of the diagnosis by the medical specialist, although particularly in the case of non-cancer patients GPs also relied on their own assessment of the diagnosis or on other information sources. The GP remained unaware that the patient would die in the foreseeable future until the last week of life in 26% of the non-cancer group, while this was the case for only 6% of the cancer patients. GP's awareness was most likely to be based on the GP's own observations of problems and/or symptoms. Conclusions: The GP often only becomes aware of a fatal diagnosis and of death in the foreseeable future at a late stage in the disease trajectory, particularly in the case of non-cancer patients. It can be assumed that if the diagnosis and the nearing death are only recognised at a late stage, palliative care is either started at a very late stage or not at all.

Context In Belgium, data on actual advance care planning (ACP) in nursing homes (NHs) are scarce. Objectives To investigate the prevalence and characteristics of documented advance directives and physicians' orders for end-of-life care in NHs, and the authorization of a legal representative in relation to the residents' demographic and clinical characteristics and care received. Methods This was a retrospective cross-sectional study, including all NH residents deceased during September and October 2006 in all 594 NHs in Flanders, Belgium. Structured mail questionnaires about the resident's characteristics, hospital transfers, palliative care delivery, ACPs, and authorization of legal representatives were completed via the NH administrators and nurses involved in the care of the resident. Results Administrators of 318 NHs (53.5%) reported 1303 deaths. Nurses provided information about 1240 (95.2%) of these deaths. At the end of life, NH residents often had dementia (65.2%) and were severely dependent (76.1%). Almost half (43.1%) had at least one hospital transfer during the last three months of life and two-thirds received palliative care. Half had an ACP, predominantly a physician's order and less often an advance directive. Having advance directives or physician's orders was associated with receiving palliative care. Residents with a physician's order more often died in the NH. Nine percent had an authorized legal representative. Conclusion Prevalence of ACPs and formal authorization of a legal representative was low among the deceased NH residents in Flanders, Belgium. There was a higher prevalence of physicians' orders, often established after the resident had lost capacity. Initiatives should be developed to stimulate more advance discussion on care options and making end-of-life decision with the residents while they retain capacity.

Item does not contain fulltext Abstract Background: Chronic diseases are considered major threats to self-rated health (SRH). In many elderly people multimorbidity is present, in elderly women more than in elderly men. This study aims at establishing the impact of multimorbidity and specific disease combinations on SRH in elderly women. Objectives: To study the relationship between the number of chronic diseases and SRH and explore possible effects of combinations of chronic conditions on SRH in elderly women. Methods: Health interview data used for this study originated from the second Dutch National Survey of General Practice, a study with a response rate of 64.5%. From the 12 699 respondents, 315 were females between 70 and 74 years old. Results: Of the women, 87% reported one or more chronic condition. Women without any chronic condition rated their health significantly better than those with one or more chronic conditions. Either severe back pain or severe headache was included in return the most prevalent combinations of two chronic conditions with a significantly higher negative impact on SRH than expected. Conclusion: All combinations including severe headache and some combinations including severe back pain and another chronic condition had a significantly more negative impact on SRH than expected in women aged 70-74 years. General practitioners should be alert on severe headache and severe back pain in elderly women to improve proactive the quality of care and thus add to the quality of later years of life. 6 p.

AIM: To describe how patients with COPD, heart failure, dementia and cancer differ in frequency and timing of referral to palliative care services. METHODS: We performed a population-based study with the Sentinel Network of General Practitioners in Belgium. Of 2405 registered deaths respectively 5%, 4% and 28% were identified as from COPD, heart failure or cancer and 14% were diagnosed with severe dementia. GPs reported use and timing of palliative care services and treatment goals in the final three months of life. RESULTS: Patients with COPD (20%) were less likely than those with heart failure (34%), severe dementia (37%) or cancer (60%) to be referred to palliative care services (p < 0.001). The median days between referral and death was respectively 10, 12, 14 and 20. Patients with COPD who were not referred more often received treatment with a curative or life-prolonging goal and less often with a palliative or comfort goal than did the other patients who were not referred. CONCLUSION: Patients with COPD are underserved in terms of palliative care compared to those with other chronic life-limiting diseases. Awareness of palliative care as an option for patients with COPD needs to increase in palliative care services, physicians and the general public.

Retinal microvascular changes can be visualized noninvasively and have been associated with cognitive decline and brain changes in relation to aging and vascular disease. We systematically reviewed studies, published between 1990 and November 2012, on the association between retinal microvascular changes and dementia, cognitive functioning, and brain imaging abnormalities, in the context of aging and vascular risk factors. In cross-sectional studies (k = 26), retinal microvascular changes were associated with the presence of dementia (range of odds ratios (ORs) 1.17;5.57), with modest decrements in cognitive functioning in nondemented people (effect sizes -0.25;0.03), and with brain imaging abnormalities, including atrophy and vascular lesions (ORs 0.94;2.95). Longitudinal studies were more sparse ( k = 9) and showed no consistent associations between retinal microvascular changes and dementia or cognitive dysfunctioning 3 to 15 years later (ORs and hazard ratios 0.77;1.55). However, there were indications of prospective associations with brain imaging abnormalities ((ORs) 0.81;3.19). In conclusion, particularly in cross-sectional studies there is a correlation between retinal microvascular changes and dementia, cognitive impairment, and brain imaging abnormalities. Associations are strongest for more severe retinal microvascular abnormalities. Retinal microvascular abnormalities may offer an important window on the brain for etiological studies.

Item does not contain fulltext OBJECTIVE: to gain insight into the scale, nature, preventability and causes of adverse events in hospitalised older patients. DESIGN: a three-stage retrospective, structured, medical record review study of 7,917 records of patients admitted in 21 Dutch hospitals in 2004. Main outcome measures: incidence, preventability, clinical process category, consequences and causes of adverse events in hospitalised patients of 65 years and older, compared with patients younger than 65. RESULTS: adverse events and preventable adverse events occur significantly more often in older patients [6.9% (95% CI: 5.9-8.0%) and 2.9% (95% CI: 2.3-3.7%), respectively] than in younger patients [4.8% (95% CI: 4.0-5.7%) and 1.8% (95% CI: 1.3-2.4%), respectively]. In older patients, the adverse events were more often related to medication (20.1 versus 9.6%) (P < 0.01). An exploration of the causes revealed that the inability to apply existing knowledge to a new and complex situation contributes more often to the occurrence of adverse events in older patients than in younger patients (36.4 versus 24.3%) (P < 0.05). CONCLUSION: to reduce the number of adverse events in older patients in the future, more particular training of hospital staff in geriatric medicine is required, with a specific focus on medication.

Schreuder F, Bernsen RM, Van der Wouden JC. Vitamine D bij pijn van het bewegingsapparaat. Huisarts Wet 2013;56(7):310-3. Veel niet-westerse allochtonen komen bij hun huisarts met chronische of recidiverende aspecifieke pijn van het bewegingsapparaat. Wij onderzochten het effect van vitamine-D 3 -suppletie op de klachten in deze groep patienten. Wij hebben ons onderzoek opgezet als een gerandomiseerde gecontroleerde semi-crossovertrial. De deelnemers waren 84 niet-westerse allochtonen die in 2008-2010 bij de huisarts kwamen vanwege chronische of recidiverende pijn en die een lage vitamine-D-spiegel hadden. Aan het begin van de trial kregen zij at random eenmalig placebo of 150.000 IE vitamine D 3 oraal. Na zes weken werden zij nogmaals gerandomiseerd naar placebo of vitamine D 3 , waarbij het niet mogelijk was om tweemaal placebo te krijgen. Primaire uitkomstmaat was de zelfgerapporteerde (sterke) verbetering van de pijn op een vijfpunts likertschaal na de eerste zes weken. Na 6 weken rapporteerde 34,9% van de patienten uit de vitamine-D-groep een (sterke) verbetering van de pijn, versus 19,5% in de placebogroep (p=0,04). Bovendien was ook het traplopen in de vitamine-D-groep vaker verbeterd (21,0% versus 8,4%; p=0,008). Na 12 weken rapporteerde de groep beide periodes vitamine D had gekregen een significant grotere verbetering van de pijn dan de groep die alleen in de tweede periode vitamine D had gekregen (p=0,005), maar niet ten opzichte van de groep die alleen in de eerste periode vitamine D had gekregen (p=0,26). Zes weken na suppletie met 150.000 IE vitamine D 3 verbeterde de zelfgerapporteerde pijn bij niet-westerse allochtonen met een aanvankelijk lage vitamine-D-spiegel en lang bestaande aspecifieke pijn van het bewegingsapparaat.

Primary health care use of cancer patients is increased, even years after active treatment. Insight into the reasons for this could help in developing and improving guidelines and planning of health care, which is important given the expected increase in cancer survivors. Using data from the Netherlands Information Network of Primary Care, we selected 1256 adult breast cancer, 503 prostate cancer and 487 colorectal cancer patients diagnosed between 2001 and 2006. We compared diseases and complaints for which they contacted their General Practitioner (GP) 2-5 years after diagnosis to age and sex matched non-cancer controls from the same practice. Cancer patients consulted their GP more often than controls for acute symptoms such as abdominal pain and fatigue (18% more in breast cancer, 26% more in prostate cancer) and infections, such as cystitis or respiratory infections (45% in breast cancer and 17% in colorectal cancer). Consultations for chronic diseases and psychosocial problems were slightly increased: breast cancer patients had more contacts related to diabetes (55%), sleep disturbance (60%) and depression (64%), prostate cancer patients had more contacts related to hypertension (53) and chronic obstructive pulmonary disease (COPD, 34%). Adverse drug effects were almost twice as often observed in prostate and colorectal cancer patients than in controls. Fear of cancer recurrence was noted as the reason for consulting the GP in only 20 patients. Concluding, increased primary health care use in cancer survivors is mostly related to common infections and acute symptoms, which may be due to direct effects of cancer treatment or increased health concerns.

To validate KalacheKickbusch's model: namely, that functional capacity peaks in early adulthood, then declines at a rate dependent on fitness level until a "disability threshold" is reached.Data came from the Australian Longitudinal Study on Women's Health, which followed three cohorts from 1996 to 2011: a young, a mid-aged and an older cohort (born in 1973-78, 1946-51 and 1921-26, respectively). The Short Form (36) Health Survey was used to measure physical functioning (score 1-100). The disability threshold was the mean physical functioning score in older women requiring assistance with daily activities (62.8). The relationship between age and physical functioning was modelled using spline regression for the entire sample, and by baseline physical functioning quintile and physical activity level.PHYSICAL DECLINE QUICKENED WITH AGE: 0.05 annual units (95% confidence interval, CI: -0.13 to 0.22) at ages 18-23 years (i.e. no decline); -2.43 (95% CI: -2.64 to -2.23) at ages 82-90 years. Decline was faster in quintiles with lower baseline physical functioning in the younger and mid-age cohorts and in quintiles with higher baseline physical functioning in the older cohort. The disability threshold was reached at a mean age of 79 years, but the range was 45-88 years, depending on baseline physical functioning and physical activity.Age and physical decline are not linearly related, as traditionally believed; decline accelerates with age. However, baseline physical functioning, but not physical activity, influences the rate of decline.Valider le modèle de KalacheKickbusch, selon lequel la capacité fonctionnelle connaît un pic chez les jeunes adultes, puis diminue à une vitesse dépendant du niveau de forme physique jusqu'à ce qu'un «seuil d'incapacité» soit atteint.Les données proviennent de l'étude australienne longitudinale sur la santé des femmes, qui a suivi trois cohortes de sujets de 1996 à 2011: un groupe jeune, un groupe d'âge moyen et un groupe plus âgé (sujets nés entre 1973 et 1978, entre 1946 et 1951 et entre 1921 et 1926, respectivement). Le court formulaire (36 questions) sur la santé a été utilisé pour mesurer le fonctionnement physique (note de 1 à 100). Le seuil d'incapacité a été la note moyenne de fonctionnement physique chez les femmes âgées nécessitant une assistance pour les activités quotidiennes (62,8). La relation entre l'âge et le fonctionnement physique a été modélisée à l'aide d'une régression par spline pour l'ensemble de l'échantillon, et par quintile de fonctionnement physique de base et de niveau d'activité physique.Le déclin physique s’accélère avec l'âge: 0,05 unités annuelles (intervalle de confiance à 95%, IC: −0,13 à 0,22) entre 18 et 23 ans (pas de déclin); –2,43 (IC à 95%: −2,64 à −2,23) entre 82 et 90 ans. Le déclin a été plus rapide pour les quintiles à fonctionnement physique de base inférieur dans les cohortes jeune et d'âge moyen et pour les quintiles à fonctionnement physique de base plus élevé dans la cohorte plus âgée. Le seuil d'incapacité a été atteint à un âge moyen de 79 ans, mais la fourchette allait de 45 à 88 ans, selon le niveau de fonctionnement physique de base et l'activité physique.L'âge et le déclin physique ne sont pas liés de façon linéaire, comme on le croit traditionnellement. Le déclin s’accélère avec l'âge. Cependant, le fonctionnement physique de base influe sur la vitesse du déclin, contrairement à l'activité physique.Validar el modelo de Kalache y Kickbusch; a saber, que la capacidad funcional alcanza su punto máximo en la edad adulta temprana y disminuye luego a un ritmo que depende del nivel de condición física hasta alcanzar el "umbral de la discapacidad".Se tomaron los datos del Estudio Longitudinal Australiano sobre la salud de la mujer, que realizó el seguimiento de tres cohortes desde 1996 a 2011: una cohorte joven, una de mediana edad y una de edad avanzada (nacidas en 1973-1978, 1946-1951 y 1921-1926, respectivamente). Se utilizó el Cuestionario de Salud SF-36 para medir la función física (puntuación 1-100). El umbral de la discapacidad fue la puntuación media de la función física en las mujeres mayores que necesitan ayuda con las actividades cotidianas (62,8). Se concibió la relación entre la edad y la función física mediante una regresión por spline para toda la muestra, así como por quintil de funcionamiento físico basal y el nivel de actividad física.El deterioro físico se aceleró con la edad: 0,05 unidades anuales (intervalo de confianza del 95%, IC: − 0,13 a 0,22) a las edades de 18 a 23 años (es decir, sin deterioro); –2,43 (IC del 95%: −2,64 a −2,23) a las edades de 82 a 90 años. El deterioro fue más rápido en los quintiles de menor función física basal en las cohortes más jóvenes y de mediana edad y en los quintiles de mayor funcionamiento físico basal en la cohorte de mayor edad. Se alcanzó el umbral de la discapacidad a una edad media de 79 años, pero el rango fue de 45 a 88 años, en función del funcionamiento físico basal y la actividad física.A diferencia de la creencia tradicional, la edad y el deterioro físico no guardan relacionan lineal, aunque el deterioro se acelera con la edad. Sin embargo, el funcionamiento físico basal, aunque no la actividad física, influye en la tasa de deterioro.اعتماد نموذج KalacheKickbusch: بلوغ القدرة الوظيفية ذروتها في المرحلة المبكرة من البلوغ، ثم انخفاضها بمعدل يعتمد على مستوى اللياقة حتى بلوغ "عتبة العجز".تم الحصول على البيانات من دراسة طولانية في أستراليا حول صحة النساء، والتي تلت ثلاث مجموعات من عام 1996 إلى عام 2011: مجموعة صغيرة وفي منتصف العمر وأكبر عمراً (ولدت في الفترة من 1973 إلى 1978 وفي الفترة من 1946 إلى 1951 وفي الفترة من 1921 إلى 1926، على التوالي). وتم استخدام استقصاء الصحة الموجز (36) لقياس الوظائف الجسمية (الدرجة من 1 إلى 100). وكانت عتبة العجز هي متوسط درجة الوظائف الجسمية لدى النساء الأكبر سناً اللاتي يحتجن إلى المساعدة في الأنشطة اليومية (62.8). وتم نمذجة العلاقة بين السن والوظائف الجسمية باستخدام الارتداد الانحداري للعينة بأكملها وبواسطة المجموعات الخمسية للوظائف الجسمية عند خط الأساس ومستوى النشاط البدني.زادت سرعة الانخفاض في الوظائف الجسمية مع العمر: 0.05 وحدة سنوية (فاصل الثقة 95 %، من -0.13 إلى 0.22) عند السن من 18 إلى 23 سنة (أي لا يوجد انخفاض)؛ -2.43 (فاصل الثقة 95 %: من -2.64 إلى -2.23) عند السن من 82 إلى 90 سنة. وكان الانخفاض أسرع في المجموعات الخمسية الأقل من حيث الوظائف الجسمية عند خط الأساس في مجموعات منتصف العمر والمجموعات الأصغر وفي المجموعات الخمسية الأعلى من حيث الوظائف الجسمية عند خط الأساس في المجموعة الأكبر سناً. وتم بلوغ عتبة العجز عند متوسط عمر 79 سنة، ولكن تراوح النطاق من 45 إلى 88 سنة، بناءً على الوظائف الجسمية عند خط الأساس والنشاط البدني.لم يرتبط العمر والانخفاض في الوظائف الجسمية على نحو خطي، وفق الاعتقاد التقليدي؛ بل يتسارع الانخفاض مع العمر. وعلى الرغم من ذلك، تؤثر الوظائف الجسمية عند خط الأساس، وليس النشاط البدني، على معدل الانخفاض.验证Kalache和Kickbusch的模型:即,机能性能力在成年早期达到高峰,然后按依赖于健身水平的速度下降,直至达到“残疾门槛”。数据来自1996 至2011 年澳大利亚妇女健康纵向研究的三组样本:年轻、中年和老年组(分别在1973-78、1946-51 和1921-26 年代出生)。使用简表(36)健康调查测量身体机能(1-100 分)。残疾阈值是日常活动需要协助的老年女性的平均身体机能分数(62.8)。整个样本使用样条回归方法并按照基线身体机能五等分和体力活动水平建立年龄和身体机能之间关系的模型。随着年龄的增长,机能下降加快:18-23 岁为0.05 年度单位(95% 置信区间,CI: -0.13 至0.22)(即,无下降);82-90 岁为-2.43(95% CI:-2.64 至-2.23)。在年轻和中年组中基线身体机能较低的五分组机能下降更快,在老年组中基线身体机能更高的五分组机能下降更快。在平均年龄79 岁达到残疾阈值,但根据基线身体机能和身体活动,其范围为45-88 岁。年龄和机能下降不是传统上认为的线性相关,机能随着年龄的增长会加速下降。然而,基线身体机能(而不是身体活动)影响下降的速度。Проверить достоверность модели Калаша и Кикбуша (KalacheKickbusch), а именно, гипотезу, согласно которой функциональная активность достигает пика в раннем взрослом возрасте, после чего идет на убыль в темпе, зависящем от уровня физической подготовки, вплоть до достижения «порога инвалидности».Использовались данные Австралийского продольного исследования женского здоровья в трех группах участниц: молодого, среднего и пожилого возраста (родившихся в 1973–78 гг., 1946–51 гг. и 1921–26 гг. соответственно). Физическое состояние оценивалось по стобалльной системе (1–100) путем сокращенного (36) медицинского обследования. Порог инвалидности определялся как среднее значение показателя физического состояния у пожилых женщин, нуждающихся в посторонней помощи при выполнении повседневных занятий (62,8). Соотношение между возрастом и физическим состоянием моделировалось при помощи сплайновой регрессии по всей выборке и посредством квинтиля базового физического состояния и уровня физической активности.Ухудшение физического состояния с возрастом ускоряется: от 0,05 единиц в год (доверительный интервал (ДИ) 95%: от -0,13 до 0,22) в возрасте 18–23 лет (то есть, ухудшение отсутствует); до -2,43 единиц (ДИ 95%: от -2,64 до -2,23) в возрасте 82–90 лет. Ухудшение проходило быстрее в квинтилях с более низким базовым уровнем физического состояния в группах молодого и среднего возраста и в квинтилях с более высоким уровнем физического состояния в группе старшего возраста. Порг инвалидности достигался в среднем к 79 годам, однако разброс по этому показателю составил от 45 до 88 лет и зависел от базового физического состояния и физической активностиЗависимость ухудшения физического состояния от возраста не является линейной, как считалось ранее; с возрастом ухудшение ускоряется. Тем не менее, скорость ухудшения зависит от базового физического состояния, а не от физической активности.

Background: The place of death is of considerable interest now, yet few studies have determined public preferences for place of end-of-life (EOL) care or final days of life. Objective: A survey was designed to answer three questions: (1) What are public preferences for the place of last days? (2) Is this place preference related to socio-demographic and other background characteristics? and (3) Is this place preference associated with specified previous death and dying experiences, the preparation of a living will or advance directive, or a viewpoint supportive of death hastening? Design: An experienced telephone survey company was commissioned to gain a representative population-based sample and survey participants. In mid-2010, 1203 adults were surveyed in Alberta. Descriptive statistics and multinomial logistic regression were conducted. Results: This survey revealed 70.8% preferred to be at home near death; while 14.7% preferred a hospice/palliative care facility, 7.0% a hospital, and 1.7% a nursing home; 5.7% had no stated preference. Marital status was the only predictor of place preference, with widowed persons more often indicating a preference for a hospital or hospice/palliative care facility. Conclusions: These findings suggest homes are the preferred EOL place now for the majority of Albertans, if not other citizens, while at the same time suggesting that marital and living arrangement realities temper EOL place choices and possibilities, with widows best realizing the need for assistance from others when dying. The widespread preference for home-based EOL care indicates public health interventions are needed to promote good home deaths.

Objective: The ageing of the population is expected to lead to an increase in the prevalence of dementia. Providing support to informal caregivers is essential to promote their wellbeing and prevent serious caregiver burden. The aim of the study is to investigate whether differences occur between the initial and later stages of dementia in terms of (1) problems experienced by informal caregivers in the provision of care, (2) use of professional support by persons with dementia, (3) informal caregivers’ needs for additional professional support. Methods: The data were collected within the framework of the Dutch National Dementia Program, which was instigated in 2005 by the Dutch Ministry of Health, Welfare and Sport to improve integrated care for people with dementia and their informal caregivers. This paper is based on data of a questionnaire survey among 1494 informal caregivers, collected between September 2007 and December 2008. Results: Most informal caregivers (98-99%) experienced problems in caring for a person with dementia, irrespective of the stage of the illness process. In later stages, informal caregivers more often experienced problems in their social networks. Most dementia patients (87-94%) received ambulatory professional support. Conclusions: Since informal caregivers indicate a need for additional professional support in all stages of dementia, professional support should be provided during the entire illness process. Informal caregivers need advice on how to cope with symptoms of dementia, how to deal with behavior problems and receive more information about (early and advanced stages of) dementia and the supply of support.

Relapsing fever is a disease caused by one of the species of Borrelia. It is often misdiagnosed as malaria and can have fatal complications such as the Jarisch-Herxheimer reaction (JHR) after the commencement of treatment with antibiotics. A 19-year-old Tanzanian woman was admitted after a term home delivery that day. She presented with a 2 day history of fever, headache, general body malaise and vomiting. She was misdiagnosed as having severe malaria and was treated with quinine. The blood slide showed Borrelia duttoni. The patient continued treatment with procaine penicillin fortified for relapsing fever. Several hours later the woman died, probably due to JHR. This case of a patient with relapsing fever who died from a JHR stresses the importance of adequate diagnosis and treatment which should include careful monitoring, especially for the first hours after starting antibiotics. © 2013, SAGE Publications. All rights reserved.

The ability to recognize masked speech, commonly measured with a speech reception threshold (SRT) test, is associated with cognitive processing abilities. Two cognitive factors frequently assessed in speech recognition research are the capacity of working memory (WM), measured by means of a reading span (Rspan) or listening span (Lspan) test, and the ability to read masked text (linguistic closure), measured by the text reception threshold (TRT). The current article provides a review of recent hearing research that examined the relationship of TRT and WM span to SRTs in various maskers. Furthermore, modality differences in WM capacity assessed with the Rspan compared to the Lspan test were examined and related to speech recognition abilities in an experimental study with young adults with normal hearing (NH). Span scores were strongly associated with each other, but were higher in the auditory modality. The results of the reviewed studies suggest that TRT and WM span are related to each other, but differ in their relationships with SRT performance. In NH adults of middle age or older, both TRT and Rspan were associated with SRTs in speech maskers, whereas TRT better predicted speech recognition in fluctuating nonspeech maskers. The associations with SRTs in steady-state noise were inconclusive for both measures. WM span was positively related to benefit from contextual information in speech recognition, but better TRTs related to less interference from unrelated cues. Data for individuals with impaired hearing are limited, but larger WM span seems to give a general advantage in various listening situations. © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

Background.General practice–based data, collected within general practice registration networks (GPRNs), are widely used in research. The quality of the data is important but the recording criteria about what type of information is collected and how this information should be recorded differ between GPRNs.Objective.We aim to identify aspects that describe the quality of general practice-based data in the Netherlands.Methods.To investigate the quality aspects, we used the method of concept mapping, a structured conceptualization process for a complex multi-dimensional topic. We explored the ideas of representatives from 10 Dutch GPRNs on the quality of general practice–based data in five steps: preparation, generation of statements, structuring, representation and interpretation. In a brainstorm session, 10 experts generated statements about good data quality from general practice, which we completed with information from the literature. In total, 18 experts participated in the ranking and clustering of the statements. These results were analysed using ARIADNE software, using a combination of principal component analysis and cluster analysis techniques. Finally, the clusters were labelled based on their content.Results.A total of 72 statements were analysed, which resulted in a two-dimensional picture with six clusters, ‘complete health record’, ‘coding of information’, ‘episode oriented recording’, ‘diagnostic validity’, ‘recording agreements’ and ‘residual category’.Conclusions.The quality of general practice–based data can be considered on five content-based aspects. These aspects determine the quality of recording.Keywords: Classification, episodes of care, data quality, general practice, medical records, registries.

Background It is beyond doubt that blood transfusion services have added to the decline in maternal mortality in high-resource countries. To quantify the clinical benefit of red blood cell (RBC) transfusion in obstetric care, we performed a hypothetical experimental study using data from a prospective nationwide cohort of women giving birth in the Netherlands. Study Design and Methods Data were abstracted from a nationwide cohort study on severe maternal morbidity, including obstetric haemorrhage requiring 4 or more units of RBC, to obtain an observed and a hypothetical control group consisting of the same women. In the hypothetical control group, we simulated a situation where RBC transfusion was unavailable and estimated how many of these women would have died in that situation. A questionnaire survey asked experts in major (obstetric) haemorrhage to choose a critical minimal number of RBC transfusions at which a woman with obstetric haemorrhage would have died if RBC transfusion was not available. Maternal mortality rate per 100000 maternities [maternal mortality ratios (MMR)] and relative risk were calculated for the observed and hypothetical group. Results The observed MMR was 13 per 100000 maternities. According to 47 responding experts, the median number of RBC units without which a woman would have most probably died was nine, resulting in a hypothetical MMR of 87per 100000 maternities (relative risk 6·5; 95% confidence interval 4·2-10·0). Conclusions It can be expected that unavailability of RBC transfusion in obstetric care increases the risk of maternal death 6.5-fold. Blood transfusion thus largely contributes to the decline of MMR and would also be an important pillar of improving quality of care in resource-poor settings. © 2012 International Society of Blood Transfusion.

Background: Non-western women living in the Netherlands are diverse in origin, which implies diversity in their needs and expectations for midwifery care. Furthermore, it has also been shown that non-western women make suboptimal use of prenatal care. Midwives may therefore face difficulties when caring for these clients.Objective: The main objective of our study was to explore Dutch primary care midwives’ experiences with non-western clients.Methods: A qualitative design was used. Thirteen midwives were interviewed individually and 8 participated in a focus group. All interviews were transcribed and analysed by two researchers who compared and discussed their results. Analytical codes were organised into subthemes and main themes.Results: Midwives perceived ethnic diversity as both difficult and interesting. Caring for these women was perceived as demanding, but also rewarding. They experienced a variety of difficulties when caring for these women: communication problems, suboptimal health literacy, socioeconomic problems, lack of knowledge of the maternity care system, pressure from the family and a strong preference for physicians. In spite of these difficulties, midwives aim for optimal care by being alert and proactive, taking these women by the hand and making use of alternative resources.Conclusion: Provision of care to non-western clients can be difficult and may require additional measures. These problems and measures should be included in midwifery education programmes as well as training programmes for midwives.

Age-related decline in processing speed has long been considered a key driver of cognitive aging. While the majority of empirical evidence for the processing speed hypothesis has been obtained from analyses of between-person age differences, longitudinal studies provide a direct test of within-person change. Using recent developments in longitudinal mediation analysis, we examine the speed-mediation hypothesis at both the within-and between-person levels in two longitudinal studies, Longitudinal Aging Study Amsterdam (LASA) and Origins of Variance in the Oldest-Old (OCTO-Twin). We found significant within-person indirect effects of change in age, such that increasing age was related to lower speed, which in turn relates to lower performance across repeated measures on other cognitive outcomes. Although between-person indirect effects were also significant in LASA, they were not in OCTO-Twin which is not unexpected given the age homogeneous nature of the OCTO-Twin data. A more in-depth examination through measures of effect size suggests that, for the LASA study, the within-person indirect effects were small and between-person indirect effects were consistently larger. These differing magnitudes of direct and indirect effects across levels demonstrate the importance of separating between- and within-person effects in evaluating theoretical models of age-related change. © 2013 American Psychological Association.

Background: Studies on trends in the self-rated health (SRH) of older people have shown conflicting results, which might partly be explained by changing associations between SRH and indicators of other health dimensions over time. Therefore, this study investigates 17-year time trends in older adults' poor SRH, in the context of trends in chronic diseases and disability, between 1992 and 2009. Methods: Data originate from six measurement waves of the Longitudinal Aging Study Amsterdam (N = 4009, ages 60-85 years). SRH was assessed with the question 'How is your health in general?' The presence of lung disease, cardiac disease, peripheral arterial disease, diabetes mellitus, stroke, arthritis and cancer was assessed by self-report. Two severity levels of disability were assessed with six questions on physical functioning. Generalized Estimating Equations (GEE) analysis was applied to assess statistical significance in each time trend. Results: There was a stable trend in the prevalence of poor SRH and severe disability, while the mean number of chronic diseases (1.3-1.8) and the prevalence of mild disability (20.5-32.1%) increased between 1992 and 2009. The association between poor SRH and chronic diseases became weaker, whereas the association between poor SRH and severe disability became stronger over time. Most unfavourable trends were observed in the older old and the lower educated. Conclusion: Our results suggest that the seeming stability of poor SRH hides underlying increases in chronic diseases and disability: over time, people may attach importance to different aspects of health when rating their overall health. © 2012 The Author. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.

The influence of mutual spousal interrelations in domains such as health and wellbeing has been demonstrated, but little is known about the domain of everyday activities of couples in late life. In the present explorative study, we considered all of the activities participating couples talked about to be their everyday activities. Its aim was to understand, over time, changes in everyday activities as experienced by late-life community-dwelling couples. In a two-year period, 41 individual and joint interviews were conducted with 8 couples, who were purposefully selected from the Longitudinal Aging Study Amsterdam. Analyses involved the construction of couple narratives and constant comparisons within and across couples. Changing everyday activities in late-life couples was interpreted to be a two-way process of (1) converging, and (2) keeping up, which occurred in three fluid phases. Converging was a slow inward movement with a shift towards diminished everyday activities performed in a smaller world. Keeping up was an outward movement in order to resist the converging process by using everyday activities as a means to keep fit, physically and mentally, and to connect with the wider social world. In the first phase, couples maintained their unique linked activity pattern. In the second phase, spouses resisted converging by keeping up. In the third phase, spouses co-performed everyday activities closely together. The findings support the need to develop couple-oriented interventions that aim to enhance the couples' functioning in the domain of everyday activities. © 2012 Elsevier Inc.

Item does not contain fulltext OBJECTIVE: It is believed that in order to reduce the number of adverse events, hospitals have to stimulate a more open culture and reflective attitude towards errors and patient safety. The objective is to examine similarities and differences in hospital patient safety culture in three countries: the Netherlands, the USA and Taiwan. DESIGN: This is a cross-sectional survey study across three countries. A questionnaire, the Hospital Survey on Patient Safety Culture (Hospital SOPS), was disseminated nationwide in the Netherlands, the USA and Taiwan. SETTING: The study was conducted in 45 hospitals in the Netherlands, 622 in the USA and 74 in Taiwan. PARTICIPANTS: A total of 3779 professionals from the participating hospitals in the Netherlands, 196 462 from the USA and 10 146 from Taiwan participated in the study. MAIN OUTCOME MEASURES: The main outcome measures of the study were 12 dimensions of patient safety culture, e.g. Teamwork, Organizational learning, Communication openness. RESULTS: Most hospitals in all three countries have high scores on teamwork within units. The area with a high potential for improvement in all three countries is Handoffs and transitions. Differences between countries exist on the following dimensions: Non-punitive response to error, Feedback and communication about error, Communication openness, Management support for patient safety and Organizational learning--continuous improvement. On the whole, US respondents were more positive about the safety culture in their hospitals than Dutch and Taiwanese respondents. Nevertheless, there are even larger differences between hospitals within a country. CONCLUSIONS: Comparison of patient safety culture data has shown similarities and differences within and between countries. All three countries can improve areas of their patient safety culture. Countries can identify and share best practices and learn from each other.

In recent years, the cost of generating genome information has shown a rapid decline.1, 2 High-throughput genomic technologies make it possible to sequence the whole exome or genome of a person at a price that is affordable for some health-care systems. More services based on these technologies are now becoming available for patients, raising the issue of how to ensure that these are provided appropriately. In order to determine both the clinical utility of genetic testing and assure a high quality of the analysis, the interpretation and communication of the results must be discussed so that patients can receive appropriate advice and genetic testing. The Public and Professional Policy Committee (PPPC) and the Quality Committee of the European Society of Human Genetics (ESHG) addressed these challenges at a joint workshop in Gothenburg, Sweden, in 2010.3 PPPC also organised workshops in Amsterdam, the Netherlands (January 2011 in collaboration with the EU-funded project TECHGENE, January 2012). A report for the Health Council of the Netherlands served as a background document for the PPPC's reflections.4 Focusing on the clinical diagnostics setting, this paper is intended to contribute to the discussion and the development of guidelines in this fast-moving field, and provide recommendations for health-care professionals. The paper and recommendations were posted on the ESHG website from 20 June to 1 August 2012 for comment by the membership. The final version was approved by the ESHG Board in December 2012.

In the Netherlands, euthanasia and physician-assisted suicide (PAS) are considered acceptable medical practices in specific circumstances. The majority of cases of euthanasia and PAS involve patients suffering from cancer. However, in 1994 the Dutch Supreme Court in the so-called Chabot-case ruled that "the seriousness of the suffering of the patient does not depend on the cause of the suffering", thereby rejecting a distinction between physical (or somatic) and mental suffering. This opened the way for further debate about the acceptability of PAS in cases of serious and refractory mental illness. An important objection against offering PAS to mentally ill patients is that this might reinforce loss of hope, and demoralization. Based on an analysis of a reported case, this argument is evaluated. It is argued that offering PAS to a patient with a mental illness who suffers unbearably, enduringly and without prospect of relief does not necessarily imply taking away hope and can be ethically acceptable.

Background: As end-of-life (EoL) care expands across Europe and the world, service developments are increasingly studied. The sociocultural context in which such changes take place, however, is often neglected in research. Aim: To explore sociocultural factors in EoL care in Belgium as represented by the literature. Design: A scoping of the empirical research literature following a systematic search procedure with a focus on thematic analysis based on the literature findings. Data sources: Searches were carried out in eight electronic databases, five journals, reference lists, and grey literature (through September 2010). Articles informing about sociocultural issues in EoL care were included. Results: One hundred and fifteen original studies met the inclusion criteria, the majority (107) published between 2000 and 2010. Four major themes were: Setting; Caregivers; Communication; and Medical EoL Decisions (the largest category). Minority Ethnic Groups was an emerging theme. Gaps included: research in Wallonia and Brussels; the role and experiences of informal caregivers; issues of access to palliative care; and experiences of minority ethnic groups. There was a paucity of in-depth qualitative studies. Conclusions: Various sociocultural factors influence the provision of EoL care in Belgium. This country provides a unique opportunity to witness how euthanasia is put into practice when legalized, in a context where palliative care is also highly developed and where many health care institutions have Catholic affiliation, providing an important example to others. Attention to how the sociocultural context affects EoL care adds to the current evidence base of service provision, which is essential in the further development of EoL care.

Contains fulltext : 116604.pdf (Publisher’s version ) (Open Access) PURPOSE. This study investigated whether visual perceptual learning can improve near visual acuity and reduce foveal crowding effects in four-to nine-year-old children with visual impairment. METHODS. Participants were 45 children with visual impairment and 29 children with normal vision. Children with visual impairment were divided into three groups: a magnifier group (n = 12), a crowded perceptual learning group (n = 18), and an uncrowded perceptual learning group (n = 15). Children with normal vision also were divided in three groups, but were measured only at baseline. Dependent variables were single near visual acuity (NVA), crowded NVA, LH line 50% crowding NVA, number of trials, accuracy, performance time, amount of small errors, and amount of large errors. Children with visual impairment trained during six weeks, two times per week, for 30 minutes (12 training sessions). RESULTS. After training, children showed significant improvement of NVA in addition to specific improvements on the training task. The crowded perceptual learning group showed the largest acuity improvements (1.7 logMAR lines on the crowded chart, P < 0.001). Only the children in the crowded perceptual learning group showed improvements on all NVA charts. CONCLUSIONS. Children with visual impairment benefit from perceptual training. While task-specific improvements were observed in all training groups, transfer to crowded NVA was largest in the crowded perceptual learning group. To our knowledge, this is the first study to provide evidence for the improvement of NVA by perceptual learning in children with visual impairment. 9 p.

Trust in government policy affects the way people perceive and handle risks. In our study, we investigated the relationships between trust in government policy regarding electromagnetic fields (EMF), perceived risk and perceived benefits of public and personal EMF sources, perceived control over exposure to EMF and responses to the possible EMF health risk (e.g. protest against placement of mobile phone base stations or power lines, or taking own measures against EMF exposure). Previous research indicated that perceived risk and benefits mediate the relationship between trust and peoples risk responses. Additionally, we suggest that perceived control over EMF exposure affects the relation between trust in government policy and perceived risk, and, consequently, the risk responses. We performed a survey among the Dutch population (n = 1009), which contained questions about risk responses to EMF, perceived risk and benefits of several EMF sources, trust in government policy and perceived control over EMF exposure. Comparing public EMF sources, i.e. power lines and mobile phone base stations, to personal EMF sources, i.e. microwave ovens and cordless and mobile phones, we tested our hypotheses. Variations in risk responses to both public and personal EMF sources were mainly explained by risk perception. In addition, perceived risk partially mediated the relationship between trust in government policy and risk responses. For public sources, perceived control over exposure weakened the negative relationship between trust and perceived risk. We conclude that, especially in people with low perceived control, a lack of trust in government policy may enhance perceptions of health risks, thereby increasing their inclination for risk responses. © 2013 Taylor & Francis Group, LLC.

Background: Selective participation in retrospective studies of families recruited after the patient's death may threaten generalizability of reports on end-of-life experiences. Objectives: To assess possible selection bias in retrospective study of dementia at the end of life using family reports. Methods: Two physician teams covering six nursing home facilities in the Netherlands reported on 117 of 119 consecutive decedents within two weeks after death unaware of after-death family participation in the study. They reported on characteristics; treatment and care; overall patient outcomes such as comfort, nursing care, and outcomes; and their own perspectives on the experience. We compared results between decedents with and without family participation. Results: The family response rate was 55%. There were no significant differences based on participation versus nonparticipation in demographics and other nursing home resident characteristics, treatment and care, or overall resident outcome. However, among participating families, physicians perceived higher-quality aspects of nursing care and outcome, better consensus between staff and family on treatment, and a more peaceful death. Participation was less likely with involvement of a new family member in the last month. Conclusions: Families may be more likely to participate in research with more harmonious teamwork in end-of-life caregiving. Where family participation is an enrollment criterion, comparing demographics alone may not capture possible selection bias, especially in more subjective measures. Selection bias toward more positive experiences, which may include the physician's and probably also the family's experiences, should be considered if representativeness is aimed for. Future work should address selection bias in other palliative settings and countries, and with prospective recruitment.

Purpose The purpose of our study was to evaluate the effect of cognitive behavioral therapy (CBT), physical exercise (PE), and of these two interventions combined (CBT/PE) on menopausal symptoms (primary outcome), body image, sexual functioning, psychological well-being, and health-related quality of life (secondary outcomes) in patients with breast cancer experiencing treatment-induced menopause. Patients and Methods Patients with breast cancer reporting treatment-induced menopausal symptoms (N = 422) were randomly assigned to CBT (n = 109), PE (n = 104), CBT/PE (n = 106), or to a waiting list control group (n = 103). Self-report questionnaires were completed at baseline, 12 weeks, and 6 months. Multilevel procedures were used to compare the intervention groups with the control group over time. Results Compared with the control group, the intervention groups had a significant decrease in levels of endocrine symptoms (Functional Assessment of Cancer Therapy–Endocrine Symptoms; P < .001; effect size, 0.31-0.52) and urinary symptoms (Bristol Female Lower Urinary Tract Symptoms Questionnaire; P = .002; effect size, 0.29-0.33), and they showed an improvement in physical functioning (36-Item Short Form Health Survey physical functioning subscale; P = .002; effect size, 0.37-0.46). The groups that included CBT also showed a significant decrease in the perceived burden of hot flashes and night sweats (problem rating scale of the Hot Flush Rating Scale; P < .001; effect size, 0.39-0.56) and an increase in sexual activity (Sexual Activity Questionnaire habit subscale; P = .027; effect size, 0.65). Most of these effects were observed at both the 12-week and 6-month follow-ups. Conclusion CBT and PE can have salutary effects on endocrine symptoms and, to a lesser degree, on sexuality and physical functioning of patients with breast cancer experiencing treatment-induced menopause. Future work is needed to improve the design and the planning of these interventions to improve program adherence.

Since the introduction of enzyme replacement therapy for Pompe disease, awareness and early diagnosis have gained importance. Because the therapy is most effective when started early and methods for dried bloodspot screening for Pompe disease are currently being explored, neonatal screening is getting increased attention. The objective of this study was to investigate the gains that might be achieved with earlier diagnosis by neonatal screening. For this purpose we analyzed the health and functional status of non-screened patients with Pompe disease at the time of diagnosis. Previously collected clinical data and results of an international patient-reported questionnaire were used. Cross-sectional data of 53 patients with Pompe disease diagnosed between 1999 and 2009 (aged 0-64 years) were analyzed. According to the World Health Organization's International Classification of Functioning, Disability and Health the following domains are described: body function, activity, participation and contextual factors. In all patients with classic infantile Pompe disease cardiac function, hearing, muscle strength and motor development were considerably impaired at the time of clinical diagnosis. The use of oxygen and/or nasogastric tube-feeding was reported in more than 70% of these cases. Most children, adolescents and adults had advanced muscle weakness and impaired respiratory function at the time of their diagnosis, causing varying degrees of handicap. About 12% of them used a walking device and/or respiratory support at the time of diagnosis. The severely impaired health status reported here provides a strong argument for earlier diagnosis and to further explore the potential of neonatal screening for Pompe disease.

Genetics and genomics have developed fast in the last decade, but have not revolutionized medicine, as some had expected. While translation of research findings to public health applications is lagging behind, direct-to-consumer (DTC) offers of genetic testing have become available, both for monogenic and severe genetic disorders and for genetic variants possibly associated with common complex diseases (susceptibility variants). The European Society of Human Genetics is concerned about the way in which commercial companies are currently introducing genetic tests into the market outside of the scope of the traditional health-care system. There is a sort of a paradox between the lagging implementation in health care of the few genetic tests with proven clinical utility, on the one hand, and the speedy DTC offer of tests, with or without clinical utility. To translate research findings into appropriate clinical applications, assessment of the clinical validity and utility is needed. Many of the parameters needed in assessment frameworks are not available yet. Clinically relevant associations between genetic variants and disease risks have been established, e.g., in oncogenetics and cardiogenetics, and can be used to reflect on the possibilities and obstacles in using the new genetics in public health. In the absence of sufficient information on clinical validity and clinical utility, introduction of genetic tests in common complex disorders is often premature. Priority should be given to settings where clinical utility is proven or likely, to gain additional information concerning diagnosis, prognosis, and disease management. Monitoring and evaluation are essential.

BackgroundIn 2011, the Ministry of Health raised the CD4 threshold for antiretroviral therapy (ART) eligibility from

In a Perspective, Ank de Jonge and Jane Sandall discuss research on models of maternity care led by midwives.

ObjectivesThe objective of this article was to compare the costs and cost-effectiveness of the two most prominent types of case management in the Netherlands (intensive case management and linkage models) against no access to case management (control group) for people with already diagnosed dementia and their informal caregivers.MethodsThe economic evaluation was conducted from a societal perspective embedded within a two year prospective, observational, controlled, cohort study with 521 informal caregivers and community-dwelling persons with dementia. Case management provided within one care organization (intensive case management model, ICMM), case management where care was provided by different care organizations within one region (Linkage model, LM), and a group with no access to case management (control) were compared. The economic evaluation related incremental costs to incremental effects regarding neuropsychiatric symptoms (NPI), psychological health of the informal caregiver (GHQ-12), and quality adjusted life years (QALY) of the person with dementia and informal caregiver.ResultsInverse-propensity-score-weighted models showed no significant differences in clinical or total cost outcomes between the three groups. Informal care costs were significantly lower in the ICMM group compared to both other groups. Day center costs were significantly lower in the ICMM group compared to the control group. For all outcomes, the probability that the ICMM was cost-effective in comparison with LM and the control group was larger than 0.97 at a threshold ratio of 0 (sic)/incremental unit of effect.ConclusionThis study provides preliminary evidence that the ICMM is cost-effective compared to the control group and the LM. However, the findings should be interpreted with caution since this study was not a randomized controlled trial.

Purpose\ud \ud To systematically assess the literature on psychosocial interventions to improve mental health (i.e. depression, anxiety, mental fatigue, loneliness, psychological stress and psychological well-being) in visually impaired adults (≥18 years).\ud \ud \ud Methods\ud \ud The databases Medline, Embase and Psychinfo were searched for relevant studies, which were categorised into randomised controlled trials (RCTs), non-RCTs and before and after comparisons (BA). The Cochrane Collaboration Risk of Bias Tool was used to assess study quality. Standardised mean differences (SMD) were calculated to quantitatively summarise the outcomes of the RCTs and non-RCTs in a meta-analysis. Meta-regression was used to explore sources of heterogeneity in the data.\ud \ud Results\ud \ud The search identified 27 papers (published between 1981 and 2015), describing the outcomes of 22 different studies (14 RCTs, four non-RCTs, and four BAs). Pooled analyses showed that interventions significantly reduced depressive symptoms (SMD −0.30, 95% confidence interval (CI) −0.60 to −0.01), while effects on anxiety symptoms, mental fatigue, psychological stress and psychological well-being were non-significant. Meta-regression analyses showed homogeneity in effect sizes across a range of intervention, population, and study characteristics. Only a higher age of participants was associated with less effective results on depressive symptoms (b = 0.03, 95% CI 0.01 to 0.05), psychological stress (b = 0.07, 95% CI 0.01 to 0.13) and psychological well-being (b = −0.03, 95% CI −0.05 to 0.01). However, after removing a clear outlier the overall effect on depressive symptoms and the influence of age on depressive symptoms and psychological stress were no longer significant, while the influence of age on psychological well-being remained.\ud \ud \ud Conclusions\ud \ud There is currently only limited evidence for the effectiveness of psychosocial interventions in the field of low vision. More well-designed trials are needed with specific attention for interventions tailored to the needs of elderly patients.