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ObjectiveTo examine trends in end-of-life communication with people with cancer in general practice.MethodsMortality follow-back survey among general practitioners (GPs) in representative epidemiological surveillance networks in Belgium (BE), the Netherlands (NL) and Spain (ES) in 2009–2010 (ES: 2010–2011) and 2013–2014. Using a standardised form, GPs registered all deceased adult patients in their practice and reported for five end-of-life care topics whether they had been discussed with the patient. Non-sudden cancer deaths were included (n=2306; BE: 1233; NL: 729; ES: 344).ResultsA statistically significant increase was found between 2009/2010 and 2014 in the prevalence of communication about diagnosis (from 84% to 94%) and options for end-of-life care (from 73% to 90%) in BE, and in GPs’ awareness of patients’ preferences for medical treatment and a proxy decision-maker in BE (from 41% and 20% up to 53% and 28%) and the NL (from 62% and 32% up to 70% and 52%). Communication about options for end-of-life care and psychosocial problems decreased in the NL (from 88% and 91% down to 73%) and ES (from 76% and 77% down to 26% and 39%).ConclusionConsiderable change in GP–patient communication seems possible in a relatively short time span, but communication cannot be assumed to increase over time. Increasing specialisation of care and task differentiation may lead to new roles in communication for healthcare providers in primary and secondary care. Improved information sharing between GPs and other healthcare providers may be necessary to ensure that patients have the chance to discuss important end-of-life topics.

De in 1957 opgerichte NHG-Commissie Wetenschappelijk Onderzoek (CWO) hield in haar ruim 60-jarige bestaan meer dan 600 maandelijkse bijeenkomsten. Wat droeg de commissie bij aan de ontwikkeling van de huisartsgeneeskunde, wat heeft zij de leden gebracht en wat kan zij betekenen voor de toekomst van de huisartsgeneeskunde? Wij rubriceerden de proefschriften van huidige en voormalige CWO-leden en interviewden een aantal van hen.

Background: The burden of severe influenza virus infections is poorly known, for which surveillance of severe acute respiratory infection (SARI) is encouraged. Hospitalized SARI patients are however not always tested for influenza virus infection. Thus, to estimate the impact of influenza circulation we studied how influenza in primary care relates to intensive care unit (ICU) admissions using a modelling approach. Methods: We used time-series regression modelling to estimate a) the number of SARI admissions to ICU associated with medically attended influenza infections in primary care; b) how this varies by season; and c) the time lag between SARI and influenza time series. We analysed weekly adult ICU admissions (registry data) and adult influenza incidence (primary care surveillance data) from July 2007 through June 2016. Results: Depending on the year, 0% to 12% of annual SARI admissions were associated with influenza (0-554 in absolute numbers; population rate: 0/10 000-0.39/10 000 inhabitants), up to 27% during influenza epidemics. The average optimal fitting lag was +1 week (SARI trend preceding influenza by 1 week), varying between seasons (-1 to +4) with most seasons showing positive lags. Conclusion: Up to 12% of yearly SARI admissions to adult ICU are associated with influenza, but with large year-to-year variation and higher during influenza epidemics. In most years, SARI increases earlier than medically attended influenza infections in the general population. SARI surveillance could thus complement influenza-like illness surveillance by providing an indication of the season-specific burden of severe influenza infections and potential early warning of influenza activity and severity. (aut. ref.)

Background The number of requests for euthanasia has increased since the Termination of Life on Request and Assisted Suicide (Review Procedures) Act entered into force. The Nivel investigated the underlying reasons for this. Method Relevant scientific articles and reports from the Netherlands and Belgium from 2003-2019 were analysed. Results A potential explanation is the ageing population: the number of older individuals has increased and hence also the number of requests for euthanasia. Moreover, a higher proportion of older individuals are requesting euthanasia and more requests are approved than in the past. A second explanation is the growing acceptance of euthanasia among the Dutch population: in 2002 12% of the Dutch population was against euthanasia, in 2016 only 5%. A third explanation is the greater involvement of general practitioners in end-of-life care, the increased willingness to comply with a request for euthanasia, and increased possibilities for doctors who are unwilling or unable to perform euthanasia to refer patients to other doctors. Lastly, in recent years more patients die of cancer than of cardiovascular causes, and cancer is a common reason to request euthanasia, whereas cardiovascular disorders are not. Conclusion The increase in the number of requests for euthanasia over the last 15 years is due to a combination of factors.

This study provides insight into circumstances that facilitate or hamper living at home with advanced dementia until the end of life. Interviews were held with 11 bereaved family caregivers, two general practitioners, and nine case managers, related to a total of 12 persons with advanced dementia who had recently died. Persons with dementia who lived at home until the end of life often had family caregivers that received timely support from professionals and their social network. In the cases where the person with dementia could not live at home until the end of life, safety issues, severely challenging behavior, and high care dependency of the person with dementia played key roles. Case management and a continuous process of advance care planning will improve the chance that the end-of-life setting is in accordance with the key values and needs of both the person with dementia and family caregivers.

Recommendations of first choice antibiotic therapy need to be based on actual antibiotic susceptibility data. We determined the antibiotic susceptibility of E. coli in uncomplicated UTI among women and compared the results with 2004 and 2009. In 30 sentinel general practitioner practices of Nivel Primary Care database, urine samples were collected from women with symptoms of uncomplicated UTI. Patient characteristics, E. coli susceptibility, and ESBL production were analyzed. Six hundred eighty-nine urine samples were collected; E. coli was the most isolated uropathogen (83%). Antibiotic susceptibility was stable over time except for ciprofloxacin (96% in 2004, 97% in 2009, and 94% in 2014; P 70 years (P = 0.005). In 2014, prescription of fosfomycin increased compared to 2009 (14.3% versus 5.6%) at the expense of co-amoxiclav, co-trimoxazole, and fluoroquinolones (P

Influenza epidemics annually cause substantial morbidity and mortality. For this reason, vaccination is offered yearly to persons with an elevated risk for complications. Assessments of the impact of vaccination are, however, hampered by year-to-year variation in epidemic size and vaccine effectiveness.We estimate the impact of the current vaccination programme comparing simulations with vaccination to counterfactual simulations without vaccination. The simulations rely on an age- and risk-structured transmission model that tracks the build-up and loss of immunity over successive seasons, and that allows the vaccine match to vary between seasons. The model parameters are estimated with a particle Monte Carlo method and approximate Bayesian computation, using epidemiological data on vaccine effectiveness and epidemic size in the Netherlands over a period of 11 years.The number of infections, hospitalisations and deaths vary greatly between years because waning of immunity and vaccine match may differ every season, which is in line with observed variation in influenza epidemic sizes. At an overall coverage of 21%, vaccination has averted on average 13% (7.2–19%, 95% range) of infections, 24% (16–36%) of hospitalisations, and 35% (16–50%) of deaths. This suggests that vaccination is mainly effective in protecting vaccinees from infection rather than reducing transmission. As the Dutch population continues to grow and age, the vaccination programme is projected (up to 2025) to gain in impact, despite a decreasing infection attack rate. Keywords: Influenza virus, Transmission model, Infection attack rate, Vaccine effectiveness, Morbidity, Mortality

Huisartsopleider Ge Donker en huisarts in opleiding Evelien Hartman ondervragen elkaar over het deelnemen aan wetenschappelijk onderzoek.

Background General practitioners (GPs) can be considered the designated professionals to identify high fall risk and to guide older people to fall preventive care. Currently it is not exactly known how GPs treat this risk. This study aims to investigate GPs’ daily practice regarding fall preventive care for frail older patients. Methods Sixty-five GPs from 32 Dutch practices participated in this study for a period of 12 months. When a GP entered specific International Classification of Primary Care-codes related to frailty and/or high fall risk in their Electronic Health Records, a pop-up appeared asking “Is this patient frail?”. If the GP confirmed this, the GP completed a short questionnaire about patient’s fall history and fear of falling (FOF), and the fall preventive care provided. Results The GPs completed questionnaires regarding 1394 frail older patients aged ≥75. Of 20% of these patients, the GPs did not know whether they had experienced a fall or not. The GPs did not know whether a FOF existed in even more patients (29%). Of the patients with a fall history and/or a FOF (N = 726), 37% (N = 271) received fall preventive care. Two main reasons for not offering fall preventive care to these patients were: I) the patient finds treatment too intensive or too much of a hassle (37%), and II) the GP identified a high fall risk but the patient did not acknowledge this (14%). When patients were treated for high fall risk, the GP and the physiotherapist were the most frequently involved health care providers. The involved health care providers most often treated mobility limitations, cardiovascular risk factors, and FOF. Conclusions The results from this study show that GPs were frequently not aware of their frail patient’s fall history and/or FOF and that the majority of the frail older patients with a fall history and/or FOF did not receive fall preventive care. Developing systematic screening strategies for the primary care setting enhancing the identification of high fall risk and the provision of fall preventive care may improve patients’ quality of life and reduce health care costs.

Background In an abdominal symptom study in primary care in six European countries, 511 cases of cancer were recorded prospectively among 61,802 patients 16 years and older in Norway, Denmark, Sweden, Netherlands, Belgium and Scotland. Colorectal cancer is one of the main types of cancer associated with abdominal symptoms; hence, an in-depth subgroup analysis of the 94 colorectal cancers was carried out in order to study variation in symptom presentation among cancers in different anatomical locations. Method Initial data capture was by completion of standardised forms containing closed questions about symptoms recorded during the consultation. Follow-up data were provided by the GP after diagnosis, based on medical record data made after the consultation. GPs also provided free text comments about the diagnostic procedure for individual patients. Fisher’s exact test was used to analyse differences between groups. Results Almost all symptoms recorded could indicate colorectal cancer. ‘Rectal bleeding’ had a specificity of 99.4% and a PPV of 4.0%. Faecal occult blood in stool (FOBT) or anaemia may indicate gastrointestinal bleeding: when these symptoms and signs were combined, sensitivity reached 57.5%, with 69.2% for cancer in the distal colon. For proximal colon cancers, none of 18 patients had ‘Rectal bleeding’ at the initial consultation, but three of the 18 did so at a later consultation. ‘Abdominal pain, lower part’, ‘Constipation’ and ‘Distended abdomen, bloating’ were less specific and also less sensitive than ‘Rectal bleeding’, and with PPV between 0.7% and 1.9%. Conclusions Apart from rectal bleeding, single symptoms did not reach the PPV 3% NICE threshold. However, supplementary information such as a positive FOBT or persistent symptoms may revise the PPV upwards. If a colorectal cancer is suspected by the GP despite few symptoms, the total clinical picture may still reach the NICE PPV threshold of 3% and justify a specific referral.

Objectives: To estimate the general practitioner (GP) consultation rate attributable to influenza in The Netherlands.Methods: Regression analysis was performed on the weekly numbers of influenza-like illness (ILI) GP consultations and laboratory reports for influenza virus types A and B and 8 other pathogens over the period 2003-2014 (11 influenza seasons; week 40-20 of the following year).Results: In an average influenza season, 27% and 11% of ILI GP consultations were attributed to infection by influenza virus types A and B, respectively. Influenza is therefore responsible for approximately 107 000 GP consultations (651/100 000) each year in The Netherlands. GP consultation rates associated with influenza infection were highest in children under 5 years of age, at 667 of 100 000 for influenza A and 258 of 100 000 for influenza B. Influenza virus infection was found to be the predominant cause of ILI-related GP visits in all age groups except children under 5, in which respiratory syncytial virus (RSV) infection was found to be the main contributor.Conclusions: The burden of influenza in terms of GP consultations is considerable. Overall, influenza is the main contributor to ILI. Although ILI symptoms in children under 5 years of age are most often associated with RSV infection, the majority of visits related to influenza occur among children under 5 years of age.

Background Suicidal behaviour is difficult to detect in the general practice. Machine learning (ML) algorithms using routinely collected data might support General Practitioners (GPs) in the detection of suicidal behaviour. In this paper, we applied machine learning techniques to support GPs recognizing suicidal behaviour in primary care patients using routinely collected general practice data. Methods This case-control study used data from a national representative primary care database including over 1.5 million patients (Nivel Primary Care Database). Patients with a suicide (attempt) in 2017 were selected as cases (N = 574) and an at risk control group (N = 207,308) was selected from patients with psychological vulnerability but without a suicide attempt in 2017. RandomForest was trained on a small subsample of the data (training set), and evaluated on unseen data (test set). Results Almost two-third (65%) of the cases visited their GP within the last 30 days before the suicide (attempt). RandomForest showed a positive predictive value (PPV) of 0.05 (0.04–0.06), with a sensitivity of 0.39 (0.32–0.47) and area under the curve (AUC) of 0.85 (0.81–0.88). Almost all controls were accurately labeled as controls (specificity = 0.98 (0.97–0.98)). Among a sample of 650 at-risk primary care patients, the algorithm would label 20 patients as high-risk. Of those, one would be an actual case and additionally, one case would be missed. Conclusion In this study, we applied machine learning to predict suicidal behaviour using general practice data. Our results showed that these techniques can be used as a complementary step in the identification and stratification of patients at risk of suicidal behaviour. The results are encouraging and provide a first step to use automated screening directly in clinical practice. Additional data from different social domains, such as employment and education, might improve accuracy., Highlights • Almost all (93%) suicidal patients had a visit at the GP in the year before the suicide • Machine learning techniques can be applied to routinely available data to make predictions • Predictive algorithms can be used as complementary step in the identification of patients at risk of suicidal behaviour

Background Despite the early development of Google Flu Trends in 2009, standards for digital epidemiology methods have not been established and research from European countries is scarce. Aim In this article, we study the use of web search queries to monitor influenza-like illness (ILI) rates in the Netherlands in real time. Methods In this retrospective analysis, we simulated the weekly use of a prediction model for estimating the then-current ILI incidence across the 2017/18 influenza season solely based on Google search query data. We used weekly ILI data as reported to The European Surveillance System (TESSY) each week, and we removed the then-last 4 weeks from our dataset. We then fitted a prediction model based on the then-most-recent search query data from Google Trends to fill the 4-week gap (‘Nowcasting’). Lasso regression, in combination with cross-validation, was applied to select predictors and to fit the 52 models, one for each week of the season. Results The models provided accurate predictions with a mean and maximum absolute error of 1.40 (95% confidence interval: 1.09–1.75) and 6.36 per 10,000 population. The onset, peak and end of the epidemic were predicted with an error of 1, 3 and 2 weeks, respectively. The number of search terms retained as predictors ranged from three to five, with one keyword, ‘griep’ (‘flu’), having the most weight in all models. Discussion This study demonstrates the feasibility of accurate, real-time ILI incidence predictions in the Netherlands using Google search query data.

Huisartsen gebruiken hun niet-pluisgevoel om kanker te diagnosticeren, maar er is weinig bekend over de relatie met patient- en huisartskenmerken. Prospectieve cohortstudie van patienten in 44 huisartsenpraktijken verspreid over Nederland, van januari 2010 tot en met december 2013. De huisartsen noteerden in een vragenlijst wat de aanleiding was voor het gevoel, het vervolgbeleid, de verwachte diagnose en drie maanden nadien werd in een follow-up vragenlijst bij dezelfde patienten nagegaan welke diagnose gesteld was en of deze conform de geanticipeerde diagnose was. Chikwadraattoets, uni- en multivariate logistische regressie en multilevel analyses werden verricht. Van 366 gerapporteerde patienten, had 35 % drie maanden later kanker als diagnose. De meest voorkomende triggers waren: onverklaard gewichtsverlies (N = 85) en sporadisch spreekuurbezoek (N = 76), gevolgd door het aanhouden van klachten (N = 64), maar in een multivariate analyse waren geen van de triggers gerelateerd aan kanker. De positief voorspellende waarde van het niet-pluisgevoel nam met 2 % toe voor elk jaar dat een patient ouder was en 3 % voor elk jaar dat de leeftijd van de huisarts toenam. Het geslacht van de huisarts bleek niet van invloed op de voorspellende waarde van het niet-pluisgevoel. Het niet-pluisgevoel van de huisarts blijkt een nuttig diagnostisch instrument voor het diagnosticeren van kanker en de relatief hoge voorspellende waarde neemt toe naarmate de huisarts ouder en meer ervaren is en naarmate de patient ouder is. Dit verdient aandacht in onderwijs en richtlijnen.

Donker GA, Wiersma E, Van der Hoek L, Heins M. Determinanten van niet-pluisgevoel bij kanker Huisarts Wet 2017;60(12):620-2. Achtergrond Huisartsen gebruiken hun niet-pluisgevoel om kanker te diagnosticeren, maar er is weinig bekend over de relatie van het niet-pluisgevoel met patient- en huisartskenmerken. Methode Prospectief cohortonderzoek onder patienten in 44 huisartsenpraktijken verspreid over Nederland, van januari 2010 tot en met december 2013. De huisartsen noteerden in een vragenlijst wat de aanleiding was voor het gevoel, het vervolgbeleid en de verwachte diagnose. Drie maanden nadien zijn we met een follow-upvragenlijst bij dezelfde patienten nagegaan welke diagnose de huisarts had gesteld en of deze conform de geanticipeerde diagnose was. We hebben een chi-kwadraattoets, uni- en multivariate logistische regressie- en multilevel-analyses uitgevoerd. Resultaten Van 366 gerapporteerde patienten had 35% drie maanden later kanker als diagnose. De meest voorkomende triggers waren: onverklaard gewichtsverlies (n = 85) en sporadisch spreekuurbezoek (n = 76), gevolgd door het aanhouden van klachten (n = 64). Uit een multivariate analyse bleek dat geen van de triggers samenhing met kanker. De positief voorspellende waarde van het niet-pluisgevoel nam met 2% toe voor elk jaar dat een patient ouder was en met 3% voor elk jaar dat de leeftijd van de huisarts toenam. Het geslacht van de huisarts bleek niet van invloed op de voorspellende waarde van het niet-pluisgevoel. Conclusie Het niet-pluisgevoel van de huisarts blijkt een nuttig diagnostisch instrument voor het diagnosticeren van kanker en de relatief hoge voorspellende waarde neemt toe naarmate de huisarts ouder en meer ervaren is, en naarmate de patient ouder is. Deze bevindingen verdienen aandacht in onderwijs en richtlijnen.

Information about influenza vaccine effectiveness (IVE) is important for vaccine strain selection and immunization policy decisions. The test-negative design (TND) case-control study is commonly used to obtain IVE estimates. However, the definition of the control patients may influence IVE estimates. We have conducted a TND study using the Dutch Sentinel Practices of NIVEL Primary Care Database which includes data from patients who consulted the General Practitioner (GP) for an episode of acute influenza-like illness (ILI) or acute respiratory infection (ARI) with known influenza vaccination status. Cases were patients tested positive for influenza virus. Controls were grouped into those who tested (1) negative for influenza virus (all influenza negative), (2) negative for influenza virus, but positive for respiratory syncytial virus, rhinovirus or enterovirus (non-influenza virus positive), and (3) negative for these four viruses (pan-negative). We estimated the IVE over all epidemic seasons from 2003/2004 through 2013/2014, pooled IVE for influenza vaccine partial/full matched and mismatched seasons and the individual seasons using generalized linear mixed-effect and multiple logistic regression models. The overall IVE adjusted for age, GP ILI/ARI diagnosis, chronic disease and respiratory allergy was 35% (95% CI: 15-48), 64% (95% CI: 49-75) and 21% (95% CI: 1 to 39) for all influenza negative, non influenza virus positive and pan-negative controls, respectively. In both the main and subgroup analyses IVE estimates were the highest using non-influenza virus positive controls, likely due to limiting inclusion of controls without laboratory-confirmation of a virus causing the respiratory disease. (C) 2017 Elsevier Ltd. All rights reserved.

Background While the burden of community-acquired pneumonia and invasive pneumococcal disease (IPD) is still considerable, there is little insight in the factors contributing to disease. Previous research on the lagged relationship between respiratory viruses and pneumococcal disease incidence is inconclusive, and studies correcting for temporal autocorrelation are lacking. Objectives To investigate the temporal relation between influenza-like illnesses (ILI) and IPD, correcting for temporal autocorrelation. Methods Weekly counts of ILI were obtained from the Sentinel Practices of NIVEL Primary Care Database. IPD data were collected from the Dutch laboratory-based surveillance system for bacterial meningitis from 2004 to 2014. We analysed the correlation between time series, pre-whitening the dependent time series with the best-fit seasonal autoregressive integrated moving average (SARIMA) model to the independent time series. We performed cross-correlations between ILI and IPD incidences, and the (pre-whitened) residuals, in the overall population and in the elderly. Results We found significant cross-correlations between ILI and IPD incidences peaking at lags -3 overall and at 1 week in the 65+ population. However, after pre-whitening, no cross-correlations were apparent in either population group. Conclusion Our study suggests that ILI occurrence does not seem to be the major driver of IPD incidence in The Netherlands.

Objective Intensive Care Unit (ICU) data are registered for quality monitoring in the Netherlands with near 100% coverage. They are a ‘big data’ type source that may be useful for infectious disease surveillance. We explored their potential to enhance the surveillance of influenza which is currently based on the milder end of the disease spectrum. We ultimately aim to set up a real-surveillance system of severe acute respiratory infections. Introduction While influenza-like-illness (ILI) surveillance is well-organized at primary care level in Europe, little data is available on more severe cases. With retrospective data from ICU’s we aim to fill this current knowledge gap and to explore its worth for prospective surveillance. Using multiple parameters proposed by the World Health Organization we estimated the burden of severe acute respiratory infections (SARI) to ICU and how this varies between influenza epidemics. Methods We analyzed weekly ICU admissions of adults in the Netherlands (2007-2016) from the national intensive care evaluation (NICE) quality registry (100% coverage of adult ICU in 2016; population size 14 million adults. A SARI syndrome was defined as admission diagnosis being any of 6 pneumonia or pulmonary sepsis codes in the Acute Physiology and Chronic Health Evaluation IV (APACHE IV) prognostic model. Influenza epidemic periods were retrieved from primary care sentinel influenza surveillance data. In recent years NICE has explored and promoted increased timeliness and automation of data transfer. Results Annually, 11-14% of medical admissions to adult ICUs were for a SARI (5-25% weekly). Admissions for bacterial pneumonia (59%) and pulmonary sepsis (25%) contributed most to ICU-SARI. Between influenza epidemics, severity indicators varied: ICU-SARI incidence (between 558-2,400 cumulated admissions nation-wide, rate: 0.40-1.71/10,000 inhabitants), average APACHE score (between 71-78), ICU-SARI mortality (between 13-20%), ICU-SARI/ILI ratio (between 8-17 SARI ICU cases per 1,000 expected medically attended influenza-like-illness in primary care), peak incidence (between 101-188 ICU-SARI admissions nationally in the highest week, rate: between 0.07-0.13/10,000 population). ICUs use different types of electronic health records (EHRs). Data submitted to the NICE registry is mainly based on routinely collected data extracted from these EHRs. The timeliness of data submission varies between a few weeks and three months. Together with ICUs, the NICE registry has recently undertaken actions to increase timeliness of ICU data submission. Conclusions In ICU data, great variation can be seen between the yearly influenza epidemic periods in terms of different influenza severity parameters. The parameters also complement each other by reflecting different aspects of severity. Prospective syndromic ICU-SARI surveillance, as proposed by the World Health Organization would provide insight into severity of ongoing influenza epidemics which differ from season to season. Currently a subset of hospitals provide data with a 6-week delay. This can be a worthwhile addition to current influenza surveillance, which, while timelier, is based on milder cases seen by general practitioners (primary care). Future increases in data timeliness will remain an aim.

BACKGROUND The Netherlands, like most European countries, has a robust influenza surveillance system in primary care. However, there is a lack of real-time nationally representative data on hospital admissions for complications of influenza. Anecdotal information about hospital capacity problems during influenza epidemics can, therefore, not be substantiated. OBJECTIVE The aim of this study was to assess whether media reports could provide relevant information for estimating the impact of influenza on hospital capacity, in the absence of hospital surveillance data. METHODS Dutch news articles on influenza in hospitals during the influenza season (week 40 of 2017 until week 20 of 2018) were searched in a Web-based media monitoring program (Coosto). Trends in the number of weekly articles were compared with trends in 5 different influenza surveillance systems. A content analysis was performed on a selection of news articles, and information on the hospital, department, problem, and preventive or response measures was collected. RESULTS The trend in weekly news articles correlated significantly with the trends in all 5 surveillance systems, including severe acute respiratory infections (SARI) surveillance. However, the peak in all 5 surveillance systems preceded the peak in news articles. Content analysis showed hospitals (N=69) had major capacity problems (46/69, 67%), resulting in admission stops (9/46, 20%), postponement of nonurgent surgical procedures (29/46, 63%), or both (8/46, 17%). Only few hospitals reported the use of point-of-care testing (5/69, 7%) or a separate influenza ward (3/69, 4%) to accelerate clinical management, but most resorted to ad hoc crisis management (34/69, 49%). CONCLUSIONS Media reports showed that the 2017/2018 influenza epidemic caused serious problems in hospitals throughout the country. However, because of the time lag in media reporting, it is not a suitable alternative for near real-time SARI surveillance. A robust SARI surveillance program is important to inform decision making.

Background To control respiratory syncytial virus (RSV), which causes acute respiratory infections, data and methods to assess its epidemiology are important. Aim We sought to describe RSV seasonality, affected age groups and RSV-type distribution over 12 consecutive seasons in the Netherlands, as well as to validate the moving epidemic method (MEM) for monitoring RSV epidemics. Methods We used 2005−17 laboratory surveillance data and sentinel data. For RSV seasonality evaluation, epidemic thresholds (i) at 1.2% of the cumulative number of RSV-positive patients per season and (ii) at 20 detections per week (for laboratory data) were employed. We also assessed MEM thresholds. Results In laboratory data RSV was reported 25,491 times (no denominator). In sentinel data 5.6% (767/13,577) of specimens tested RSV positive. Over 12 seasons, sentinel data showed percentage increases of RSV positive samples. The average epidemic length was 18.0 weeks (95% confidence intervals (CI): 16.3–19.7) and 16.5 weeks (95% CI: 14.0–18.0) for laboratory and sentinel data, respectively. Epidemics started on average in week 46 (95% CI: 45–48) and 47 (95% CI: 46–49), respectively. The peak was on average in the first week of January in both datasets. MEM showed similar results to the other methods. RSV incidence was highest in youngest (0–1 and >1–2 years) and oldest (>65–75 and > 75 years) age groups, with age distribution remaining stable over time. RSV-type dominance alternated every one or two seasons. Conclusions Our findings provide baseline information for immunisation advisory groups. The possibility of employing MEM to monitor RSV epidemics allows prospective, nearly real-time use of surveillance data.

Background In the Netherlands, general practitioners (GPs) and community nurses play a central role in the palliative care for home-dwelling patients with advanced cancer and their relatives. To optimize the palliative care provision at home, it is important to have insight in the elements that patients and relatives consider essential for high-quality palliative care, and whether these essentials are present in the actual care they receive. Methods Qualitative semi-structured interviews were conducted with 13 patients with advanced cancer and 14 relatives. The participants discussed their experiences with the care and support they received from the GP and community nurses, and their views on met and unmet needs. Interview data were analysed according to the principles of thematic analysis. Results Patients as well as relatives considered it important that their GP and community nursing staff are medically proficient, available, person-focused and proactive. Also, proper information transfer between care professionals and clear procedures when asking for certain resources or services were considered essential for good palliative care at home. Most interviewees indicated that these essential elements were generally present in the care they received. However, the requirements of ‘proper information transfer between professionals’ and ‘clear and rapid procedures’ were mentioned as more difficult to meet in actual practice. Patients and relatives also emphasized that an alert and assertive attitude on their own part was vital in ensuring they received the care they need. They expressed worries about other people who are less vigilant regarding the care they receive, or who have no family to support them in this. Conclusions Medical proficiency, availability, a focus on the person, proper information transfer between professionals, clear procedures and proactivity on the part of GPs and community nursing staff are considered essential for good palliative care at home. Improvements are particularly warranted with regard to collaboration and information transfer between professionals, and current bureaucratic procedures. It is important for care professionals to ensure that the identified essential elements for high-quality palliative care at home are met, particularly for patients and relatives who are not so alert and assertive.

Due to differences in the circulation of influenza viruses, distribution and antigenic drift of A subtypes and B lineages, and susceptibility to infection in the population, the incidence of symptomatic influenza infection can vary widely between seasons and age-groups. Our goal was to estimate the symptomatic infection incidence in the Netherlands for the six seasons 2011/2012 through 2016/2017, using Bayesian evidence synthesis methodology to combine season-specific sentinel surveillance data on influenza-like illness (ILI), virus detections in sampled ILI cases and data on healthcare-seeking behaviour. Estimated age-aggregated incidence was 6.5 per 1000 persons (95% uncertainty interval (UI): 4.7–9.0) for season 2011/2012, 36.7 (95% UI: 31.2–42.8) for 2012/2013, 9.1 (95% UI: 6.3–12.9) for 2013/2014, 41.1 (95% UI: 35.0–47.7) for 2014/2015, 39.4 (95% UI: 33.4–46.1) for 2015/2016 and 27.8 (95% UI: 22.7–33.7) for season 2016/2017. Incidence varied substantially between age-groups (highest for the age-group

Background While influenza-like-illness (ILI) surveillance is well-organized at primary care level in Europe, few data are available on more severe cases. With retrospective data from intensive care units (ICU) we aim to fill this current knowledge gap. Using multiple parameters proposed by the World Health Organization we estimate the burden of severe acute respiratory infections (SARI) in the ICU and how this varies between influenza epidemics. Methods We analyzed weekly ICU admissions in the Netherlands (2007–2016) from the National Intensive Care Evaluation (NICE) quality registry (100% coverage of adult ICUs in 2016; population size 14 million) to calculate SARI incidence, SARI peak levels, ICU SARI mortality, SARI mean Acute Physiology and Chronic Health Evaluation (APACHE) IV score, and the ICU SARI/ILI ratio. These parameters were calculated both yearly and per separate influenza epidemic (defined epidemic weeks). A SARI syndrome was defined as admission diagnosis being any of six pneumonia or pulmonary sepsis codes in the APACHE IV prognostic model. Influenza epidemic periods were retrieved from primary care sentinel influenza surveillance data. Results Annually, an average of 13% of medical admissions to adult ICUs were for a SARI but varied widely between weeks (minimum 5% to maximum 25% per week). Admissions for bacterial pneumonia (59%) and pulmonary sepsis (25%) contributed most to ICU SARI. Between the eight different influenza epidemics under study, the value of each of the severity parameters varied. Per parameter the minimum and maximum of those eight values were as follows: ICU SARI incidence 558–2400 cumulated admissions nationwide, rate 0.40–1.71/10,000 inhabitants; average APACHE score 71–78; ICU SARI mortality 13–20%; ICU SARI/ILI ratio 8–17 cases per 1000 expected medically attended ILI in primary care); peak-incidence 101–188 ICU SARI admissions in highest-incidence week, rate 0.07–0.13/10,000 population). Conclusions In the ICU there is great variation between the yearly influenza epidemic periods in terms of different influenza severity parameters. The parameters also complement each other by reflecting different aspects of severity. Prospective syndromic ICU SARI surveillance, as proposed by the World Health Organization, thereby would provide insight into the severity of ongoing influenza epidemics, which differ from season to season. Electronic supplementary material The online version of this article (10.1186/s13054-018-2274-8) contains supplementary material, which is available to authorized users.

BACKGROUND The number of cancer survivors is steadily increasing and these patients often experience long-lasting health problems. To make care for cancer survivors sustainable for the future, it would be relevant to put the effects of cancer in this phase into perspective. Therefore, the authors compared health-related quality of life (HRQOL) and health care use among cancer survivors with that of patients with chronic diseases. METHODS Patients diagnosed at age >18 years with a cancer with a 5-year survival rate > 20% and no distant metastases at the time of diagnosis and patients aged >18 years with physician-diagnosed somatic chronic diseases without cancer were sent a questionnaire. HRQOL was measured with the RAND-36, a measure of HRQOL. Self-reported health care use was measured for general practitioner care, specialist care, rehabilitative care, physical therapy, ambulatory mental health care, and occupational health care. RESULTS A total of 601 cancer survivors and 1052 patients with chronic diseases without cancer were included in the current study. Multimorbidity was observed in 63% of the cancer survivors and 61% of the patients with chronic diseases. The HRQOL of the cancer survivors was significantly better than that of patients with chronic diseases after adjustment for age and sex. For the mental functioning subscale, no significant differences were found between the 2 groups. Cancer survivors were found to be less likely to have visited a general practitioner or cardiologist compared with patients with chronic diseases. CONCLUSIONS When considering physical HRQOL and health care use, cancer survivors appear to fare better than the average patient with chronic diseases. No difference in mental functioning was observed in the current study. Cancer 2015. © 2015 American Cancer Society.

BackgroundThe Netherlands, like most European countries, has a robust influenza surveillance system in primary care. However, there is a lack of real-time nationally representative data on hospital admissions for complications of influenza. Anecdotal information about hospital capacity problems during influenza epidemics can, therefore, not be substantiated.ObjectiveThe aim of this study was to assess whether media reports could provide relevant information for estimating the impact of influenza on hospital capacity, in the absence of hospital surveillance data.MethodsDutch news articles on influenza in hospitals during the influenza season (week 40 of 2017 until week 20 of 2018) were searched in a Web-based media monitoring program (Coosto). Trends in the number of weekly articles were compared with trends in 5 different influenza surveillance systems. A content analysis was performed on a selection of news articles, and information on the hospital, department, problem, and preventive or response measures was collected.ResultsThe trend in weekly news articles correlated significantly with the trends in all 5 surveillance systems, including severe acute respiratory infections (SARI) surveillance. However, the peak in all 5 surveillance systems preceded the peak in news articles. Content analysis showed hospitals (N=69) had major capacity problems (46/69, 67%), resulting in admission stops (9/46, 20%), postponement of nonurgent surgical procedures (29/46, 63%), or both (8/46, 17%). Only few hospitals reported the use of point-of-care testing (5/69, 7%) or a separate influenza ward (3/69, 4%) to accelerate clinical management, but most resorted to ad hoc crisis management (34/69, 49%).ConclusionsMedia reports showed that the 2017/2018 influenza epidemic caused serious problems in hospitals throughout the country. However, because of the time lag in media reporting, it is not a suitable alternative for near real-time SARI surveillance. A robust SARI surveillance program is important to inform decision making.

IntroductionDespite the early development of Google Flu Trends in 2009, digital epidemiology methods have not been adopted widely, with most research focusing on the USA. In this article we demonstrate the prediction of real-time trends in influenza-like illness (ILI) in the Netherlands using search engine query data.MethodsWe used flu-related search query data from Google Trends in combination with traditional surveillance data from 40 general sentinel practices to build our predictive models. We introduced an artificial 4-week delay in the use of GP data in the models, in order to test the predictive performance of the search engine data.Simulating the weekly use of a prediction model across the 2017/2018 flu season we used lasso regression to fit 52 prediction models (one for each week) for weekly ILI incidence. We used rolling forecast cross-validation for lambda optimization in each model, minimizing the maximum absolute error.ResultsThe models accurately predicted the number of ILI cases during the 2017/18 ILI epidemic in real time with a mean absolute error of 1.40 (per 10,000 population) and a maximum absolute error of 6.36. The model would also have identified the onset, peak, and end of the epidemic with reasonable accuracyThe number of predictors that were retained in the prediction models was small, ranging from 3 to 5, with a single keyword (‘Griep’ = ‘Flu’) having by far the most weight in all models.DiscussionThis study demonstrates the feasibility of accurate real-time ILI incidence predictions in the Netherlands using internet search query data. Digital ILI monitoring strategies may be useful in countries with poor surveillance systems, or for monitoring emergent diseases, including influenza pandemics. We hope that this transparent and accessible case study inspires and supports further developments in field of digital epidemiology in Europe and beyond.

Climatic factors affect the survival and transmissibility of respiratory viruses causing influenza-like illness (ILI), and we hypothesized that changes in absolute humidity and temperature may affect long-term trends of ILI incidence rate in temperate countries. We tested this hypothesis using ILI and meteorological time series in the Netherlands for the period 1970-2016.We described the long-term trends of ILI incidence, absolute humidity and temperature; modelled the association between climatic factors and ILI activity using negative binomial regression models; and assessed the strength of the association between the seasonal average absolute humidity (or temperature) and ILI incidence rate using the Spearman's rank correlation coefficient.The ILI incidence rate declined from 1970 and reached a minimum in the season 2002-03, but started to increase again from the season 2003-04 onwards. In the negative binominal regression models, the weekly ILI count was inversely associated (p 0.001) with 0- and 1-week lagged absolute humidity and temperature. After three decades of rising absolute humidity and temperature (1970-2000), the early 2000s represented a trend-reversal point for the climatic time series. The seasonal average ILI incidence rate and absolute humidity (or temperature) were strongly (inversely) correlated.Our findings suggest that climate change may have played a role in the long-term trends of ILI incidence rates in the Netherlands, as we were able to show that lower humidity and temperature in a given week were associated with higher ILI incidence in the next week, there was a clear time point reversal in climatic parameters and ILI rates in the 2000s, and the average annual ILI incidence was inversely related to average annual temperatures and humidity.

BackgroundDifferent abdominal symptoms may signal cancer, but their role is unclear.AimTo examine associations between abdominal symptoms and subsequent cancer diagnosed in the abdominal region.Design and settingProspective cohort study comprising 493 GPs from surgeries in Norway, Denmark, Sweden, Scotland, Belgium, and the Netherlands.MethodOver a 10-day period, the GPs recorded consecutive consultations and noted: patients who presented with abdominal symptoms pre-specified on the registration form; additional data on non-specific symptoms; and features of the consultation. Eight months later, data on all cancer diagnoses among all study patients in the participating general practices were requested from the GPs.ResultsConsultations with 61 802 patients were recorded and abdominal symptoms were documented in 6264 (10.1%) patients. Malignancy, both abdominal and non-abdominal, was subsequently diagnosed in 511 patients (0.8%). Among patients with a new cancer in the abdomen (n = 251), 175 (69.7%) were diagnosed within 180 days after consultation. In a multivariate model, the highest sex- and age-adjusted hazard ratio (HR) was for the single symptom of rectal bleeding (HR 19.1, 95% confidence interval = 8.7 to 41.7). Positive predictive values of >3% were found for macroscopic haematuria, rectal bleeding, and involuntary weight loss, with variations according to age and sex. The three symptoms relating to irregular bleeding had particularly high specificity in terms of colorectal, uterine, and bladder cancer.ConclusionsA patient with undiagnosed cancer may present with symptoms or no symptoms. Irregular bleeding must always be explained. Abdominal pain occurs with all types of abdominal cancer and several symptoms may signal colorectal cancer. The findings are important as they influence how GPs think and act, and how they can contribute to an earlier diagnosis of cancer.

A seasonal reassortant A(H1N2) influenza virus harbouring genome segments from seasonal influenza viruses A(H1N1)pdm09 (HA and NS) and A(H3N2) (PB2, PB1, PA, NP, NA and M) was identified in March 2018 in a 19-months-old patient with influenza-like illness (ILI) who presented to a general practitioner participating in the routine sentinel surveillance of ILI in the Netherlands. The patient recovered fully. Further epidemiological and virological investigation did not reveal additional cases.

Background In many countries, GPs and home care nurses are involved in care for patients with advanced cancer. Given the varied and complex needs of these patients, providing satisfactory care is a major challenge for them. We therefore aimed to study which aspects of care patients, GPs and home care nurses consider important and whether patients receive these aspects. Methods Seventy-two Dutch patients with advanced cancer, 87 GPs and 26 home care nurses rated the importance of support when experiencing symptoms, respect for patients’ autonomy and information provision. Patients also rated whether they received these aspects. Questionnaires were based on the CQ index palliative care. Results Almost all patients rated information provision and respect for their autonomy as important. The majority also rated support when suffering from specific symptoms as important, especially support when in pain. In general, patients received the care they considered important. However, 49% of those who considered it important to receive support when suffering from fatigue and 23% of those who wanted to receive information on the expected course of their illness did not receive this or only did so sometimes. Conclusion For most patients with advanced cancer, the palliative care that they receive matches what they consider important. Support for patients experiencing fatigue may need more attention. When symptoms are difficult to control, GPs and nurses may still provide emotional support and practical advice. Furthermore, we recommend that GPs discuss patients’ need for information about the expected course of their illness.

Purpose: The purpose of this study is to describe and compare the relation between treatment aims, hospitalizations, and hospital mortality for Dutch patients who died from lung, colorectal, breast, prostate, or pancreatic cancer. Methods: A mortality follow-back study was conducted within a sentinel network of Dutch general practitioners (GPs), who recorded the end-of-life care of 691 patients who died from one of the abovementioned cancer types between 2009 and 2015. Differences in care by type of cancer were analyzed using multilevel analyses to control for clustering within general practices. Results: Among all cancer types, patients with prostate cancer most often and patients with pancreatic cancer least often had a palliative treatment aim a month before death (95% resp. 84%). Prostate cancer patients were also least often admitted to hospital in the last month of life (18.5%) and least often died there (3.1%), whereas lung cancer patients were at the other end of the spectrum with 41.8% of them being admitted to hospital and 22.6% dying in hospital. Having a palliative treatment aim and being older were significantly associated with less hospital admissions, and having a palliative treatment aim, having prostate cancer, and dying in a more recent year were significantly associated with less hospital deaths. Conclusion: There is large variation between patients with different cancer types with regard to treatment aims, hospital admissions, and hospital deaths. The results highlight the need for early initiation of GP palliative care to support patients from all cancer types to stay at the place they prefer as long as possible.

Purpose: This four-country study (Belgium, the Netherlands, Italy and Spain) examines prevalence and types of final transitions between care settings of cancer patients and the extent to which patient/family wishes are cited as a reason for the transition.Methods: Data were collected from the EUROSENTI-MELC study over a 2-year period. General practitioners within existing Sentinel Networks registered weekly all deaths of patients within practices using a standardized questionnaire. This registration included place of care in the final 3 months and wishes for the final transition to place of death. All non-sudden deaths due to cancer (+18 years) were included in the analyses.Results: We included 2048 non-sudden cancer deaths; 63% of patients had at least one transition between care settings in the final 3 months of life. 'Hospital death from home' (25-55%) and 'home death from hospital' (16-30%) were the most frequent types of final transitions in all countries. Patients' or families' wishes were mentioned as a reason for a final transition in 5-27% (P < 0.001) and 10-22% (P = 0.002) across countries.Conclusions: 'Hospital deaths from home' is the most prevalent final transition in three of four countries studied, in a significant minority of cases because of patient/family wishes.

Objective Cancer and its treatment often have a profound impact on patients, leading to increased health care use in the years after diagnosis. Social support is an important determinant of health care use. Partners of cancer patients may not always be able to provide all support patients need and patients may then revert to professional health care. We examined whether partners' health and the support they provide affect the use of general practitioner (GP) care in cancer patients. Methods Cancer patients aged ≥18, diagnosed 20% and no distant metastases were sent a questionnaire, along with their partners. Patients' self-reported recent use of GP care, i.e. whether they had discussed health problems with the GP in the past year, was assessed. Partner support as perceived by the patient was measured on three scales: Active engagement, protective buffering and overprotection. Results We included 219 patients and partners. Many patients discussed physical and emotional problems with their GP (60% and 28% of patients, respectively). Patients were less likely to discuss physical problems when they experienced active engagement and protective buffering, the latter only for females. Conclusion Partner support affects use of GP care in cancer patients. GPs should therefore pay attention to the support style of the partner. GPs could ask about the support provided by the partner and inform both patients and partners about support groups where they can share experiences. Copyright © 2015 John Wiley & Sons, Ltd.

Background: Transitions between care settings may be related to poor quality in end-of-life care. Yet there is a lack of cross-national population-based data on transitions at the end of life. Method: International mortality follow- back study with data collection in Belgium, Netherlands, Italy and Spain (2009-11) via existing representative epi- demiological surveillance networks of general practitioners (GPs). All general practitioners reported weekly, on a standardized registration form, every deceased patient (18 years) in their practice and identified those who died 'non-suddenly'. Results: Among 4791 non-sudden deaths in Belgium, Netherlands, Italy and Spain, 59%, 55%, 60% and 58%, respectively, were transferred between care settings at least once in the final 3 months of life (10%, 8%, 10% and 13% in final 3 days of life); 10%, 5%, 8% and 12% were transferred three times or more (P < 0.001 in multivariate analyses adjusting for country differences in age, sex, cause of death, presence of dementia). In all countries, transitions were more frequent among patients residing at home (61-73%) than among patients residing in a care home (33-40%). Three months before death 5-7% of patients were in hospital, and this rose to 27-39% on the day of death. Patient wishes were cited as the reason for the last transition before death in 27%, 39%, 9% and 6% of cases in Belgium, Netherlands, Italy and Spain, respectively (P < 0.001). Conclusion: End-of-life transitions between health care settings are common across EU countries, in particular late hospitalizations for people residing at home. Frequency, type and reasons for terminal hospitalizations vary between countries.

Introduction Chlamydia prevalence remains high despite scaled-up control efforts and recurrent infection frequently occurs. Objective We investigated the potential of direct partner treatment for chlamydia related to current practice and attitude of GPs towards partner notification (PN) and partner treatment (PT). Methods Four data-sources were combined: 1) Information on current practice via two short questionnaires at a national GP conference; 2) GPs’ attitudes towards PN/PT were explored in a vignette questionnaire study among GPs in NIVEL Primary Care Database (NIVEL-PCD); 3) Quantitative data on (potential) PT were obtained from prescriptions in electronic patient data of NIVEL-PCD; 4) GP recorded questionnaires related to STI consultations in the sentinel practices of NIVEL-PCD. Results Questionnaires showed that the large majority of GPs (>95%) discuss PN of current and ex-partner(s) with chlamydia-patients. Usually, GPs leave further steps to the patients (83%); partners are rarely treated directly (4%), except when partners are registered in the same practice (16%). In the vignette study, 16-20% of GPs indicated willingness to provide direct PT, depending on patient/partner profile, and 24-45% if possible after patient-initiated PN. Prescription data showed that double dosages of Azithromycin were prescribed in 1-2% of cases. STI consultation data revealed PT in 6/100 cases, via partner prescription or double doses for the index. Conclusions At present, GPs in the Netherlands rarely treat partners of chlamydia cases directly, except for partners registered in the same practice. GPs may be open to options for direct PT, provided there are clear guidelines to arrange this adequately. Key messages: •At present, GPs in the Netherlands rarely treat partners of chlamydia cases directly, except for partners registered in the same practice. •GPs may be open to options for direct PT, provided there are clear guidelines to arrange this legally and practically. (aut. ref.)

Source at https://doi.org/10.1016/j.heliyon.2017.e00328 . Background Abdominal symptoms are diagnostically challenging to general practitioners (GPs): although common, they may indicate cancer. In a prospective cohort of patients, we examined abdominal symptom frequency, initial diagnostic suspicion, and actions of GPs in response to abdominal symptoms. Methods Over a 10-day period, 493 GPs in Norway, Denmark, Sweden, Belgium, the Netherlands, and Scotland, recorded consecutive consultations: sex, date of birth and any specified abdominal symptoms. For patients with abdominal symptoms, additional data on non-specific symptoms, GPs’ diagnostic suspicion, and features of the consultation were noted. Data on all cancer diagnoses among all included patients were requested from the GPs eight months later. Findings Consultations with 61802 patients were recorded. Abdominal symptoms were recorded in 6264 (10.1%) patients. A subsequent malignancy was reported in 511 patients (0.8%): 441 (86.3%) had a new cancer, 70 (13.7%) a recurrent cancer. Abdominal symptoms were noted in 129 (25.2%) of cancer patients (P < 0.001), rising to 34.5% for the 89 patients with cancer located in the abdominal region. PPV for any cancer given any abdominal symptom was 2.1%. In symptomatic patients diagnosed with cancer, GPs noted a suspicion of cancer for 85 (65.9%) versus 1895 (30.9%) when there was no subsequent cancer (P < 0.001). No suspicion was noted in 32 (24.8%) cancer patients. The GP’s intuitive cancer suspicion was independently associated with a subsequent new cancer diagnosis (OR 2.11, 95% CI 1.15–3.89). Laboratory tests were ordered for 45.4% of symptomatic patients, imaging for 10.4%, referral or hospitalization for 20.0%: all were more frequent in subsequent cancer patients (P < 0.001). Interpretation Abdominal symptoms pointed to abdominal cancers rather than to other cancers. However, the finding of abdominal symptoms in only one third of patients with an abdominal cancer, and the lack of cancer suspicion in a quarter of symptomatic cancer patients, provide challenges for GPs’ diagnostic thinking and referral practices.

The European Alliance against Depression (EAAD) program is to be introduced in The Netherlands from 2017 onwards. This program to combat suicide consists of interventions on four levels: (1) increasing the awareness of suicide by local media campaigns; (2) training local gatekeepers, such as teachers or police officers; (3) targeting high-risk persons in the community; and (4) training and support of professionals in primary care settings. The implementation starts in seven Dutch pilot regions. Each region is designated as a Suicide Prevention Action NETwork (SUPRANET). This paper describes the SUPRANET program components and the evaluation of its feasibility and impact. The findings will be used to facilitate the national implementation of EAAD in The Netherlands and to add new findings to the existing literature on EAAD.

BackgroundA recent Dutch study in general practice showed a clear relationship between the diagnosis of vulvovaginal candidiasis (VVC) and symptoms suggestive of provoked vulvodynia (PVD). PVD accounts for the largest group of vulvar pains, but is often not recognised by GPs.AimTo investigate whether diagnostic uncertainty about VVC in general practice could also point to the diagnosis of PVD, and whether and how this diagnostic uncertainty affects management.Design & settingAn observational study in 2014 in Dutch general practices of the NIVEL Primary Care Database.MethodWomen with an uncertain diagnosis of VVC were distinguished from those with certain VVC based on the occurrence of recurrent episodes and persisting complaints, despite treatment. Factors known to be associated with PVD were hypothesised to be more prevalent in women with uncertain VVC. Data on symptom management by GPs were collected.ResultsIn total 7066 women with VVC or uncertain VVC were included. Uncertain VVC was found to account for 28% of these patients. Compared to VVC, the group uncertain VVC included significantly more women with female genital symptoms, tiredness, irritable bowel syndrome (all PPPP = 0.009), and higher mean numbers of prescriptions per patient (PConclusionThis study's findings indicate that uncertain VVC could be a marker of PVD. GPs might reconsider their diagnostics and management when women present recurrent and persistent vulvovaginal complaints, especially if accompanied by dyspareunia, functional syndromes, micturition symptoms, and psychological conditions.

Background Chlamydia prevalence remains high despite scaling-up control efforts. Transmission is not effectively interrupted without partner notification (PN) and (timely) partner treatment (PT). In the Netherlands, the follow-up of partners is not standardized and may depend on GPs’ time and priorities. We investigated current practice and attitude of GPs towards PN and PT to determine the potential for Patient-Initiated Partner Treatment, which is legally not supported yet. Methods Multiple data-sources were combined for a landscape analysis. Quantitative data on (potential) PT were obtained from prescriptions in the national pharmacy register (2004–2014) and electronic patient data from NIVEL-Primary Care Database (PCD) and from STI consultations in a subgroup of sentinel practices therein. Furthermore, we collected information on current practice via two short questionnaires at a national GP conference and obtained insight into GPs’ attitudes towards PN/PT in a vignette study among GPs partaking in NIVEL-PCD. Results Prescription data showed Azithromycin double dosages in 1–2% of cases in the pharmacy register (37.000 per year); probable chlamydia-specific repeated prescriptions or double dosages of other antibiotics in NIVEL-PCD (115/1078) could not be interpreted as PT for chlamydia with certainty. STI consultation data revealed direct PT in 6/100 cases, via partner prescription or double doses. In the questionnaires the large majority of GPs (>95% of 1411) reported to discuss PN of current and ex-partner(s) with chlamydia patients. Direct PT was indicated as most common method by 4% of 271 GPs overall and by 12% for partners registered in the same practice. Usually, GPs leave further steps to the patients (83%), advising patients to tell partners to get tested (56%) or treated (28%). In the vignette study, 16–20% of 268 GPs indicated willingness to provide direct PT, depending on patient/partner profile, more (24–45%) if patients would have the chance to notify their partner first. Conclusion GPs in the Netherlands already treat some partners of chlamydia cases directly, especially partners registered in the same practice. Follow-up of partner notification and treatment in general practice needs more attention. GPs may be open to implement PIPT more often, provided there are clear guidelines to arrange this legally and practically.

Den Heijer CDJ, Van Dongen MCJM, Donker GA, Stobberingh EE. Diagnostiek van urineweginfecties bij mannen. Huisarts Wet 2014;57(8):390-4. De diagnostiek van urineweginfecties bij mannen leidt mogelijk tot overbehandeling in de huisartsenpraktijk. Wij formuleerden een beslisregel op basis van een dipsticktest en leeftijd (ouder dan 60 jaar), en gingen na in hoeverre die regel het beleid beinvloedde ten opzichte van de gebruikelijke praktijk. Surveillanceonderzoek binnen de peilstations van NIVEL Zorgregistraties eerste lijn over de periode van januari 2009 tot juli 2011. Via de participerende huisartsen verzamelden wij dipstickresultaten en overige klinische informatie. Bij 103 kolonievormende eenheden per ml urine beschouwden wij de urineweginfectie (UWI) als microbiologisch bevestigd. Wij vergeleken de sensitiviteit en de specificiteit van de beslisregel met die van de gebruikelijke zorg (antibiotica bij een bevestigde urineweginfectie, geen antibiotica bij een niet-bevestigde urineweginfectie). Wij beschikten over de complete gegevens van 490/603 (81%) mannen. Bij 321/490 (66%) werd een UWI bevestigd. De beslisregel adviseert een antibioticum voor te schrijven aan patienten met een positieve nitriettest en aan patienten ouder dan 60 jaar met een positieve leukocytenesterasetest. Bij negatieve testuitslagen was de kans op een UWI 40%, bij mannen jonger dan 60 jaar 29%. De sensitiviteit en de specificiteit van de beslisregel weken niet significant af van die van gebruikelijke zorg: respectievelijk 75% versus 79%, en 70% versus 63% (beide p > 0,05). In de praktijk verbetert de door ons opgestelde beslisregel de diagnostiek van urineweginfecties bij mannen niet. Wanneer er ondanks een negatieve dipstick toch enige verdenking op een urineweginfectie blijft bestaan, volstaat een afwachtend empirisch antibioticumbeleid aangezien de kans op een infectie relatief klein is.

SUMMARYIn 2009 two notable outbreaks, Q fever and the novel influenza A(H1N1)pdm09, occurred in The Netherlands. Using a composite health measure, disability-adjusted life years (DALYs), the outbreaks were quantified and compared. DALYs were calculated using standardized methodology incorporating age- and sex-stratified data in a disease progression model; years lost due to disability and years of life lost were computed by outcome. Nationally, influenza A(H1N1)pdm09 caused more DALYs (24 484) than Q fever (5797). However, Q fever was 8·28 times more severe [497 DALYs/1000 symptomatic cases (DP1SC)] than A(H1N1)pdm09 (60 DP1SC). The A(H1N1)pdm09 burden is largely due to mortality while the Q fever burden is due primarily to long-term sequelae. Intervention prioritization for influenza should support patients in a critical condition while for Q fever it should target immediate containment and support for patients with long-term sequelae. Burden estimates provide guidance for focusing intervention options during outbreaks of infectious diseases.

The publisher regrets that the co-authors in the “European region influenza surveillance network” were not tagged correctly. The full and complete list of authors and their affiliations for this article is given above. The publisher would like to apologise for any inconvenience caused.

De werkdruk van huisartsen is hoog en wordt nog hoger door veroudering van de bevolking en een dreigend tekort aan huisartsen. Een oplossing is om verpleegkundigen taken te laten overnemen van de huisarts. De auteurs van een cochranereview bekeken wat patienten, huisartsen en verpleegkundigen hiervan vinden en welke ervaring ze hiermee hebben. Daaruit blijkt dat goede scholing, goede verwijsmogelijkheden, duidelijke taakverdeling en goede begeleiding randvoorwaarden voor succes zijn.