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Introduction: This study aimed to assess the effect of integrated palliative care (IPC) on potentially inappropriate end- of-life care and healthcare-costs in the last 30 days of life in the Netherlands., Methods: Nationwide health-insurance claims data were used to assess potentially inappropriate end-of-life care (≥2 emergency room visits; ≥2 hospital admissions; >14 days hospitalization; chemotherapy; ICU admission; hospital death) and healthcare-costs in all deceased adults in IPC regions pre- and post- implementation and in those receiving IPC compared to a 1:2 matched control group., Results: In regions providing IPC deceased adults (n = 37,468) received significantly less potentially inappropriate end-of-life care post-implementation compared to pre-implementation (26.5% vs 27.9%; p < 0.05). Deceased adults who received IPC (n = 210) also received significantly less potentially inappropriate end-of-life care compared to a matched control group (14.8% vs 28.3%; p < 0.05). Mean hospital costs significantly decreased for deceased adults who received IPC (€2,817), while mean costs increased for general practitioner services (€311) and home care (€1,632)., Discussion: These results highlight the importance of implementation of integrated palliative care and suitable payment. Further research in a larger sample is needed., Conclusion: This study shows less potentially inappropriate end-of-life care and a shift in healthcare costs from hospital to general practitioner and home care with IPC., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2024 The Author(s).)

Background: Advance care planning in dementia includes supporting the person and their family to consider important goals of care. International research reports the importance of psycho-social-spiritual aspects towards end of life., Aim: To develop a multidimensional international palliative care goals model in dementia for use in practice., Design: International Delphi study integrating consensus and evidence from a meta-qualitative study. The Delphi panel rated statements about the model on a 5-point agreement scale. The criteria for consensus were pre-specified., Setting/participants: Seventeen researchers from eight countries developed an initial model, and 169 candidate panellists were invited to the international online Delphi study., Results: Panellists (107; response 63.3%) resided in 33 countries. The model comprised four main care goals: (1) Comfort ensured; (2) Control over function maintained; (3) Identity protected and personhood respected and (4) Coping with grief and loss-person and caregiver supported. The model reflects how needs and care goals change over time with the progression of dementia, concluding with bereavement support. The first version of the model achieved a consensus after which it was slightly refined based on feedback. We did not achieve a consensus on adding a goal of life prolongation, and on use of the model by people with dementia and family themselves., Conclusion: A new palliative care goals model for people with dementia and their families includes relationship aspects for use by professionals and achieved a consensus among a panel with diverse cultural background. The position of life prolongation in relation to palliative care goals needs further research., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: This study was performed with the same expert panel as with EAPC’s ACP Delphi study, but this study was not designed by the EAPC ACP in dementia task force. This separate study was not conducted as part of the remit of the EAPC task force. There are no conflicts of interest.

Introduction: Interprofessional collaboration (IPC) within and during movements between care settings is crucial for optimal palliative dementia care. The objective of this study was to explore the experiences of persons with dementia regarding collaboration with and between healthcare professionals (HCPs) and their perceptions of a possible future move to the nursing home (NH) in palliative dementia care. Method: We conducted a cross-sectional qualitative study and performed semi-structured interviews with a purposive sample of persons with dementia living at home ( N  = 18). Data analysis involved content analysis. Results: Our study demonstrated that even though most persons with dementia find it difficult to perceive the collaboration amongst HCPs, they could describe their perceived continuity of care ( Theme 1. My perception of collaboration among HCPs ). Their core needs in collaboration with HCPs were receiving information, support from informal caregivers, personal attention and tailored care ( Theme 2. My needs in IPC ). Regarding a possible future move to the NH, persons with dementia cope with their current decline, future decline and a possible future move to the NH ( Theme 3. My coping strategies for a possible future move to the NH ). They also prefer to choose the NH, and continue social life and activities in their future NH ( Theme 4. My preferences when a NH becomes my possible future home ). Conclusion: Persons with dementia are collaborative partners who could express their needs and preferences, if they are willing and able to communicate, in the collaboration with HCPs and a possible future move to the NH.

A qualitative study was conducted to examine the experiences of informal caregivers of persons with dementia pertaining interprofessional collaboration with and among healthcare professionals in home care (HC), nursing homes and during home to nursing home transitions in palliative care. Semi-structured interviews were performed with bereaved informal caregivers. Data were analysed using a critical realist approach. The two main themes that emerged were: ( 1) Informal caregivers' roles in interprofessional collaboration with healthcare professionals and ( 2) Informal caregivers' perception of interprofessional collaboration among healthcare professionals . Informal caregivers' roles were identified in three collaboration processes: information exchange, care process and shared decision-making. Interprofessional collaboration among healthcare professionals was more perceptible on the collaboration outcome level (e.g. being up to date with the health status of the person with dementia; acting proactive, being adequate and consistent in the care process; and giving a warm welcome) than on the collaboration processes level (e.g. communicating and being involved in team processes). Our study revealed that intrinsic and extrinsic factors and interprofessional collaboration among healthcare professionals affected informal caregivers' collaborative roles. In summary, our study showed that informal caregivers have important roles as team members in the continuity and quality of palliative care for persons with dementia.

Background: Dementia palliative care is increasingly subject of research and practice improvement initiatives., Aim: To assess any changes over time in the evaluation of quality of care and quality of dying with dementia by family caregivers., Design: Combined analysis of eight studies with bereaved family caregivers' evaluations 2005-2019., Setting/participants: Family caregivers of nursing home residents with dementia in the Netherlands ( n = 1189) completed the End-of-Life in Dementia Satisfaction With Care (EOLD-SWC; quality of care) and Comfort Assessment in Dying (EOLD-CAD, four subscales; quality of dying) instruments. Changes in scores over time were analysed using mixed models with random effects for season and facility and adjustment for demographics, prospective design and urbanised region., Results: The mean total EOLD-SWC score was 33.40 (SD 5.08) and increased by 0.148 points per year (95% CI, 0.052-0.244; adjusted 0.170 points 95% CI, 0.055-0.258). The mean total EOLD-CAD score was 30.80 (SD 5.76) and, unadjusted, there was a trend of decreasing quality of dying over time of -0.175 points (95% CI, -0.291 to -0.058) per year increment. With adjustment, the trend was not significant (-0.070 EOLD-CAD total score points, 95% CI, -0.205 to 0.065) and only the EOLD-CAD subscale 'Well being' decreased., Conclusion: We identified divergent trends over 14 years of increased quality of care, while quality of dying did not increase and well-being in dying decreased. Further research is needed on what well-being in dying means to family. Quality improvement requires continued efforts to treat symptoms in dying with dementia.

Background: the prevalence of sarcopenia increases with age. Physical activity might slow the rate of muscle loss and therewith the incidence of sarcopenia., Objective: to examine the association of physical activity with incident sarcopenia over a 5-year period., Design: data from the population-based Age, Gene/Environment, Susceptibility-Reykjavik Study were used., Setting: people residing in the Reykjavik area at the start of the study., Subjects: the study included people aged 66-93 years (n = 2309)., Methods: the amount of moderate-vigorous physical activity (MVPA) was assessed by a self-reported questionnaire. Sarcopenia was identified using the European Working Group on Sarcopenia in Older People algorithm, including muscle mass (computed tomography imaging), grip strength (computerised dynamometer) and gait speed (6 m)., Results: mean age of the participants was 74.9 ± 4.7 years. The prevalence of sarcopenia was 7.3% at baseline and 16.8% at follow-up. The incidence proportion of sarcopenia over 5 years was 14.8% in the least-active individuals and 9.0% in the most-active individuals. Compared with the least-active participants, those reporting a moderate-high amount of MVPA had a significantly lower likelihood of incident sarcopenia (OR = 0.64, 95% CI 0.45-0.91). Participants with a high amount of MVPA had higher baseline levels of muscle mass, strength and walking speed, but baseline MVPA was not associated with the rate of muscle loss., Conclusion: a higher amount of MVPA seems to contribute to counteracting the development of sarcopenia. To delay the onset of sarcopenia and its potential adverse outcomes, attention should be paid to increasing physical activity levels in older adults., (© The Author 2016. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background & Aims: Many residents in European healthcare institutions are malnourished, with reported malnutrition prevalence rates of up to 60%. Due to the negative effects of malnutrition it is important to optimize the quality of nutritional care. If structural quality indicators of nutritional care might improve resident care and outcome is not yet known. The aim of this study is to explore whether structural quality indicators for nutritional care influence malnutrition prevalence in Dutch, German and Austrian nursing homes., Methods: This study follows a cross-sectional, multi-center design. Data were collected by using a standardised questionnaire at resident, ward and institution level., Results: Data from 214 nursing homes (NL = 133, G = 61, A = 20) were analysed. The prevalence of malnutrition varied significantly between the three countries (NL = 18.2% G = 20.1% A = 22.5%). Two structural quality indicators at ward level namely (1) the policy that the care file should include the nutritional intake for each patient and (2) having a weight measurement policy at ward level are predictive for malnutrition prevalence. Furthermore also the variable country was of influence., Conclusions: A policy of registering nutritional intake in the file of the patient and a policy to assess the patient's weight regularly have a positive influence on malnutrition prevalence., (Copyright © 2014 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Objectives: Research shows that nursing home residents are largely inactive. This inactivity negatively influences physical fitness, and participation in daily activities is known to have a positive influence on physical function and quality of life. Existing research does not provide sufficient insight into the daily activities in which nursing home residents participate. This insight is needed to develop future interventions so as to encourage nursing home residents to participate in daily activities and, thereby, decrease inactivity. The purpose of this study was to obtain insight into daily (in)activities of psychogeriatric and somatic nursing home residents during the day and their body positions during these (in)activities., Design: Cross-sectional observation study., Setting: Nursing homes in the Netherlands (19 psychogeriatric and 11 somatic wards)., Participants: Participants were 723 home residents in 7 nursing homes., Measurements: Observations were conducted using a self-developed observation list. Residents were observed in their wards during 5 random observation times between 7:00 am and 11:00 pm, in which the daily activity and position of the resident during this activity were scored. Percentages of activities and positions were calculated for each observation time., Results: In total, 3282 observations (91% of the intended 3615 observations) were conducted. Nursing home residents of both psychogeriatric and somatic wards were mainly observed partaking in in activities, such as sleeping, doing nothing, and watching TV (range: 45%-77% of the 5 observation times). Furthermore, residents were engaged in activities of daily living (ADLs) (range: 15%-38%) that mainly comprised activities related to mobility (range: 10%-19%) and eating and drinking (range: 2%-17%). Engagement of residents in instrumental ADLs (IADLs) was rarely observed (up to 3%). Residents were largely observed in a lying or sitting position (range: 89%-92%)., Conclusion: Most of the psychogeriatric and somatic nursing home residents spend their day inactive in a lying or sitting position in the ward. To encourage nursing home residents in daily activities in the wards, interventions are needed that (1) focus on increasing ADLs and IADLs, and (2) encourage standing and walking., (Copyright © 2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: Both sarcopenia and physical frailty are geriatric syndromes causing loss of functionality and independence. This study explored the association between sarcopenia and physical frailty and the overlap of their criteria in older people living in different community (care) settings. Moreover, it investigated the concurrent validity of the FRAIL scale to assess physical frailty, by comparison with the widely used Fried criteria., Design: Data were retrieved from the cross-sectional Maastricht Sarcopenia Study (MaSS)., Setting: The study was undertaken in different community care settings in an urban area (Maastricht) in the south of the Netherlands., Participants: Participants were 65 years or older, gave written informed consent, were able to understand Dutch language, and were not wheelchair bound or bedridden., Intervention: Not applicable., Measurements: Sarcopenia was identified using the algorithm of the European Working Group on Sarcopenia in Older People. Physical frailty was assessed by the Fried criteria and by the FRAIL scale. Logistic regression was performed to assess the association between sarcopenia and physical frailty measured by the Fried criteria. Spearman correlation was performed to assess the concurrent validity of the FRAIL scale compared with the Fried criteria., Results: Data from 227 participants, mean age 74.9 years, were analyzed. Sarcopenia was identified in 23.3% of the participants, when using the cutoff levels for moderate sarcopenia. Physical frailty was identified in 8.4% (≥3 Fried criteria) and 9.3% (≥3 FRAIL scale criteria) of the study population. Sarcopenia and physical frailty were significantly associated (P = .022). Frail older people were more likely to be sarcopenic than those who were not frail. In older people who were not frail, the risk of having sarcopenia increased with age. Next to poor grip strength (78.9%) and slow gait speed (89.5%), poor performance in other functional tests was common in frail older people. The 2 physical frailty scales were significantly correlated (r = 0.617, P < .001)., Conclusion: Sarcopenia and physical frailty were associated and partly overlap, especially on parameters of impaired physical function. Some evidence for concurrent validity between the FRAIL scale and Fried criteria was found. Future research should elicit the value of combining sarcopenia and frailty measures in preventing disability and other negative health outcomes., (Copyright © 2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to explore whether structural quality indicators for nutritional care influence malnutrition prevalence in the Netherlands, Germany, and Austria. Furthermore, differences in malnutrition prevalence and structural quality indicators for nutritional care nursing homes in the three countries were examined., Methods: This was a cross-sectional, multicenter study using a standardized questionnaire at the patient, ward, and institutional levels. Malnutrition was assessed by low body mass index, undesired weight loss, and reduced intake. Structural quality indicators of nutritional care were measured at the ward and institutional levels., Results: The prevalence of malnutrition differed significantly between the three countries (Netherlands 18%, Germany 20%, and Austria 22.7%). Structural quality indicators related to nutritional care as having a guideline of prevention and treatment of malnutrition were related to malnutrition and explained malnutrition prevalence variance between the Netherlands and Germany. Differences between the Netherlands and Austria in malnutrition prevalence still existed after controlling for these quality structural indicators., Conclusions: Structural quality indicators of nutritional care are important in explaining malnutrition variance between the Netherlands and Germany. However, they did not explain the difference in malnutrition prevalence between the Netherlands and Austria. Investigating the role of process indicators may provide insight in the role of structural quality indicators of nutritional care in explaining the malnutrition prevalence differences between the Netherlands and Austria., (Copyright © 2014 Elsevier Inc. All rights reserved.)

To date, no information is available about the effect of structural and process factors of nutritional care on the prevalence of malnutrition over time in the long-term care sector. This study analyzes the trend of malnutrition prevalence rates between 2007 and 2011 in the long-term care sector, and the related effects of(1) process indicators such as nutritional screening and treatment and 2) structural indicators (guideline, protocol or nutritional screening policy). From 2007 to 2011, the Dutch National Prevalence Measurement of Care Problems (LPZ) was performed in Dutch long-term care organizations using a standardized questionnaire involving measurements at institutional, ward and resident level. The data were analyzed by mixed-linear regression for longitudinal data. Presence of malnutrition was assessed by BMI, undesired weight loss and nutritional intake. Seventy-four care homes were included (26,101 residents). The malnutrition prevalence trend significantly decreased (P < 0.001) from 26% to 18% from 2007 to 2011. In the final model of the mixed effects analysis only the interacted process indicators nutritional screening and oral nutritional supplementation (ONS) were significant in influencing malnutrition prevalence rates over time. Structural indicators had no impact on the malnutrition prevalence over time. In conclusion, over time a lower prevalence of malnutrition is associated with a higher degree of nutritional screening. As might be expected, a higher prevalence of malnutrition is associated with higher use of ONS. Structural nutritional screening is an important intervention to tackle the problem of malnutrition in the long term care sector., (Copyright © 2013 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Background: Dysphagia has been found to be strongly associated with aspiration pneumonia in frail older people. Aspiration pneumonia is causing high hospitalization rates, morbidity, and often death. Better insight in the prevalence of (subjective) dysphagia in frail older people may improve its early recognition and treatment., Objective: First, to assess the prevalence of subjective dysphagia in care home residents in the Netherlands. Second, to assess the associations of subjective dysphagia with potential risk factors of dysphagia., Design: Retrospective data-analysis of a cross-sectional, multi-centre point prevalence measurement., Setting: 119 care homes in the Netherlands., Participants: Data of 8119 care home residents aged 65 years or older were included and analyzed., Methods: Subjective dysphagia was assessed by a resident's response to a dichotomous question with regard to experiencing swallowing problems. If a resident was not able to respond (e.g. residents with dementia or aphasia), the question was answered by the ward care provider, or the resident's file was consulted for registered swallowing complaints and/or dysphagia. Several residents' data were collected: gender, age, (number of) diseases, the presence of malnutrition, the Care Dependency Scale score, and the body mass index., Results: Subjective dysphagia was found in 751 (9%) residents. A final model for subjective dysphagia after multivariate backward stepwise regression analysis revealed eight significant variables: age (B -0.022), Care Dependency Scale score (B -0.985), 'malnutrition' (OR 1.58; 95% CI 1.31-1.90), 'comorbidity' (OR 1.07; 95% CI 1.01-1.14), and the disease clusters 'dementia' (OR 0.55; 95% CI 0.45-0.66), 'nervous system disorder' (OR 1.55; 95% CI 1.20-1.99), 'cardiovascular disease' (OR 0.81; 95% CI 0.67-0.99) and 'cerebrovascular disease/hemiparesis' (OR 1.74; 95% CI 1.45-2.10)., Conclusion: It seems justified to conclude that subjective dysphagia is a relevant care problem in older care home residents in the Netherlands. Care Dependency Scale score, 'malnutrition', and the disease clusters 'dementia', 'nervous system disorder', and 'cerebrovascular disease/hemiparesis' were associated with the presence of subjective dysphagia in this study. Age, 'comorbidity' and 'cardiovascular disease' showed very small influence., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Economic evaluations for medical nutrition, such as oral nutritional supplements (ONS), are relatively uncommon compared with other health technologies, and represent an area that has not been reviewed so far. In this systematic review, economic evaluations of enteral medical nutrition in the management of disease-related malnutrition (DRM) were reviewed and qualified to estimate the economic value. Initially, 481 studies were found, of which 37 full-text articles were assessed for eligibility and were rated on their quality using the Quality of Health Economic Studies (QHES) instrument. The final review focused on the high QHES quality economic evaluation studies. As both the studied medical nutrition intervention and the form of the economic evaluation varied, a quantitative synthesis (meta-analysis) was not attempted but a critical analysis and comparison of the individual study results were performed. ONS was the most studied intervention, covering several patient populations and different health care settings. Outcomes included cost savings (n = 3), no significant extra costs per unit of clinical and/or functional improvement (n = 1), or significantly higher costs per unit of clinical and/or functional improvement but still cost-effective for the used threshold (n = 4). This review shows that the use of enteral medical nutrition in the management of DRM can be efficient from a health economic perspective., (Copyright © 2014 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Sarcopenia is probably an important causal factor for functional decline in acutely ill hospitalized geriatric patients. Low skeletal muscle mass, low gait speed and low grip strength are hallmarks of diagnosing sarcopenia. However there are many different diagnostic criteria to assess sarcopenia., Objectives: In this study the influence of different criteria for sarcopenia was studied on sarcopenia prevalence in geriatric patients admitted to an acute care hospital., Design: Cross sectional study design., Setting: A geriatric ward of a large Dutch hospital., Participants: Geriatric patients., Measurements: Skeletal muscle mass measured using bio impedance analysis (BIA), gait speed using the 4 meter walking test and grip strength. The sarcopenia prevalence was investigated according to criteria of: muscle mass, grip strength, the European Working Group on Sarcopenia in Elderly People, the International Working Group on Sarcopenia and the Special Interest Group of Society of Sarcopenia, Cachexia and Wasting Disorders., Results: 85 geriatric patients were included (61 women). Applying the 17 different criteria, the sarcopenia prevalence varied from 26-75% for women and from 42-100% for men. Comparing the Janssen calculation with the Maltron calculation sarcopenia prevalence ranged from respectively 26-67% and 67-70% for women and from 42-71% and 75-100% for men. Almost all patients (96%) had a low gait speed., Conclusions: Sarcopenia is highly prevalent in an acute hospitalized geriatric population, although the prevalence varies widely depending on the diagnostic criteria applied. A prospective study is needed to discover which criteria of sarcopenia can predict best adverse outcomes.

Objectives: To investigate the malnutrition prevalence in Dutch care home residents with dementia over the years. Secondly, to examine the relationship of malnutrition and dementia and the role of care dependency and co-morbidity within this relationship., Design: This study is a secondary analysis of data of the annual independent Dutch National Prevalence Measurement of Care Problems of Maastricht University. The design involves a cross-sectional, multicenter point prevalence measurement., Setting: Care homes., Participants: 75399 residents older than 65 years (4523 resident with dementia) participated over 5 years (2006-2010). Sixty organizations measured 4 times, 31 organizations 3 times, 68 organizations 2 times, 511 organizations 1 time., Measurements: A standardized questionnaire was used to register amongst others data of weight, height, nutritional intake, undesired weight loss, comorbidity, dementia, and care dependency., Results: The study was able to show that there is a significant decline in malnutrition prevalence in the group of non-demented residents over the years (Non-demented group p <0.001). The prevalence of malnutrition in the demented group showed no significant reduction over the years. GEE analysis showed that malnutrition and dementia are related and that care dependency and age are important influencing factors in this relation., Conclusion: The results show that compared to the non-demented residents, the prevalence of malnutrition does not decline in demented care home residents over the years. Moreover, the findings of this study stress that malnutrition and dementia are related, while care dependency and age are confounding factors in this relationship.

Since 1998, the National Prevalence Measurement of Care Problems (LPZ) has annually measured the prevalence, prevention and treatment of a number of care problems in many health care organisations. These problems include pressure ulcers, incontinence, intertrigo, malnutrition, falls and the use of restraints. This article describes trends in the prevalence of these problems during the past few years and the preventive and treatment measures taken for clients residing in psychogeriatric and/or somatic wards of nursing homes. The results show that the prevalence of these care problems has declined in general. Nevertheless, the individual interventions (preventive measures and treatment) have not really changed in recent years. It is concluded that the extra attention paid to these care problems might already have had a positive effect on their prevalence. This must be further investigated. In any case, extra follow-up steps need to be taken to bring about a further decline. The article describes which steps the project group has already taken in this respect.

Aim: The aim of this article was to describe the design of an international audit of the prevalence of care problems in different healthcare sectors using identical methodologies., Background: Audits, defined as a monitor of quality of health care, are increasingly applied in many countries as a strategy to improve professional practice and quality and safety of care. A prerequisite to enable a reliable comparison of quality of care audits is the use of identical instruments and methodology., Design: Annual cross-sectional multi-centre point prevalence survey., Method: This international prevalence measurement of care problems in hospitals, care homes and home care is performed in the Netherlands, Austria, Switzerland and New Zealand. This study is based on a prevalence measurement of care problems originally performed in the Netherlands. For each care problem (pressure ulcer, incontinence, malnutrition, falls and restraints) at patient level, next to patient characteristics, data are gathered about the prevalence, prevention and treatment of each care problem. In addition, at ward/department and institution level, specific quality indicators are measured related to the care problems. After the measurement, institutions enter their data into a web-based data-entry program. Institutions receive an overview of their own results and results at national level to enable a process of benchmarking., Discussion: A uniform way of measuring the prevalence of care problems internationally is a significant step forward in gaining insight into the quality of basic care in different healthcare settings in different countries and may lead to more awareness and improvement programmes., (© 2013 John Wiley & Sons Ltd.)

Aim: This report describes the results from the last international prevalence measurement of care problems in the Netherlands, Austria and Switzerland, including the course of the prevalence rates during the past 4 years., Background: Basic care problems such as pressure ulcers, malnutrition and falls occur frequently in healthcare organizations. Measuring these care problems provides insight into their occurrence, and, while a measurement is included of the prevention, treatment and structural quality indicators, this gives institutions the possibility of improving their care regarding these care problems., Design: An annual cross-sectional multicentre study., Method: The prevalence measurement of care problems is conducted annually on one specific day in different healthcare settings, among which are hospitals and care homes. Data are collected by means of a comprehensive, standardized questionnaire that comprises three levels: institutional, ward/department and patient level., Results: Besides general characteristics of patients, results are presented for prevalence rates, prevention, treatment and quality indicators regarding each care problem for each country., (© 2013 John Wiley & Sons Ltd.)

Objective: The main objective of this study was to develop a feedback system that improves the translation of malnutrition performance data from the Dutch National Prevalence Measurement of Care Problems (LPZ) into relevant evidence- and practice-based interventions in care homes., Methods: The process consisted of two stages. The first was the development of a feedback system. Twenty-four interviews were held with health care professionals in care homes that participated in the LPZ to gain insight into needs regarding the translation of performance data into relevant improvement interventions. Subsequently, three multidisciplinary focus groups discussed how to develop a feedback system to deal with those needs. In the second stage, the feasibility of this system was evaluated via a questionnaire (N = 93) that was sent to care homes participating in LPZ., Results: It was important that performance data be more transparent regarding which information was relevant and that insight was gained into how to improve nutritional care. To address these needs, a dashboard was developed to present performance data in a transparent way. Subsequently, a decision tree was developed that links LPZ dashboard outcomes to evidence-based nutritional interventions for care homes. Forty-seven respondents (50.5%) evaluated the new feedback system (the dashboard and the decision tree) as feasible. The content and design were perceived to be very useful. Half of the participating institutions had already started working with improvement activities., Conclusion: The developed feedback system was evaluated as useful for improving nutritional patient care in the future. This system will also be developed for other health care settings., (Copyright © 2013. Published by Elsevier Inc.)

In the second in the series, Professor Ruud Halfens and Dr Judith Meijers give an overview of statistics, both descriptive and inferential. They describe the first principles of statistics, including some relevant inferential tests.

Background: This study critically appraises the measurement properties of tools to measure muscle mass, strength, and physical performance in community-dwelling older people. This can support the selection of a valid and reliable set of tools that is feasible for future screening and identification of sarcopenia., Methods: The databases PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Cochrane were systematically searched (January 11, 2012). Studies were included if they investigated the measurement properties or feasibility, or both, of tools to measure muscle mass, strength, and physical performance in community-dwelling older people aged ≥60 years. The consensus-based standards for the selection of health status measurement instruments (COSMIN) checklist was used for quality appraisal of the studies., Results: Sixty-two publications were deemed eligible, including tools for muscle mass (n = 16), muscle strength (n = 15), and physical performance (n = 31). Magnetic resonance imaging, computed tomography, and a 4-compartment model were used as gold standards for muscle mass assessment. Other frequently used measures of muscle mass are dual-energy x-ray and the bioelectrical impedance (BIA); however, reliability data of the BIA are lacking. Handheld dynamometry and gait speed or a short physical performance battery provide a valid and reliable measurement of muscle strength and physical performance, respectively., Conclusions: It can be concluded that several tools are available for valid and reliable measurements of muscle mass, strength, and performance in clinical settings. For a home-setting BIA, handheld dynamometry and gait speed or a short physical performance battery are the most valid, reliable, and feasible. The combination of selected instruments and its use for the screening and identification of sarcopenia in community-dwelling older people need further evaluation., (Copyright © 2013. Published by Elsevier Inc.)

Background & Aims: Disease related malnutrition (under-nutrition caused by illness) is a worldwide problem in all health care settings with potentially serious consequences on a physical as well as a psycho-social level. In the European Union countries about 20 million patients are affected by disease related malnutrition, costing EU governments up to € 120 billion annually. The aim of this study is to calculate the total additional costs of disease related malnutrition in The Netherlands., Methods: A cost-of-illness analysis was used to calculate the additional total costs of disease related malnutrition in adults (>18 years of age) for The Netherlands in 2011 in the hospital, nursing- and residential home and home care setting, expressed as an absolute monetary value as well as a percentage of the total Dutch national health expenditure and as a percentage of the total costs of the studied health care sectors in The Netherlands., Results: The total additional costs of managing adult patients with disease related malnutrition were estimated to be € 1.9 billion in 2011 which equals 2.1% of the total Dutch national health expenditure and 4.9% of the total costs of the health care sectors analyzed in this study., Conclusions: The results of this study show that the additional costs of disease related malnutrition in adults in The Netherlands are considerable., (Copyright © 2012 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Objective: The aim of this study was to describe and compare structural and process indicators of nutritional care in Austrian hospitals and nursing homes., Methods: A multicenter, cross-sectional study was performed using a standardized and tested questionnaire. Data were collected on patient and institutional levels of hospitals and nursing homes., Results: Data from 18 Austrian hospitals (n = 2326 patients) and 18 Austrian nursing homes (n = 1487 residents) were collected. The prevalence of malnutrition was 23.2% in hospitals and 26.2% in nursing homes. All hospitals and 83.3% of the nursing homes employed dietitians. Guidelines for the prevention and treatment of malnutrition were used infrequently. Nutritional screening at admission was performed in 62.6% of the hospitalized patients and 93.4% of the nursing home residents. Nutritional screening tools were used in 28.9% of the nursing home residents and 14.5% of the hospitalized patients. Oral nutritional support was preferred to enteral and parenteral nutrition in the two settings. Dietitians were consulted in 27.5% of the malnourished hospitalized patients and 74.7% of the malnourished nursing home residents., Conclusion: The study demonstrated that nursing homes fulfilled more structural indicators and performed nutritional screening at admission more often than hospitals. Nevertheless, the prevalence of malnutrition was high in the two settings and a substantial number of malnourished patients/residents received no nutritional intervention at all. These results show the necessity for improvements in the nutritional care in Austria, for instance, through the routine use of nutritional screening tools followed by tailored nutritional interventions in patients/residents in need., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Unlabelled: To investigate the role of malnutrition, impaired mobility and care dependency in predicting fallers in older Dutch home care clients., Design: This study is a secondary analysis of data of the annual independent national prevalence measurement of care problems of Maastricht University. The design involves a cross-sectional, multicentre point prevalence measurement (malnutrition, mobility), and a 30 days incidence measurement (falls)., Setting: Dutch home care organisations., Participants: 2971 clients (older than 65 years) from 22 home care organizations participated., Measurements: A standardized questionnaire was used to register amongst others data of weight, height, number and type of diseases (like for example neurologic diseases, dementia, CVA, COPD, eye/ear disorders, musculoskeletal disorders), nutritional intake, use of psychopharmaca, undesired weight loss, fall history, mobility, and care dependency., Results: The study was able to show that fallers are more often malnourished than non-fallers in the univariate analysis. Most importantly the study indicated by multivariate analysis that fallers could be predicted by the risk factors immobility ((OR 2.516 95% CI 1.144-5.532), high care dependency (OR 1.684 95% CI 1.121-2.532) and malnutrition (OR 1.978 95% CI 1.340-2.920)., Conclusion: The findings of this study stress that malnutrition, impaired mobility and care dependency are potential reversible factors related to falls. Therefore early identification and management of nutritional status, impaired mobility and care dependency are important aspects for a possible fall prevention strategy.

Backgrounds & Aims: Malnutrition in western health care involves a tremendous burden of illness. In this study the economic implications of malnutrition in Dutch nursing homes are investigated as part of the Health and Economic Impact of Malnutrition in Europe Study from the European Nutrition for Health Alliance., Methods: A questionnaire was developed, focussing on the additional time and resources spent to execute all relevant nutritional activities in nursing home patients with at risk of malnutrition or malnourished. Results were extrapolated on national level, based on the prevalence rates gathered within the national Prevalence Measurement of Care Problems 2009., Results: The normal nutritional costs are 319 million Euro per year. The total additional costs of managing the problem of malnutrition in Dutch nursing homes involve 279 million Euro per year and are related to extra efforts in nutritional screening, monitoring and treatment. The extra costs for managing nursing home residents at risk of malnutrition are 8000 euro per patient and 10000 euro for malnourished patients., Conclusions: The extra costs related to malnutrition are a considerable burden for the nursing home sector and urge for preventive measures., (Crown Copyright © 2011. Published by Elsevier Ltd. All rights reserved.)

Aims and Objectives: This study investigates possible differences in malnutrition prevalence rates in Dutch and German nursing homes. It seeks to provide insight into the screening, prevention and treatment of malnutrition and the indicators for nutritional care policy., Background: For decades, malnutrition has been an important problem in health care settings worldwide. A considerable percentage of frail older people suffer from malnutrition. In European nursing homes, the reported prevalence rates range widely (2% to 85%)., Method: This is a multicentre, cross-sectional prevalence study of malnutrition in Dutch and German nursing homes using standardised methodology, with the participation of respectively 5848 and 4923 residents (65+ years)., Results: Patient characteristics differed significantly between the two countries. Dutch residents were more often male, younger, more care-dependent and significantly more at risk of malnutrition (31·7%). However, overall malnutrition prevalence rates did not differ significantly (Netherlands 26·8% and Germany 26·5%). All German residents were screened at admission, whereas only 73·1% of the Dutch residents were. As part of screening, nutritional screening tools were used in 38·0% of Dutch and 42·1% of the German residents. A dietician was consulted for 36·7% Dutch and 9·3% German malnourished residents. The proportion of malnourished receiving nutritional intervention was larger in Germany than in the Netherlands. Structural indicators for nutritional policy were fulfilled more often in the Netherlands care at institutional level whereas in Germany they were fulfilled more often at ward level., Conclusion: In this study, German residents had a somewhat better nutritional status than Dutch residents and more is done to enhance nutritional status in German nursing homes. The differences would be somewhat larger if both populations were more comparable., Relevance to Clinical Practice: Comparing malnutrition prevalence rates, prevention and interventions in health care institutions and countries gives insight into international differences in quality of care., (© 2011 Blackwell Publishing Ltd.)

Objectives: Pressure ulcers (PU) remain a major health care problem throughout the world. Although malnutrition is considered to be one of the intrinsic risk factors for PU, more evidence is needed to identify the exact relation between PU and malnutrition. This study aims to identify whether there exists a relationship between PU and malnutrition in hospitals and nursing homes., Methods: A cross-sectional study was performed in April 2007 in hospitals and nursing homes in Germany. PU were assessed using the Braden scale. Malnutrition was assessed by low body mass index (BMI), undesired weight loss, and insufficient nutritional intake., Results: Two thousand three hundred ninety-three patients from 29 nursing homes and 4067 patients from 22 hospitals participated in the study. PU in both hospital and nursing home patients were significantly (P < 0.01) related to undesired weight loss (5%-10%). Moreover low nutritional intake and low BMI (<18.5) were also significantly related to PU in hospitals and nursing homes., Conclusion: There is a significant relationship between malnutrition parameters like undesired weight loss, BMI < 18.5, and low nutritional intake and PU., ((c) 2010 Elsevier Inc. All rights reserved.)

Objective: Although screening for malnutrition in health care has expanded enormously, a gold standard for the optimal definition and operationalism of malnutrition is still lacking. This report reflects expert opinions on the elements of the definition and operationalism of malnutrition and is meant to trigger further debate within the nutritional societies., Methods: A Delphi study was performed consisting of three phases. After a literature review (phase 1), questions for a semistructured interviews (phase 2) were formulated. Subsequently, the results of these semistructured interviews were used to develop the final list of elements (for defining and operationalism of malnutrition). In phase 3 (final phase), experts were asked to provide written feedback regarding the ranking of elements concerning the importance of these elements., Results: Twenty-two experts (response 73.3%) were included in the final phase of this Delphi study. No overall agreement could be reached. The elements deficiencies of energy or protein and decrease in fat-free mass were most often mentioned to be particularly important in defining malnutrition. Elements mentioned to be important in operationalism of malnutrition were involuntary weight loss, body mass index, and no nutritional intake. Opinions on cutoff points regarding these elements differed strongly among experts., Conclusion: This study shows that there is no full agreement among experts on the elements defining and operationalism of malnutrition. The results of this study may fuel the discussion within the nutritional societies, which will most ideally lead to an international consensus on a definition and operationalism of malnutrition., (Copyright 2010 Elsevier Inc. All rights reserved.)

To our knowledge, no studies have analyzed the influence of annual audit and feedback on the prevalence rates of malnutrition. This study analyzes the trend of malnutrition prevalence rates between 2004 and 2007 and the effects of previous audits and feedback from the annual Dutch National Prevalence Measurement of Care Problems (LPZ) and the effect of the participation in Dutch national improvement programs. From 2004 to 2007, an annual multicenter study was performed in Dutch hospitals, nursing homes, and home care organizations using a standardized questionnaire involving measurements at institutional, ward, and patient levels. The data were analyzed by logistic multilevel analysis. Nutritional status was assessed by BMI, undesired weight loss, and nutritional intake. In total, 80 hospitals, 141 nursing homes, and 48 home care organizations participated. The prevalence of malnutrition tended to decrease in hospitals and home care over the years. In nursing homes, prevalence rates were stable. Furthermore, the more often hospitals and home care organizations participated in the annual LPZ audits, the lower the prevalence rate of malnutrition (P < 0.001). Participation in national improvement programs also resulted in lower prevalence rates (P = 0.027). In conclusion, malnutrition prevalence rates have decreased over the last 4 y in hospitals and home care in The Netherlands. Participation in the LPZ and involvement in national improvement programs positively influenced these malnutrition prevalence rates, possibly indicating that increasing awareness and actively working toward improvement could be important in lowering these rates.

Objective: In most health care organizations there is still insufficient awareness for recognizing and treating malnourished patients. To gain more insight into nutritional care policies in Dutch health care organizations, this study investigated screening, treatment, and other quality indicators of nutritional care., Methods: In 2007 a cross-sectional multicenter study was performed that included 20 255 patients (hospitals, n = 6021; nursing homes, n = 11 902; home care, n = 2332). A standardized questionnaire was used to study nutritional screening and treatment at the patient level and quality indicators at institutional and ward levels (e.g., malnutrition guidelines/protocols, nutritional education, and weighing policy)., Results: Nutritional screening was performed more often in nursing homes (60.2%) than in hospitals (40.3%) and home care (13.9%, P < 0.001). In general, one in every five patients was malnourished, and nutritional treatment was applied in fewer than 50% of all malnourished patients in nursing homes, hospitals, and home care. At ward level nursing homes focused more on the quality of nutritional care than did hospitals and home care, especially with respect to controlling the use of nutritional guidelines (54.6%, P < 0.03), weighing at admission (82.9%, P < 0.01), and mealtime ambiance (91.8%, P < 0.01)., Conclusion: This large-scale study shows that malnutrition is still a considerable problem in one of every five patients in all participating health care settings. It furthermore demonstrates that recognizing and treating malnutrition continues to be problematic. To target the problem of malnutrition adequately, more awareness is needed of the importance of nutritional screening, appropriate treatment, and other nutritional quality indicators.

The objective of this study was to provide data on malnutrition prevalence in hospitals, nursing homes and home-care organisations in The Netherlands in a nationally representative sample, and to assess the factors such as age, sex, time since admission, ward type and disease for identifying patients at high risk of malnutrition. A cross-sectional, multi-centre design with a standardised questionnaire was used to measure the prevalence of malnutrition. Nutritional status was assessed by BMI, undesired weight loss and nutritional intake. In this study, 12 883 patients were included. The prevalence of malnutrition was the highest in hospitals (23.8 %), followed by home-care organisations (21.7 %) and nursing homes (19.2 %). Logistic regression analysis revealed no association with age, time since admission and ward type. Being female was associated with malnutrition only in nursing homes. Blood diseases, gastrointestinal tract diseases, infection, chronic obstructive pulmonary disease, dementia and cancer were the factors associated with malnutrition in hospitals. Dementia was associated with malnutrition in nursing homes, while gastrointestinal tract diseases, diabetes mellitus and cancer were the associated factors in home care. This study shows that malnutrition is still a substantial problem in hospitals, nursing homes and home care in The Netherlands. Malnutrition is a problem for more than one in five patients. Despite growing attention to the problem, more continued alertness is required.

Background & Aims: Consensus regarding definitions of malnutrition and methods to assess nutritional state is lacking. We propose a definition and its operationalization., Methods: A definition was formulated on the basis of the pathophysiology of malnutrition, while reviewing the metabolic and physiological characteristics of different populations, considered to be malnourished. The definition was operationalized to yield measures to perform nutritional assessment., Results: Malnutrition was defined as "a subacute or chronic state of nutrition in which a combination of varying degrees of over- or undernutrition and inflammatory activity has led to a change in body composition and diminished function". Its operationalization led to four elements that may serve as the basis of nutritional assessment: (1) measurement of nutrient balance, (2) measurement of body composition, (3) measurement of inflammatory activity, and (4) measurement of muscle, immune and cognitive function. Most elements measured should be validated with gold standards; normal values should be obtained in different populations. Values obtained in people considered to be at nutritional risk should be related to outcome., Conclusion: A definition is proposed that reflects the pathophysiology of malnutrition and that, when operationalized, will lead to measures reflecting this pathophysiology. Such an approach may yield comparable and reproducible rates and degrees of malnutrition in populations as well as in individuals.

Objective: Malnutrition, characterized by a loss of lean body mass, enhances the risk of pressure ulcers (PUs). Because the intrinsic risk factor nutritional status in PU development can be influenced by practitioners' interventions, the use of clinical guidelines might be a satisfactory management approach. This study investigated the influence of using nutritional guidelines in daily practice on the actual nutritional care that PU (prone) patients receive, and barriers with regard to providing nutritional support were also explored., Methods: A cross-sectional study was carried out in 1087 hospitals, nursing homes, and home care organizations in the Netherlands, Germany, and the United Kingdom. Because this study focused on comparing nutritional care in daily practice in PU (prone) patients using and not using nutritional guidelines, for the analyses two groups (health care organizations with and without guidelines) were identified. Differences between groups were tested using chi-square test and by analysis of variance., Results: Respondents from 363 organizations participated in the study, of which 66.1% used nutritional guidelines for PU care in practice. Significant differences between organizations with nutritional guidelines versus organizations without guidelines were mostly on nutritional screening (P = 0.001) and the extent of nutritional assessments that included significantly more weight history recalls, weight measurements, and body mass index measurements (all P < 0.05). The most important barrier to providing nutritional support for PU (prone) patients in both groups was knowledge and skills., Conclusion: Using a nutritional guideline in PU care contributes to the amount of nutritional screening conducted in daily practice and to the content and extent of the assessment.

Objective: In 2004 the European Pressure Ulcer Advisory Panel nutritional working group developed a nutritional guideline for pressure ulcer prevention and treatment. This study investigated the degree to which the guideline was disseminated and implemented in clinical practice., Method: A cross-sectional study was undertaken in health-care organisations in The Netherlands, Germany and the UK. A printed, standardised questionnaire which followed Rogers' model of the innovation-decision process was developed, translated and distributed to 1087 health-care organisations., Results: The response rate was 33% (n = 363). Sixty-one per cent of respondents knew of the guideline. Twenty-five per cent had applied it to their clinical practice and used it for nutritional screening. The main barrier to the provision of nutritional support appeared to be lack of knowledge and skills., Conclusion: One year after its dissemination, more than half of respondents knew of the guideline, with one in four applying it to their practice. The guideline was better disseminated and implemented in The Netherlands and UK than in Germany, where only 4% of participants had used it.

Aim: This paper reports a systematic literature review examining relationships between contextual factors and research utilization in nursing, examining the strength of these relationships, and mapping the contextual factors to the Promoting Action on Research Implementation in Health Services model of research implementation., Background: Healthcare organizations have long struggled with how to improve clinical care outcomes. Understanding which contextual factors enhance nursing research utilization may support organizations in creating environments that facilitate the uptake of evidence in nursing practice to improve these outcomes., Methods: A search of five electronic bibliographic databases and a manual search of specific journals were conducted for studies that were published in English and examined contextual factors as independent variables and research utilization as the dependent variable from the perspective of nurses working in clinical practice. The studies were assessed for quality of design, sample, measurement and statistical analysis., Results: Ten papers met the search criteria. Six contextual factors were identified as having a statistically significant relationship with research utilization, namely the role of the nurse, multi-faceted access to resources, organizational climate, multi-faceted support, time for research activities and provision of education. The contextual factors could successfully be mapped to the dimensions of context in the Promoting Action on Research Implementation in Health Services framework (context, culture, leadership), with the exception of evaluation., Conclusion: The strength of the relationship between the six contextual factors and research utilization by nurses is still largely unknown as (a) few studies were found of sufficient quality because of methodological limitations and (b) the results in reviewed studies were mixed. More robust methods in future work would yield a better understanding of the full impact of contextual factors on nurses' use of research.

Objectives: To analyse the mortality patterns of former Dutch coal miners, focusing on coal workers' pneumoconiosis (CWP) and chronic obstructive pulmonary diseases (COPD) in relation to pre-existing impairment of lung function., Methods: 3790 selected miners, medically examined between 1952 and 1963, were followed up to the end of 1991 with the municipal population registries and the causes of death from the death certificates were ascertained and converted to the codes from the ninth revision of the international classification of diseases (ICD-9). Mortality comparisons were made with the male population in The Netherlands, resulting in standardised mortality ratios (SMRs). 3367 miners had radiological manifestation of CWP at medical examinations., Results: 80% of the miners died during the follow up period. Excess mortalities from CWP (SMR 4523) and COPD (SMR 179) were found. Coal miners without CWP also showed an increased mortality from COPD (SMR 2913). A diminished lung function (forced expiratory volume in one second (FEV1), or FEV1/FVC (forced vital capacity) ratio) at medical examination resulted in a significantly increased SMR for COPD (322 and 212 respectively) whereas normal lung function yielded expected mortalities from COPD. A positive correlation also emerged between diminished lung function and the SMR due to CWP. The body mass index (BMI) at the moment of medical examination was correlated with the risk of dying of COPD and CWP: a decreasing BMI resulting in an increased SMR., Conclusions: Not only infectious diseases and CWP but also COPD is an important cause of occupational mortality in miners with extensive exposure to coal mine dust. No obvious connection between pre-existing CWP and the COPD mortality exists. Impaired FEV1 and FEV1/FVC ratios are predictors of an increased risk of COPD death. The BMI seems to indicate the severity of the COPD, resulting in premature death.

Carcinogenic effects of chemicals can be investigated in animal experiments and epidemiological studies of exposed humans, mostly in the workplace. In this article epidemiologic evidence is compared with the animal data for 35 chemicals. Risk calculations are compared for 22 chemicals. The chemicals showing no or unclear carcinogenic effects in humans were more likely to show toxic side effects in the animal studies, indicating that the test concentrations were above the maximum tolerated dose. In addition, the animal experiments with these chemicals more often showed neoplastic effects on multiple sites than chemicals for which clear positive epidemiological studies are available. These findings may explain the existence of discrepancies between the outcomes of animal testing and human studies. They suggest that carcinogenic effects in multiple organs in animals could be seen as ultimate manifestations of the side effects of the testing method and that they have limited predictive value for the human situation.

A retrospective cohort study in 1794 male ceramic workers in the Netherlands was carried out to analyze the lung cancer risk in relation to crystalline silica exposure and silicosis. They had all been employed for two years or longer in ceramic industries between 1972 and 1982. During a health survey, 124 cases of simple pneumoconiosis were diagnosed; after 14 years of follow-up, 161 deaths had occurred. No increased overall and cause-specific mortality was found in the total group of ceramic workers, and a statistically significant cumulative dose-response relation for silica exposure and lung cancer did not emerge. An excess lung cancer mortality appeared among workers with simple pneumoconiosis. The authors conclude that the disease process resulting in silicosis in the ceramic industry carries an increased risk of lung cancer, which is supportive of a nongenotoxic pathway.

Objectives: This study was carried out to investigate the mortality patterns in a group of 3790 coal miners. The study population had abnormal chest x ray films at a routine medical examination that was performed in the 1950s., Methods: The total group of 3790 coal miners were followed up for mortality up to 1 January 1992. Causes of death, determined and coded at time of death, were traced with help from the Central Bureau of Statistics., Results: Total mortality in this group of coal miners with abnormal chest x ray films was significantly higher than expected (SMR 127.1, 95% CI 122.5-131.6), mainly a reflection of the increase in mortality from non-malignant respiratory disease (SMR 411.0, 95% CI 382.3-441.3). Mortality from gastric cancer was also significantly increased (SMR 147.5, 95% CI 122.3-176.3). This risk of mortality from gastric cancer was confined to workers with no pneumoconiosis or only a mild form. Despite the strong relation to duration of employment and pneumoconiosis the group of workers with more severe manifestations of pneumoconiosis did not experience an excess in mortality from gastric cancer., Conclusion: This study confirms the earlier reported risk of gastric cancer in coal miners. Also it confirms the hypothesis that this risk of gastric cancer is limited to workers with a mild degree of pneumoconiosis or none. In workers with severe forms of pneumoconiosis the pulmonary clearance system is impaired in such a way that the inhaled coal dust does not reach the digestive tract.

Several studies in recent years have raised the possibility that exposure to extreme low frequency (ELF) electromagnetic fields may be hazardous to human health, in particular by the promotion or initiation of leukaemia and other cancers. To determine if this exposure creates a long-term hazard to the public, the mortality of a group of people identified as having lived in an urban quarter of Maastricht in which two 150 kiloVolt (kV) powerlines and one transformer substation are located was investigated. Using the Dutch population registry it was possible to identify retrospectively 3549 inhabitants of the quarter who lived there for at least 5 years between 1956 and 1981. Of these 1552 study subjects lived within 100 m of the electricity transmission equipment and were exposed to magnetic field intensity of 1.0-11.0 milliGauss. The overall standardized mortality ratio and cancer mortality ratios were either not or only slightly elevated. The study does not support previously reported associations of exposure to ELF electromagnetic fields with leukaemia, brain cancer and breast cancer.

The role of epidemiological and animal experimental studies in the process of qualitative and quantitative risk assessment is discussed. So far little agreement exists between animal experimental data and epidemiological outcomes in the procedure of qualitative risk assessment. Several reasons for these discrepancies are mentioned. The application of existing epidemiological study results in quantitative risk assessment is hampered by factors, such as the lack of exact exposure information (compound, level, duration), undefined other exposures in and outside the working environment, small sample sizes, the comparatively short duration of epidemiological studies and the absence of detailed information about the specific effects. All this resulted in a relatively small impact of epidemiological studies in risk assessment. Recommendations are made in order to improve the impact of epidemiology in risk assessment.

In this article the sex- and age-specific trends and geographical distribution of asbestos related pleural mesothelioma mortality in the Netherlands between 1970 and 1987 are investigated. For men total mortality increased from 10.8 per million during 1970-1978 to 20.9 per million during 1979-1987. The highest mortality occurred with 147.7 per million in 1987 in the age group between 65 and 74 years. Mortality rates for the age group between 55 and 64 years amounted to 96.5 per million in 1987. The geographical distribution over the country showed a strong concentration of male mesothelioma cases in the regions with many harbours, shipyards and heavy industries round Amsterdam, IJmuiden, Rotterdam, Dordrecht and Walcheren. Using linear regression techniques, it was calculated that several thousands new mesothelioma cases will occur in the Netherlands during the next two decades. A significant decrease in mesothelioma mortality can not be expected before 2010.

In order to investigate whether the prolonged exposure to coal mine dust increases the cancer risk for coal miners, a pilot study in a selected cohort of 334 Dutch miners with coal workers' pneumoconiosis (CWP), followed from 1956 until 1983, was conducted. In total, 165 miners had died (49.4%); for 162 (98.2%) the cause of death was traced. In comparison to the general Dutch male population, total mortality in the cohort was statistically significantly increased (SMR: 153). This was in general due to the significantly higher than expected cancer mortality (SMR: 163), cancer of stomach and small intestine (SMR: 401) and nonmalignant respiratory disease (SMR: 426). The lung cancer mortality was within the expected range.

The sex and age related trends and geographical distribution of asbestos related mortality from pleural mesothelioma in the Netherlands between 1970 and 1987 were investigated. Deaths from pleural malignancies recorded by the Dutch Central Bureau of Statistics (CBS) were used and death rates were age adjusted per year by the indirect method. Standardised mortality ratios (SMRs) were computed for 43 regions over the period 1979-86. For men, total mortality increased from 10.8 per million in the period 1970-8 to 20.9 per million during 1979-87. The highest mortality occurred in the group aged between 65 and 74 with 147.7 per million in 1987. The death rate for the group aged between 55 and 64 was 96.5 per million in 1987. For women, total death rates for pleural mesothelioma showed a moderate increase from 2.5 per million in the period 1970-8 to 3.6 per million during 1979-87. The highest mortality occurred in the group aged over 65, fluctuating around 10-15 per million. For men and women under 45 mortality was very low and presented no upward trend. The geographical distribution over the country for the period 1979-86 showed a pattern with a clear concentration of deaths from mesothelioma in men, in conurbations with many harbours, shipyards, and heavy industry near the river mouths and along the North Sea Coast.

The results are presented from a case-control study, concerning the possible relation between silica exposure in the Dutch fine ceramic industry and lung cancer. For this purpose 381 male, age-matched pairs of primary lung cancer cases and controls were selected from the pathology department of the University Hospital in the region, where two large ceramic companies are located. Information about employment in the ceramic industry was obtained from the personnel and financial administration departments of the two companies. On the basis of job titles a panel of occupational hygiene experts reached consensus about the qualitative exposures of each individual worker. Twenty one per cent of the cases were employed in the ceramic industry, compared with 19% of the controls (odds ratio 1.11; 95% Cl: 0.77-1.61). Although the average employment period of cases and their relative silica exposure surpassed those of controls, odds ratios for long duration of employment and considerable exposure to respirable silica dust did not reach statistical significance. After constructing a qualitative exposure index, based on the amount and duration of exposure, a tendency towards a positive correlation with lung cancer emerged. No relation between specific histological tumour cell types and working in the ceramic industry emerged. Although the study does not suggest a consistent cause-effect relation between silica exposure in the regional, Dutch fine ceramic industry and lung cancer, an increased risk for the high exposure group in the past can not be totally excluded.

The results of two epidemiologic investigations on dust-related lung diseases are presented. The two studies had different aims and designs. A cross-sectional study was done to investigate the silicosis prevalence in Dutch fine ceramic workers. In the small ceramic workshops in the Gouda region, simple pneumoconiosis is still commonly present (13.3%), whereas the silicosis prevalence in the highly mechanized industries is low (1.7%). Furthermore, heavy smoking seems to enhance the risk for silicosis after long-term exposure to quartz. A case-control study was performed to analyze the relation between dust exposure in the fine ceramic and coal mining industries and lung cancer. No relation between a work history in the dusty trades and lung cancer emerged, and a correlation with a specific histologic tumor cell type could not be demonstrated. Apparently, workers in the Dutch fine ceramic or coal mining industry have no increased risk of developing lung malignancies.

This case-control study was undertaken to determine whether exposure to organic solvents, as experienced by Dutch painters, causes an increased risk of disability due to neuropsychiatric disorders. Cases and controls were selected from the Dutch Painters' and Construction Workers' Organizations. Cases were defined as male persons receiving disability benefits due to neuropsychiatric disorders. The controls consisted of a random sample of 1000 male persons from the total study population. Cases (n = 252) and controls (n = 822) participated in our study by returning the completed questionnaires. The questionnaire was used to collect information about occupational history and the presence of potentially confounding factors. The adjusted Odds Ratio for the total group of neuropsychiatric disorders did not reach a statistically significant level (OR = 1.17; P less than 0.30). Although a stronger association was suggested between "neuroses" (ICD 300) and exposure to organic solvents (OR = 2.30; P less than 0.05), there are indications that this relationship is merely the result of classification bias. The results of this study do not confirm, but also do not completely exclude, that Dutch painters are at increased risk of being prematurely disabled due to neuropsychiatric disorders.

It is generally accepted that fibrotic lung diseases are mediated by macrophage-derived cytokines and growth factors. Basic research continues to find new factors involved in these disease processes to incorporate into new hypotheses. Two hypotheses implicitly generated by recent findings were tested in an epidemiologic approach among workers in coal mines. This approach is described as molecular epidemiology and is exemplified by two studies focused on different mechanistic aspects of coal workers' pneumoconiosis (CWP): antioxidants in red blood cells of miners with CWP and generation of tumor necrosis factor (TNF) by blood monocytes of miners with CWP. Most findings in the antioxidant study may merely be reflections of pulmonary inflammatory processes. Some data in the TNF study indicate, however, that TNF release is a risk factor for the development of lung fibrosis after prolonged exposure to coal mine dust.