Child abuse: a common problem in Curaçao? / Abuso infantil: ¿Un problema común en Curazao?

OBJECTIVE: To assess the prevalence of child abuse among high school students in Curaçao. METHODS: A questionnaire survey among high school students up to 17 years of age was conducted. The questionnaire was based on existing literature and validated questionnaires. The questionnaire used was analysed and adapted to the situation in Curaçao by a panel of experts on child abuse. The primary objective was to gain insight into the incidence, prevalence and various forms of child abuse among students in Curaçao. Five forms of child abuse are distinguished in the literature: physical abuse, emotional abuse, sexual abuse, neglect and exploitation. Furthermore, the degree of confidence of the students in general practitioners (GPs) as care providers in the field of child abuse was explored. RESULTS: Questionnaires from 545 of the 628 respondents were included. In total, 43% of the respondents had ever-experienced an event which could be defined as (a form of) child abuse. More than one-third of the respondents reporting child abuse ever had an experience that could be interpreted as physical abuse. More than 15% of the respondents reporting child abuse had experienced sexual abuse. Girls experienced significantly more sexual abuse than boys. Emotional abuse in the last year was experienced by 3% of the respondents. One per cent of the respondents ever-experienced neglect. according to most respondents, GPs were not seen as care providers in cases of child abuse; they believed that GPs were mainly to be consulted for illnesses or physical symptoms and not for forms of child abuse. CONCLUSION: The prevalence of ever-having-experienced a form of child abuse is estimated at 431 per 1000 students. Child abuse, particularly physical abuse, is common in Curaçao, and is probably comparable to other surrounding countries. General practitioners were not seen as care providers in identifying and reporting cases of child abuse according to most respondents.

OBJETIVO: Evaluar la prevalencia del abuso infantil entre estudiantes de secundaria en Curazao. MÉTODOS: Se aplicó un cuestionario entre estudiantes de secundaria de hasta 17 años de edad. El cuestionario se basó en la literatura existente y cuestionarios validados. El cuestionario usado fue analizado y adaptado a la situación de Curazao por un panel de expertos en abuso infantil. El objetivo principal fue profundizar los conocimientos acerca de la incidencia, prevalencia y diversas formas de abuso infantil entre estudiantes en Curazao. La literatura distingue cinco formas de abuso infantil: abuso físico, abuso emocional, abuso sexual, negligencia y explotación. Además, se exploró el grado de confianza de los estudiantes en los médicos generales (MGs) como proveedores de cuidado en el área del abuso infantil. RESULTADOS: Se incluyeron los cuestionarios de 545 de los 628 encuestados. En total, 43% de los encuestados nunca habían pasado por una experiencia que pudiera interpretarse como (forma de) abuso infantil. Más de un tercio de los encuestados a los que se les pidió reportar abuso infantil, jamás había tenido una experiencia que pudira interpretarse como abuso físico. Más del 15% de los encuestados sobre abuso infantil habían experimentado abuso sexual. Las niñas experimentaron significativamente más abuso sexual que los niños. El abuso emocional en el último año fue experimentado por 3% de los encuestados. El uno por ciento de los encuestados jamás experimentó negligencia. Los médicos generales no eran vistos como proveedores de cuidado en los casos de abuso infantil, de acuerdo con la mayoría de los encuestados. Según ellos, los MGs deben ser consultados principalmente en el caso de enfermedades o síntomas físicos, y no en casos de formas de abuso infantil. CONCLUSIÓN: La prevalencia de nunca haber experimentado una forma de maltrato infantil se estima en 431 por 1000 estudiantes. El abuso infantil, en particular el abuso físico, es común en Curazao, y es probablemente comparable a otros países circundantes. Los médicos generales no eran vistos como proveedores de cuidado en cuanto a identificar y reportar casos de abuso infantil, según la mayor parte de los encuestados.

Child abuse: a common problem in Curaçao?

OBJECTIVE: To assess the prevalence of child abuse among high school students in Curacao. METHODS: A questionnaire survey among high school students up to 17 years of age was conducted. The questionnaire was based on existing literature and validated questionnaires. The questionnaire used was analysed and adapted to the situation in Curaçao by a panel of experts on child abuse. The primary objective was to gain insight into the incidence, prevalence and various forms of child abuse among students in Curaçao. Five forms of child abuse are distinguished in the literature: physical abuse, emotional abuse, sexual abuse, neglect and exploitation. Furthermore, the degree of confidence of the students in general practitioners (GPs) as care providers in the field of child abuse was explored. RESULTS: Questionnaires from 545 of the 628 respondents were included. In total, 43% of the respondents had ever-experienced an event which could be defined as (a form of) child abuse. More than one-third of the respondents reporting child abuse ever had an experience that could be interpreted as physical abuse. More than 15% of the respondents reporting child abuse had experienced sexual abuse. Girls experienced significantly more sexual abuse than boys. Emotional abuse in the last year was experienced by 3% of the respondents. One per cent of the respondents ever-experienced neglect. According to most respondents, GPs were not seen as care providers in cases of child abuse; they believed that GPs were mainly to be consulted for illnesses or physical symptoms and not for forms of child abuse. CONCLUSION: The prevalence of ever-having-experienced a form of child abuse is estimated at 431 per 1000 students. Child abuse, particularly physical abuse, is common in Curaçao, and is probably comparable to other surrounding countries. General practitioners were not seen as care providers in identifying and reporting cases of child abuse according to most respondents.

Medical abortion in primary care: pitfalls and benefits / Aborto medico en la atención primaria: riesgos y beneficios

We describe five pitfalls of medical abortion: ectopic pregnancy not terminated after misoprostol, but without negative side-effects; long-term vaginal blood loss with suspicious retained products which disappeared spontaneously; a patient with uterus myomatatosus with severe pain and retained products in the uterus; repetition of misoprostol because of retained products in the uterus after two weeks and an allergic reaction to methotrexate. Despite these pitfalls, there are enough benefits to consider medical abortion with methotrexate and misoprostol as a safe method with a high success rate of more than 91% and a good alternative for surgical abortion. An invasive procedure is not necessary, there are no long-term complications and it can be performed at an earlier stage, which makes it more acceptable in society. In Curaçao, where abortion is legally restricted, medical abortion is performed with methotrexate and misoprostol. In countries where abortion is legal, mifepristone and misoprostol are the first choice.

Describimos cinco riesgos del aborto medico: el embrazo ectópico no terminado después de misoprostol, pero sin efectos secundarios negativos; la pérdida de sangre vaginal a largo plazo sin productos retenidos sospechosos que desaparecieron espontáneamente; una paciente con útero miomatoso con dolor severo y productos retenidos en el útero; repetición del misoprostol debido a productos retenidos en el útero después de dos semanas y una reacción alérgica al metotrexato. A pesar de estas dificultades, hay suficientes beneficios para considerar el aborto médico con metotrexato y misoprostol como un método seguro con una alta tasa de éxito superior al 91%, y como una buena alternativa al aborto quirúrgico. No se requiere un procedimiento invasivo, no hay complicaciones a largo plazo, y puede realizarse en una etapa más temprana, lo que resulta más aceptable para la sociedad. En Curazao, donde el aborto está legalmente restringido, el aborto médico se realiza con metotrexato y misoprostol. En países donde el aborto es legal, la mefepristona y el misoprostol son la primera elección.

Telephone consultations on palliative sedation therapy and euthanasia in general practice in The Netherlands in 2003: a report from inside.

BACKGROUND: GPs with a special interest and with specific training in palliative medicine (GP advisors) supported professional carers (mostly GPs) through a telephone advisory service. Each telephone call was formally documented on paper and subsequently evaluated. OBJECTIVE: Data from 2003 were analysed independently to reveal how often and in what way palliative sedation and euthanasia were discussed. METHODS: The telephone documentation forms and corresponding evaluation forms of two GP advisors were systematically analysed for problems relating to the role of sedation and/or euthanasia both quantitatively and qualitatively. RESULTS: In 87 (21%) of 415 analysed consultations, sedation and/or euthanasia were discussed either as the presenting question (sedation 26 times, euthanasia 37 times and both 10 times) or arising during discussion (sedation 11 times and euthanasia three times). Qualitative analysis revealed that GPs telephoned to explore therapeutic options and/or wanted specific information. Pressure on the GP (either internal or external) to relieve suffering (including shortening life by euthanasia) had often precipitated the call. On evaluation, 100% of the GPs reported that the advice received was of value in the patient's care. CONCLUSION: GPs caring for patients dying at home encountered complex clinical dilemmas in end-of-life care (including palliative sedation therapy and euthanasia). They valued practical advice from, and open discussion with, GP advisors. The advice often helped the GP find solutions to the patient's problems that did not require deliberately foreshortening life.

Diabetes specialist nurse as main care provider for patients with type 2 diabetes.

BACKGROUND: The objective of this study was to determine whether the management of type 2 diabetes (DM2) can be transferred from an internist to a nurse specialised in diabetes (NSD). METHODS: Ninety-three patients with DM2 referred by their general practitioner were randomised; 84 patients completed the study. The intervention group received care from an NSD who treated glycaemia, blood pressure and lipid profile by protocol. The control group received care from an internist. The primary endpoint was the main decrease in HbA1c. Secondary endpoints included blood pressure, lipid profile, healthcare costs, QOL , and patient satisfaction. RESULTS: HbA1c, total cholesterol, LDL cholesterol and cholesterol/HDL ratio decreased significantly in both study populations after a follow-up time of 12 months. Cholesterol/HDL ratio decreased by 0.4 and 0.9 in the NSD and control group respectively (p=0.034 for the difference between groups). The decreases (95% confidence interval) in systolic blood pressure were 8.6 mmHg (2.6, 14.7) in the NSD group and 4.0 mmHg (-0.9, 8.9) in the control group, without a significant difference between groups. After one year, 33.3% of the patients in the NSD group achieved an HbA1c level. <7% compared with 2.2%at baseline (p=0.002). Healthcare costs were less and patient satisfaction with the NSD s was significantly better(p<0.001), while maintaining the same QOL . CONCLUSION: NSD s using treatment protocols are able to provide effective care for patients with DM 2, comparable with the care provided by an internist, with respect to clinical parameters, and superior with respect to healthcare costs and patient satisfaction.

Medical abortion in primary care: pitfalls and benefits.

We describe five pitfalls of medical abortion: ectopic pregnancy not terminated after misoprostol, but without negative side-effects; long-term vaginal blood loss with suspicious retained products which disappeared spontaneously; a patient with uterus myomatatosus with severe pain and retained products in the uterus; repetition of misoprostol because of retained products in the uterus after two weeks and an allergic reaction to methotrexate. Despite these pitfalls, there are enough benefits to consider medical abortion with methotrexate and misoprostol as a safe method with a high success rate of more than 91% and a good alternative for surgical abortion. An invasive procedure is not necessary, there are no long-term complications and it can be performed at an earlier stage, which makes it more acceptable in society. In Curaçao, where abortion is legally restricted, medical abortion is performed with methotrexate and misoprostol. In countries where abortion is legal, mifepristone and misoprostol are the first choice.

[Good results of early medicinal pregnancy termination in a general practice on Curaçao]. / Goede uitkomsten van vroege medicamenteuze zwangerschapsafbreking in een huisartspraktijk op Curaçao.

OBJECTIVE: To evaluate the results of early medicinal pregnancy termination. DESIGN: Prospective, non-blinded, clinical study. METHOD: Between 2001 and 2005, 371 women presented to a medium-sized solo general practice in the centre of Willemstad, Curaçao, to request termination of an undesired pregnancy. Ofthese women, 74 first indicated a preference for abortion via curettage, and the remaining 297 chose to be treated medicinally. In the first trimester of the pregnancy, they were given methotrexate i.m. and misoprostol vaginally 3-5 days later, or only misoprostol vaginally when methotrexate was unavailable. The result was evaluated by abdominal echography two days after the treatment. RESULTS: The result of the medicinal pregnancy termination could be determined in 271 of the 297 women. In 219 (81%) of these, the pregnancy had been terminated after a single treatment, and in 29 (11%) success was achieved after a second vaginal administration of misoprostol. The total success rate of the medicinal pregnancy termination was 92% (248/271). Curettage was required in 23 women (8%) after the medicinal treatment had failed. There was no significant difference in success rate between treatment with the methotrexate-misoprostol combination and treatment with misoprostol alone. CONCLUSION: Medicinal pregnancy termination with methotrexate and misoprostol, or with misoprostol alone, was a safe method with a relatively small risk of an ongoing pregnancy. It was a good alternative for surgical abortion.

Late effects in adult survivors of childhood cancer: the need for life-long follow-up.

BACKGROUND: To assess health status and health-related quality of life (HRQoL) in childhood cancer survivors who were not involved in regular long-term follow-up. PATIENTS AND METHODS: One hundred and twenty-three long-term survivors, median age 33 (19-50) years, follow-up 27 (9-38) years, were recalled to the long-term follow-up clinic. Most of them were treated in the period 1970-1990. Late effects were graded using the Common Terminology Criteria for Adverse Events, version 3 (CTCAEv3). HRQoL was assessed by RAND-36. Socio-economic factors were compared with data from Statistics Netherlands (CBS). RESULTS: Grade 1-2 late effects were found in 54% of the survivors, grade 3-4 in 39%, two or more late effects in 70% and grade 2-4 previously unknown late effects in 33%. Survivors had significantly lower scores on RAND-36 compared with controls. CONCLUSIONS: As nearly 40% of these long-term childhood cancer survivors suffer from moderate to severe late effects and 33% had previously unknown late effects it is worthwhile recalling these patients to follow-up. Where and by whom this follow-up can best be done is still a question that needs to be answered.

[Measuring the blood pressure in both arms is of little use; longitudinal study into blood pressure differences between both arms and its reproducibility in patients with diabetes mellitus type 2]. / Weinig nut van bloeddrukmeting aan beide armen; longitudinale studie naar interarmbloeddrukverschillen en de reproduceerbaarheid daarvan bij patiënten met diabetes mellitus type 2.

OBJECTIVE: To determine the prevalence of inter-arm blood pressure differences > 10 mmHg in patients with diabetes mellitus type 2 (DM2) and to determine whether these differences are consistent over time. DESIGN: Descriptive. METHOD: In an evaluation study of 169 DM2 patients from 5 general practices in 2003 and 2004, different methods of oscillatory measurement were used to investigate inter-arm blood pressure differences > 10 mmHg systolic or diastolic. These methods were: one measurement in each arm non-simultaneously (method A), one measurement simultaneously (B) and the mean of two simultaneous measurements (C). RESULTS: With method A an inter-arm blood pressure difference was found in 33% of patients. This percentage diminished to 9 with method C. In 44% (n = 7) of the patients in whom method C detected a relevant blood pressure difference, this difference was not found with method A. In 79% of patients the inter-arm blood pressure difference was not reproduced after one year. CONCLUSION: In daily practice, one non-simultaneous blood pressure measurement in each arm (method A) was of little value for identification of patients with inter-arm blood pressure differences. The reproducibility was poor one year later. Bilateral blood pressure measurement is therefore of little value.

Pitfalls in blood pressure measurement in daily practice.

BACKGROUND: Accurate blood pressure (BP) readings and correctly interpreting the obtained values are of great importance. However, there is considerable variation in the different BP measuring methods suggested in guidelines and used in hypertension trials. OBJECTIVE: To compare the different methods used to measure BP; measuring once, the method used for a large study such as the UKPDS, and the methods recommended by various BP guidelines. METHODS: In 223 patients with type 2 diabetes from five family practices BP was measured according to a protocol to obtain the following data: A = first reading, B = mean of two initial readings, C = at least four readings and the mean of the last three readings with less than 15% coefficient of variation difference, D = mean of the first two consecutive readings with a maximum of 5 mm Hg difference. Mean outcomes measure is the mean difference between different BP measuring methods in mm Hg. RESULTS: Significant differences in systolic/diastolic BP were found between A and B [mean difference (MD) systolic BP 1.6 mm Hg, P < 0.001], B and C (MD 5.7/2.8 mm Hg, P < 0.001), B and D (MD 6.2/2.8 mm Hg, P < 0.001), A and C (MD 7.3/3.3 mm Hg), and A and D (MD 7.9/3.0 mm Hg, P < 0.001). CONCLUSION: Different methods to assess BP during one visit in the same patient lead to significantly different BP readings and can lead to overestimation of the mean BP. These differences are clinically relevant and show a gap between different methods in trials, guidelines and daily practice.

[Changes in the medical curriculum in Mongolia]. / Veranderingen in de medische opleiding in Mongolië.

Since 1996, general practitioners from the universities in Amsterdam, Groningen and Leeds (England) have been involved in restructuring the medical curriculum in Mongolia. The Mongolians desired a problem-based and integrated new curriculum that would be suitable for training generalists. We started by training Mongolian teachers in modern pedagogic developments and in multidisciplinary consultation. The new curriculum started in 1999 and after a cumbersome start, integration was achieved, the library was completely renewed and equipped for self-study and rural opportunities were created so that medical students could acquire practical experience outside of the university hospital. The new curriculum is a step in the direction of training doctors who will be able to function independently in the new Mongolian health-care system.

[Cause of death: from primary disease to direct cause of death]. / Doodsoorzaak: van primair grondlijden tot directe doodsoorzaak.

Following the death of a patient, the treating physician in the Netherlands is required to fill out two forms. Form A, which is the certificate of death and Form B, which is used by the Statistics Netherlands to compile data on causes ofdeath. The latter form often poses difficulty for the physician with respect to the primary cause of death. This applies particularly to cases of sudden death, which account for one third of all deaths in the Netherlands. As a result, the statistical analyses appear to lead to an incorrect representation of the distribution of causes of death. A more thorough investigation into the primary cause of death is desirable, if necessary, supported by a request for an autopsy. The primary cause of death is to be regarded as the basic disease from which the cascade of changes ultimately leading to death originated.

Cross-sectional relationship between glycaemic control, hyperglycaemic symptoms and quality of life in type 2 diabetes (ZODIAC-2).

BACKGROUND: To describe the relationship between glycaemic control, hyperglycaemic symptoms and quality of life (HRQOL) in type 2 diabetic patients. METHODS: In a shared-care diabetes project HRQOL was assessed. A total of 1664 patients with type 2 diabetes were identified in 32 primary healthcare practices. Of these patients, 1149 were included. HRQOL was measured using a generic questionnaire (Rand-36), completed by 1006 of the 1149 participants. RESULTS: The number of hyperglycaemic symptoms was higher in women (1.88) compared with men (1.64), without differences in mean haemoglobin A1c (HbA1c) (7.5%)-Univariate analyses showed negative relationships between all dimensions of the Rand-36 and hyperglycaemic symptoms (p<0.001), but between only one dimension and HbA1c (p=0.005). Multivariate analyses showed no association between any of the dimensions of the Rand-36 and HbA1c, but the relationship between hyperglycaemic symptoms persisted in all dimensions (p<0.001). Notwithstanding these results, the presence of hyperglycaemic symptoms was related to higher HbA1c. CONCLUSION: In type 2 diabetic patients, as assessed by a generic questionnaire, there is an evident relationship between hyperglycaemic symptoms and HRQOL and not between HbA1c and HRQOL. Subjective hyperglycaemic symptoms are, independent of HbA1c, important for HRQOL in type 2 diabetic patients, and should therefore not be neglected in the management of diabetes.

Shared care with task delegation to nurses for type 2 diabetes: prospective observational study.

BACKGROUND: To study the effects of two different structured shared care interventions, tailored to local needs and resources, in an unselected patient population with type 2 diabetes mellitus. METHODS: A three-year prospective observational study of two interventions and standard care. The interventions involved extensive (A) or limited (B) task delegation from general practitioners to hospital-liaised nurses specialised in diabetes and included a diabetes register, structured recall, facilitated generalist-specialist communication, audit and feedback, patient-specific reminders, and emphasised patient education. The target population consisted of 2660 patients with type 2 diabetes treated in the primary care setting. Patients who were terminally ill or who had been diagnosed with dementia were excluded from the study. RESULTS: The participation rates were high (90%) for patients, and none of the 64 GPs discontinued their participation in the study. Longitudinal analyses showed significant improvements in quality indicators for both intervention groups (process parameters and achieved target values on the individual patient level); in standard care, performance remained stable or deteriorated. Both patients and caregivers appeared satisfied with the project. CONCLUSION: This study shows that structured shared care with task delegation to nurses, targeted at a large unselected general practice population, is feasible and can positively affect the quality of care for patients with type 2 diabetes.

[Use of stairs in a hospital increased by a sign near the stairs or the elevator]. / Trapgebruik in een ziekenhuis bevorderd met een bordje bij de trap of de lift.

OBJECTIVE: To investigate whether signs encouraging taking the stairs or discouraging taking the elevator lead to an increasing number of patients taking the stairs instead of the elevator in a hospital. DESIGN: Interventional study. METHOD: During a period of 6 weeks in the period October-December 2004, an investigator recorded how many patients took the stairs and how many took the elevator on the first floor of a hospital close to a diabetes outpatient clinic. A baseline measurement was done over a period of 2 weeks and 4 weeks were used for evaluating the effect of 2 different interventions, each lasting 2 weeks. During the first intervention, a sign was hung up near the elevator, which read: 'Exercise is healthy, take the stairs'. During the second intervention the sign read: 'Use of this elevator is exclusively for personnel and persons with restricted mobility'. Staff members and disabled patients were excluded from the study. RESULTS: A total of 2674 movements were counted. Use of the stairs increased statistically significantly during both interventions: from 54.6% to 63.4% during the first intervention and to 70.4% during the second intervention. CONCLUSION: Signs in a diabetes outpatient clinic that either encouraged the use of the stairs or discouraged the use of the elevator increased the patients' use of the stairs.

[Microalbuminuria in patients with type 2 diabetes mellitus in general practice]. / Microalbuminurie bij patiënten met diabetes mellitus type 2 in de huisartspraktijk.

OBJECTIVE: Determine the prevalence of microalbuminuria in patients with type 2 diabetes mellitus (DM) in general practice, as an independent risk factor for cardiovascular diseases. DESIGN: Prospective, descriptive. METHOD: Data were collected on patients with type 2 DM in the Zwolle region of the Netherlands, all of whom were being treated by their general practitioner. The inclusion period was 1 February 2000-31 January 2001. The study formed part of a larger investigation, in which the albumin concentration in a urine sample and the albumin-creatinin ratio were determined once per year. A total of 32 general practitioners took part in the study. RESULTS: In the general practices studied, 2094 patients were known with type 2 DM and 1653 (79%) were treated exclusively by the general practitioner. Of these 1653 patients, 67 (4%) were excluded and of the 1586 invited patients remaining, 1441 (91%) participated. Microalbuminuria was present in 33% of the patients and macroalbuminuria in 7% of the patients, and the prevalences increased with age: < 50, 50-70 and > 70 years. 18% (6/33) of the patients aged < 50 years with microalbuminuria were treated with an ACE inhibitor or angiotensin II antagonist compared to 33% (183/548) of patients > or = 50 years. 91% (488/539) of the patients > or = 50 years with microalbuminuria had hypertension and/or lipid profile abnormalities and 82% (402/488) of them were not treated or did not receive adequate treatment for this condition. CONCLUSION: Microalbuminuria and macroalbuminuria were present in respectively 33% and 7% of the patients with type 2 DM in primary care. The treatment of hypertension and lipid profile abnormalities was often inadequate. Therefore, screening patients aged 50 years and older with type 2 DM for albuminuria is justified.

Increased alpha-linolenic acid intake lowers C-reactive protein, but has no effect on markers of atherosclerosis.

OBJECTIVE: To investigate the effects of increased alpha-linolenic acid (ALA)-intake on intima-media thickness (IMT), oxidized low-density lipoprotein (LDL) antibodies, soluble intercellular adhesion molecule-1 (sICAM-1), C-reactive protein (CRP), and interleukins 6 and 10. DESIGN: Randomized double-blind placebo-controlled trial. SUBJECTS: Moderately hypercholesterolaemic men and women (55 +/- 10 y) with two other cardiovascular risk factors (n = 103). INTERVENTION: Participants were assigned to a margarine enriched with ALA (fatty acid composition 46% LA, 15% ALA) or linoleic acid (LA) (58% LA, 0.3% ALA) for 2 y. RESULTS: Dietary ALA intake was 2.3 en% among ALA users, and 0.4 en% among LA users. The 2-y progression rate of the mean carotid IMT (ALA and LA: +0.05 mm) and femoral IMT (ALA:+0.05 mm; LA:+0.04 mm) was similar, when adjusted for confounding variables. After 1 and 2 y, ALA users had a lower CRP level than LA users (net differences -0.53 and -0.56 mg/l, respectively, P < 0.05). No significant effects were observed in oxidized LDL antibodies, and levels of sICAM-1, interleukins 6 and 10. CONCLUSIONS: A six-fold increased ALA intake lowers CRP, when compared to a control diet high in LA. The present study found no effects on markers for atherosclerosis. SPONSORSHIP: The Dutch 'Praeventiefonds'.