[A woman with balls in the lower abdomen]. / Een vrouw met bolletjes in de onderbuik.

A 34-year old woman visited the general practitioner because of nausea and diarrhoea. A large abdominal swelling was palpable. Ultrasound showed a cyst containing 'floating balls', pathognomic for a mature teratoma. An ovariectomy was performed. Macroscopic the ovary contained greasy balls existing of hairs and sebum. Our diagnosis: Dermoid cyst.

[The effects of pharmacological and psychotherapeutic treatment of comorbid anxiety disorders in patients with bipolar disorder]. / De effectiviteit van medicamenteuze en psychotherapeutische behandeling van comorbide angststoornissen bij patiënten met bipolaire stoornis.

BACKGROUND: The co-occurrence of bipolar disorder and anxiety disorder is associated with a worse prognosis. Clinical guidelines do not give clear therapeutic recommendations on this subject.
AIM: To review the evidence on the effectiveness of both psychotherapy and pharmacotherapy for anxiety disorders in patients with a bipolar disorder.
METHOD: A systematic search in PubMed, Embase, Cochrane en Psycinfo and subsequent screening of potential studies resulted in 11 included studies.
RESULTS: Five studies examined the effect of pharmacotherapy on treatment of comorbid anxiety disorders. One of these studies showed that both olanzapine and lamotrigine provided positive results in treating the anxiety disorders, with olanzapine being the more effective of the two. Conflicting results were found for quetiapine and valproic acid. The conclusion of one study was that risperidone was not effective. No studies were found researching the effect of psychotherapy on treatment of comorbid anxiety disorders. However, two case studies and four studies that included patients with mixed diagnoses, including bipolar disorder, proposed evidence that behavioral and cognitive behavioral therapy (cbt) had a positive effect on treatment of the comorbid anxiety disorder.
CONCLUSION: There is little evidence on the treatment of comorbid anxiety disorders in people with bipolar disorder. Psychotherapy is preferred due to the uncertainty of the effects of pharmacotherapy and the associated risk of causing side effects. Pharmacotherapy can be considered in cases where this is insufficiently effective.

[Safe medication administration in hospitals]. / Veilig toedienen van geneesmiddelen in ziekenhuizen.

- Every day medication is administered to thousands of hospital inpatients, and medication administration errors can occur.- Interventions to reduce medication administration errors have been developed and tested; these include training, double-checking procedures, and technological solutions (such as smart infusion pumps and barcode-controlled drug administration).- Most of the studies that investigated these interventions were small, meaning it is unclear which intervention is the most effective. More research is needed to identify the best solutions.

Guidelines for the management of vitiligo: the European Dermatology Forum consensus.

The aetiopathogenic mechanisms of vitiligo are still poorly understood, and this has held back progress in diagnosis and treatment. Up until now, treatment guidelines have existed at national levels, but no common European viewpoint has emerged. This guideline for the treatment of segmental and nonsegmental vitiligo has been developed by the members of the Vitiligo European Task Force and other colleagues. It summarizes evidence-based and expert-based recommendations (S1 level).

[Primary care in homes for the elderly]. / Huisartsgeneeskundige zorg in het verzorgingshuis.

Dutch GP's (General Practitioners) take care of people living in homes for the elderly. The population of these homes is selected on the basis of poor functioning on ADL (activities of daily living). We expected to find a group of elderly people within these homes that need more complex primary care. We describe the characteristics of care for an institutionalized elderly population and compare these to the care provided to their independently living peers. The design of this study is a matched case-control study in a Dutch General Practice in the study period 1/1/1998 to 1/7/2004. Our main results show that the rate of cognitive problems is two times, the prevalence of depression even three times higher in older people living in a home for the elderly than in those who live independently. Locomotory problems are a frequent problem in homes for the elderly. Rates of chronic pulmonary problems, atherosclerosis-related diseases and urinary tract infection are higher, whereas no significant differences for CVA, diabetes and cancer were found. Institutionalized older patients use more different types of medication. GP's do not have more contacts with people living in a home for the elderly than with older people living independently. We conclude that people living in homes for the elderly have complex problems, and need special attention for their specific vulnerability. Differences in care are not primarily explained by chronic disease but by problems with mobility, confusion, depression and cognition.

[Use of rofecoxib in family practice in the north of Netherlands, 2000-2004: background and consequences]. / Gebruik van rofecoxib in de noord-nederlandse huisartspraktijk, 2000-2004: achtergronden en gevolgen.

OBJECTIVE: To gain insight into the trends in the prescription ofrofecoxib, the medication and disease histories of rofecoxib users, and the occurrence of cardiac complications during the follow-up. DESIGN: Longitudinal comparative study in family practice. METHOD: Based on the data from family practices (17 family physicians) affiliated with the Registration Network Groningen, a network with about 30,000 patients in the northern part of the Netherlands, the incidence and prevalence ofrofecoxib use were determined per 1000 patients at risk for every quarter during the period 2000-2004. Data on duration, dosage and indications were taken from the rofecoxib prescriptions. Differences in morbidity between rofecoxib users and the users of traditional NSAIDs were compared using logistic regression, and differences between the two groups in the occurrence of cardiac complications were assessed by means of Cox regression analysis. RESULTS: During the period investigated, rofecoxib was prescribed with increasing frequency in family practice; there was a total of 1784 prescriptions for 509 patients. The drug was used increasingly for short durations and for a growing number of indications. Rofecoxib was selectively prescribed to former users of traditional NSAIDs. The occurrence of acute myocardial infarction, stroke or 'transient ischaemic attack' in the follow-up period was associated especially with pre-existing cardiovascular disease, but these complications were also seen more often among patients without pre-existing cardiovascular disease who used rofecoxib than among those who used the traditional NSAIDs (the difference was not significant). CONCLUSION: The observations indicate that, via a process of channelling, rofecoxib was prescribed to a highly-specific population of patients who, paradoxically, were at a higher risk of developing the same cardiac complications with which rofecoxib had been shown to be associated in randomised clinical trials.

[Increasing trend in prescription of methylphenidate in general practices in the north-east of The Netherlands, 1998-2003]. / Toenemend aantal voorschriften voor methylfenidaat in huisartspraktijken in Noordoost-Nederland, 1998-2003.

OBJECTIVE: To obtain information on the frequency of and the indications for prescription of methylphenidate in general practices in the north-east of The Netherlands. DESIGN: Descriptive. METHOD: Data were collected from 1998 to 2003 from 6 general practices in the north-east of The Netherlands (17 general practitioners, approximately 30,000 patients) that were affiliated to the Registration Network in Groningen. The number of new and existing patients who were prescribed methylphenidate was calculated by age group per 1000 person-years per calendar year. The indication on which the drug was prescribed was looked at, as was the number of patients who were referred to a specialist on that indication. RESULTS: The number of new users per 1000 person-years more than doubled from 17 in 1999 to 42 in 2003. In all years studied the highest number of new users fell into the age group 5-9 years. The total number of users per 1000 person-years tripled (boys: 1.8 in 1998 and 6.2 in 2003; girls: 0.5 in 1998 and 0.8 in 2003). The prevalence of use in boys was 3 to 8 times as high as that of girls and increasing more quickly. In people under 59 years of age attention deficit hyperactivity disorder (ADHD) was the most frequent indication (55%). In the group aged > or = 60 years methylphenidate was mainly prescribed in the palliative phase of somatic morbidity. Over half of the 140 new patients (57%) were referred nor to a specialist in the year before neither in the year after the first prescription of methylphenidate.

Nutritional deficiency in Dutch primary care: data from general practice research and registration networks.

OBJECTIVE: To explore incidence and prevalence rates of nutritional deficiency in adults in general practice. METHODS: Six Dutch general practice research and registration networks supplied incidence and prevalence rates of nutritional deficiency by the International Classification of Primary Care (ICPC) or 'E-list' labels ('loss of appetite, feeding problem adult, iron, pernicious/folate deficiency anaemia, vitamin deficiencies and other nutritional disorders, weight loss'). In case of disease-related nutritional deficiency, we asked whether this was labelled separately ('co-registered') or included in the registration of the underlying disease. RESULTS: 'Iron deficiency anaemia' had highest incidence (0.3-8.5/1000 person years), and prevalence rates (2.8-8.9/1000 person years). Nutritional deficiency was mostly documented in the elderly. In two networks 'co-registration' was additional, two only documented the underlying disease and two did not specify 'co-registration'. No clear difference was found between networks considering the difference in 'co-registration'. CONCLUSION: Nutritional deficiency is little documented in general practice, and generally is not registered separately from the underlying disease.

[The small epidemiologic transition: further decrease in infant mortality due to medical intervention during pregnancy and childbirth, yet no decrease in childhood disabilities]. / De kleine epidemiologische transitie: verdere daling van de zuigelingensterfte door medische interventie rond zwangerschap en bevalling, maar geen daling van handicaps op de kinderleeftijd.

The small epidemiologic transition, which started to occur during the 1960s, was a continuation of the large epidemiologic transition. The large epidemiologic transition concerned a strong increase in the life expectancy as a result of the virtual disappearance of mortality during the early life years. During the most recent stage of this epidemiologic transition, two types of medical intervention in pregnancy and childbirth were introduced: antenatal screening and diagnosis followed by selective abortion, and neonatal intensive care for preterm babies. These two types of intervention have opposite epidemiologic effects. On the one hand these have led to a further decrease in the mortality. Yet, on the other hand the prevalence of childhood disabilities has scarcely decreased or has not decreased at all, because intensive interventions after childbirth can lead to more disabilities occurring in the population than those removed due to selective abortion. The small epidemiologic transition has arisen from an expansion in knowledge and possibilities to observe and intervene. These have indeed led to an increase in options before, during and after pregnancy, but not to a reduced morbidity at the start of life.

Co-morbidity of 'clinical trial' versus 'real-world' patients using cardiovascular drugs.

PURPOSE: To examine discrepancies between co-morbidity of patients included in pre-marketing clinical trials of cardiovascular drugs and patients from daily practice, representing the actual users after marketing, and to investigate the availability of data regarding co-morbidity in registration files. METHODS: Data were collected from phase III trials of registration files of 16 drugs, registered in the Netherlands in the period 1985 through 1994 for the indications hypertension, angina pectoris or hypercholesterolemia, and from a general practitioners database. Patients were selected who used drugs from the same therapeutic classes for the same indication as the patients in the pre-marketing trials. Prevalences of concomitant cardiovascular, endocrine and metabolic diseases were compared between pre- and postmarketing populations. Discrepancies were defined as more than 10% difference in prevalences. RESULTS: Data regarding co-morbidity were present in 13 out of 16 registration files and differed in format of reporting. For all indications, coexisting cardiovascular, endocrine and metabolic diseases were less prevalent in the pre-marketing populations, except ischemic heart disease, which was more prevalent coexisting with angina pectoris and hypercholesterolemia. Discrepancies were found for hypertensive disease, heart failure, diabetes mellitus and myocardial infarction. CONCLUSIONS: Phase III trials testing cardiovascular drugs included patients with concomitant cardiovascular, endocrine and metabolic diseases, but discrepancies were present with patients in daily practice. Development of guidelines for uniform collection and reporting of co-morbidity data in pre-marketing trials is recommended, as well as further utilization of data.

Photo(chemo)therapy in private practice in Belgium, France and The Netherlands.

Photo(chemo)therapy is used widely, and ultraviolet (UV) sources, protocols and indications are numerous. A survey was carried out to examine how photo(chemo)therapy is employed in private practice and to determine whether safety guidelines are respected. A questionnaire survey sent to Belgian, French and Dutch dermatologists generated 593 useful responses. UV sources, doses of UV and 8-methoxypsoralen (8-MOP), as well as the frequency of the treatment, were all different in the three countries. UV starting doses were rarely chosen according to the minimal phototoxic dose (MPD) or to the minimal erythema dose (MED). Total cumulative UV doses were not always determined. Maintenance PUVA therapy for psoriasis was still performed by 15 to 40% of dermatologists in the respective countries. Another striking fact was that genital protection is not universal. On the other hand, the irradiance of tubes is checked regularly, and contraindications are respected. Despite the availability of guidelines, clinicians seem to be inconstant in their assessment of the carcinogenic risk of UV radiation.

Comment on "Compromised birth outcomes and infant mortality among racial and ethnic groups".

Frisbie, Forbes, and Pullum (1996) show that it is meaningful to account for low birth weight, preterm delivery, and intrauterine growth-retardation when analyzing differences in compromised birth outcomes and infant mortality among racial and ethnic groups. I compare their findings for the 1987 U.S. birth cohort with findings for the 1988 U.S. birth cohort, using linked birth and infant death vital statistics from the National Center for Health Statistics. I focus on their calculation of fetal growth curves, which are highly at odds with the curves commonly used in the obstetric and pediatric literature. I compare birth outcome distributions and infant death probabilities using Frisbie et al.'s method and other standards. I conclude that Frisbie et al.'s method is not suited for the study of intrauterine growth-retardation at the population level because of the major flaws in gestational age measurement that exist in the type of data they use. An appropriate alternative is to apply a standard of normal intrauterine growth derived from antenatal estimation of fetal weight-for-gestational-age to the vital statistics data.

A demographic approach to the assessment of Down syndrome screening performance.

The aim of this article is to examine the performance of screening for fetal Down syndrome (DS) in the context of demographic variation in time and place, using population and fertility data for several European countries. Two screening approaches are distinguished: one on the basis of maternal serum screening with human chorionic gonadotropin (hCG) and alpha-fetoprotein (AFP) in combination with maternal age, and one on the basis of maternal age only. Screening performance, as measured by detection and false-positive ratios, is shown to be the result of the screening approach chosen and of the demographic characteristics of the population under consideration. A proper distinction between these two determinants of DS screening performance should be made, in order to distinguish between an improvement in screening performance that is brought about by a new screening approach and an improvement that is brought about by demographic change. We recommend that measures of DS screening performance be standardized for demographic variation. The methodology and demographic data presented in this article can be used for this purpose.

Does it matter where I live in Western Europe? An analysis of regional mortality differentials in Belgium, Germany and the Netherlands.

"Regional differentials in life expectancy at birth during the 1980s in Belgium, The Netherlands and some parts of the former Federal Republic of Germany are presented and commented upon. Life expectancy at birth during the 1980s was highest in the Netherlands, and lowest in some parts of southern Belgium. Substantial differentials existed in 1980, particularly because of differential mortality due to diseases of the circulatory system, lung cancer, breast cancer, motor vehicle accidents and suicide. These differentials persisted throughout the 1980s, but gradually converged. Gains in life expectancy were mainly due to declining cardiovascular and cerebrovascular mortality. Sharp and persistent differentials between border regions in the study area point to societal and cultural forces bringing about dividing lines between relatively homogeneous mortality profiles." (SUMMARY IN FRE)

[Institutional care for the aged in the 2d half of the 19th century. A case study]. / Institutionele zorg voor ouderen in de tweede helft van de 19e eeuw. Een case-study.

This study focuses on the residents of three ecclesiastical homes for the elderly in 19th century. The Hague. These homes took in poor members of the church who were at least 60 years old. Most of the elderly who resided in these homes had received poor relief prior to admission. The main reason to request admission was that they were no longer able to independently run a household. Most of the residents were well past the age of 60 upon entering the home, women generally being a few years older than men. There were no significant gender differences in duration of residence. The female age at death was a few years higher than for males. The health of the residents appeared to be worse than that of the total elderly population of The Hague, resulting in a higher death rate. In general, residents had independently run a household prior to admission.