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Polypharmacy in older people should be addressed by an annual review of the chronic medication. In the PIL-study this was done by an integrated approach by GP, practice nurse, pharmacist, specialist and patient. All patients were first visited at home by the practice nurse.What 'over the counter' (OTC) medications do polypharmacy patients use? Do they know the indications of the prescribed medication? Does medication use according to the patient match with medication use according to the records of GP and pharmacist?Inclusion criteria were: age 60 years or older, daily use of five or more chronic medications, mental competence, and adequate command of the Dutch language. All patients were visited at home by the practice nurse, who made an inventory of the actual drug use.Five hundred fifty patients used a total of 5576 drugs, including 527 (9.4%) OTC medication. Patients knew the indication of 64% of the prescribed medication. The number of prescribed drugs that a patient actually used did not match the numbers known to GP and pharmacist. In 60.4% of all medication prescriptions there was complete agreement between GP, pharmacist and patient. On a patient level agreement was 18.7%.Home visits by the nurse practitioner to make an inventory of the medication as reported by the patient seem to have an added value.

In a recent review the effectiveness of influenza vaccination in the elderly was brought into question. Selection bias, which would occurr if healthy people were more likely to be vaccinated than their infirm peers, and the use of non-specific outcomes, such as death from all causes, were considered to have contributed to the effectiveness of the vaccine as to morbidity and mortality being overestimated. However, a recent study has shown that even when potential bias and residual confounding were addressed, influenza vaccination was associated with a significant reduction in the risk of influenza-related morbidity and mortality among community-dwelling elderly persons. Direct estimates of influenza-related morbidity were hampered by delayed and insufficiently sensitive diagnostics. Excess studies, however, comparing morbidity and mortality during periods with and without influenza predominance, present reliable indirect estimates in favour of vaccination. While the vaccination rate of high-risk subjects in The Netherlands is traditionally high, the age limit for influenza vaccination was lowered from 65 to 60 in 2008, taking into account influenza-related morbidity and mortality in healthy people aged 60 to 65 years and the undisputed effectiveness of vaccination against influenza.

The Health Council of the Netherlands [Dutch name: Gezondheidsraad] is an independent, statutory advisory body whose task is to inform the Dutch government on the current level of knowledge with respect to public health issues. Its work covers the entire terrain of curative and preventive healthcare, environmental protection, nutrition, occupational hygiene and environmental hygiene. The Health Council has existed in one form or another since 1 August 1902. Its present form was established by the 1956 Health Act, which was amended in 1997. To perform its task, the Health Council brings together multidisciplinary committees of leading experts--nominated in a personal capacity--on specific topics both at the government's request and on its own initiative. About thirty committees are operative at any one time. The Health Council has published more than 2000 advisory reports during its 100 years of existence.

A recent Cochrane review does not nullify the evidence supporting the practice of mammographic population screening for breast cancer for women aged 50 years and over. Thus concludes the Health Council of the Netherlands in an advisory report to the Dutch Government. A central feature of the Cochrane review is the conclusion that breast-cancer mortality is an unreliable outcome that is biased in favour of screening. The Health Council finds this conclusion too extreme and does not support the view that breast-cancer mortality must be replaced by overall mortality as an outcome. The Health Council does agree with the view that the use of disease-specific mortality as the only endpoint renders cancer-screening trials subject to bias. Therefore, careful attention should be paid to total cancer mortality, other important causes of death, and overall mortality.

Evaluation of health research output can have important implications for departments, institutes and individual careers. Typically, a peer review of the scientific quality of the output is central in this evaluation, increasingly with a bibliometric analysis at its core. Such an analysis is based on counting publications and citations from journals included in the (Social) Science Citation Index. Although the methodology is still far from perfect, there seems to be consensus on how to evaluate the scientific quality. This is in contrast to the evaluation of the social relevance of health research output, as there is no agreement on its importance, the dimensions involved, or the relevant methods of assessment. There is a need for the assessment of the social impact of applied health research, next to its scientific quality. As an initial rough approximation, counting publications in national professional journals may provide a suitable indicator of the social relevance of the research output.

Comparison of (cumulative) incidences of traumatic events from population surveys and registration systems as well as from studies in general practice.Literature study.Literature searches were done about the frequencies of accidents, sudden death, physical and sexual abuse listed in electronic databases and relevant catalogs covering 1986-1998, after which more references were searched via the references found, going back to 1984.There were large discrepancies between frequencies found in the several studies, such as national registration systems (n = 4), surveys in the open population (n = 10) and studies in general practice (n = 4). The incidence (per 1000 persons per year) of physical abuse were 66, 2.7 and 1-3 for surveys in the open population, police and general practitioners' registration systems respectively. For sexual abuse the figures were 21, 0.025 and 0.2-2.9 respectively. Different definitions and methods were used in the studies.General practitioners are aware of only a fraction of what their patients experience.

To determine to what extent the general practitioner (GP) is aware of the health status and functioning of his elderly patients and in which areas this knowledge can be completed with the aid of community nurses.Cross-sectional, descriptive.Department of General Practice. State University Limburg, Maastricht, the Netherlands.A random sample of 59 patients aged 79 years and over, belonging to the population of a primary health care centre, were visited by community nurses. One patient was lost. The nurses inventoried the patients health complaints and their daily functioning by means of a structured questionnaire. Data from these home visits were compared with data from the same questionnaire, regarding the same patients, which the three GPs of the health centre had filled in on the basis of their medical records.Of the complaints recorded by the community nurses. 34% were not known to the general practitioners. This concerned mainly symptoms of depression, urinary incontinence, disabilities and handicaps of the musculoskeletal system. sleep disturbances, daily functioning and ability to cope. The main determinants of the ability to cope were impaired walking and to a lesser degree symptoms of depression.A structured interview of elderly patients by a community nurse yields substantial information about health problems.

To determine the prevalence of grades of glucose intolerance in subjects over 64 years of age.Point prevalence study.Twello, a rural village in the Netherlands.Of a total of 696 persons aged over 64 years recruited from a general practice, 460 subjects had an oral glucose tolerance test (OGTT) in 1985, 56 were known with non-insulin-dependent diabetes mellitus. Glucose estimations were done in capillary whole blood with a Glucometer. OGTT results were classified according to WHO 1985 recommended cut-off points and combination rules.The prevalence of normal glucose tolerance was 42%, of impaired glucose tolerance 27% and of diabetes mellitus 31%. The estimated prevalence in the source population were 45% (44.4-44.6), 28% (28.3-28.5) and 27% (95% CI: 27.1-27.2) respectively, adjusted for age and gender by standardization to the Dutch population of 1985. Re-evaluation of the earlier diagnoses of 'diabetes mellitus' according to the new WHO guidelines revealed that 55% of earlier diabetic with diet as the only therapy were no longer classified as diabetics. The prevalence of diabetes mellitus in persons over 64 was 10% before the investigation took place, and 30% afterwards.Te prevalence of diabetes mellitus as well as of impaired glucose tolerance from the Twello study rank among the higher rates reported in Caucasian populations. Case finding of glucose intolerance in those at risk over 64 years of age is recommended.

Since recent insights indicate that most patients with heart failure and a normal cardiac rhythm (HFNR) should not be treated with digitalis, we investigated the treatment policy of general practitioners in this respect. Our descriptive study consisted of a questionnaire followed by a computer based review of patient records of 14 family practices cooperating in the Registration Network of Family Practice (RNFP) and 10 'external' practices. All GPs (n = 51) received the questionnaire on the prescription policy of the GP and cooperating specialists, and on their experience with adverse effects of digitalis therapy. After 2-4 months the GPs of the RNFP (n = 41) received a floppy disc with an algorithm selecting from their problem lists patients with a registered diagnosis of heart failure. The external GPs (n = 10) received an algorithm selecting patients treated with digitalis, since their problem lists were not completely up to date. In all, data of 63,500 patients were examined. On anonymised standard forms, generated by the practice computer, the GPs provided data on the exact diagnosis, medication and adverse effects. Outcome measures of the study were: prescription attitudes (questionnaire) and actual digitalis use (in the selected cases). 33% of the GPs stated that they used digitalis as the preferred therapy of heart failure with normal cardiac rhythm; 30% of the 82 selected HFNR patients had digitalis, while in 42% of the 149 selected patients treated with digitalis a HFNR was registered. Adverse effects had been observed in 3 cases, but could not be excluded retrospectively in 70 cases (49%). Many GPs have not yet adapted their prescription behaviour to recently published insights. Development of a 'digitalis standard in general practice' is recommended.

Comparison of the effectiveness of liquid nitrogen and of cryotherapy by means of the Histofreezer in the treatment of hand warts.Randomized therapeutic trial.Six general practices in Limburg, The Netherlands.Of the patients 43 (with 83 warts) were treated with nitrogen (if necessary twice) and 50 (with 108 warts) with the Histofreezer (if necessary 4 times), with a final control visit after 2.5 months. After a training session, the general practitioners performed the treatments and the observations. In these groups, 7 patients (with 18 warts) and 10 patients (with 20 warts) respectively did not fully comply with the protocol. At the start the number of warts per patient, their size, protruberance and localization were registered. Statistical analysis was performed by chi 2 test (unpaired case) in an intention to treat approach and of compliers only.Disappearance of warts, pain (on a 3-point scale), wounds, depigmentation. Non-compliers were asked by telephone if their warts had been cured.Of all patients 58% was cured by liquid nitrogen and 28% by Histofreezer (p = 0.01). Among the compliers these percentages were 67% and 35% of the patients (p = 0.01) and 66% and 49% of the warts (p = 0.08). The treatments were about equally effective in dorsal non protuberant and small (less than 5 mm) warts, and among young (less than 20 years) patients.The overall results of liquid nitrogen were better. The Histofreezer seems to be attractive in certain cases (e.g. children), but this should be the subject of further study.

It has long been recommended that one should be careful in prescribing drugs for the elderly. However, it has been shown that more than 20% of those over 65 use diuretics. With advancing age this percentage increases. The sign of ankle oedema appears to be an important factor in the decision to prescribe diuretics. If the oedema is not caused by heart failure, chronic renal failure or hypoproteinaemia, the use of diuretics in ankle oedema is controversial. We used a questionnaire survey to obtain information on the opinions of Dutch general practitioners about the differential diagnosis and treatment of ankle oedema in the elderly. In the questionnaire we presented the case of a 68-year-old woman who complained of ankle oedema without any symptom or sign of heart failure. The questionnaire was sent to 200 Dutch general practitioners (response rate 64%). Chronic venous insufficiency was mentioned by 86% and heart failure by 12% of the responders as the most probable cause of the oedema. The treatment proposed by 59% was advice and (or) compression therapy without drugs, while 40% would have prescribed diuretics.