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The aim of orthodontic retention is to counteract post-treatment changes and thereby to preserve the result of active treatment. For active orthodontic treatment, a certain level of patient compliance is necessary and the same applies for the retention phase. Ideally, the retainer will never fail or get lost, the patient will adhere to all recommendations and will wear the retainer in accordance with the instructions, necessary precautions with the fixed retainer are followed, the patient reports a problem immediately, and appointments for retention check-ups will always be met. Unfortunately, the reality is often different. This article considers the need to provide the patient with information about retention before treatment and the problems that may arise during the retention phase. Recommendations are made on how to avoid these problems as much as possible, and solutions are offered for problems that do arise. Finally, it is made clear how the orthodontist, patient and dentist can be jointly responsible for the retention phase.Retentie heeft als doel veranderingen die na een orthodontische behandeling kunnen ontstaan tegen te gaan om daarmee het resultaat van de actieve behandeling te behouden. Bij een orthodontische behandeling is een zekere medewerking van de patiënt noodzakelijk en hetzelfde geldt voor de retentiefase. Idealiter houdt de patiënt zich aan alle aanbevelingen, wordt de uitneembare retainer volledig volgens voorschrift gedragen en gaat nooit verloren, met de vaste retainer wordt de noodzakelijke voorzichtigheid betracht, meldt de patiënt een probleem direct en worden de afspraken voor retentiecontroles altijd nagekomen. Jammer genoeg luidt de realiteit geregeld anders. In dit artikel wordt ingegaan op de noodzaak van informatievoorziening omtrent retentie voorafgaande aan de behandeling en de problemen die zich tijdens de retentiefase kunnen voordoen. Tevens worden aanbevelingen gedaan hoe deze problemen zoveel mogelijk te voorkomen en oplossingen aangedragen voor wanneer er problemen zijn ontstaan. Tot slot wordt duidelijk gemaakt hoe voor de retentiefase een gezamenlijke verantwoordelijkheid kan gelden van orthodontist, patiënt en tandarts.

Total parenteral nutrition may be considered for a carefully selected group of palliative patients with ileus. Predictive factors include a strong desire to live, low burden of disease other than the ileus and expected increase in quality of life as a result of starting with total parenteral nutrition. Therapy compliance is required and a strong social network is desirable. Close collaboration between hospital and general practitioners and frequent reviews of the palliative care plan are also required for success.

To describe and study (a) the implementation of direct discharge from a Dutch Emergency Department (ED) for patients with relatively simple stable injuries (SSIs), (b) preliminary logistical and financial effects, and (c) patients' experiences.Prospective cohort study.Following the example of a healthcare reorganisation in the United Kingdom, in May 2019 we changed the treatment protocols of eleven SSIs. Since that time, no standard follow-up appointment has been scheduled for these patients. Patients are given information about treatment and the recovery period, and a form of immobilization is applied which can easily be removed at home. This information is summarised in a discharge leaflet and a smartphone application. A telephone helpline is available for any concerns or questions. During the implementation phase we determined compliance with, and deviation from, the protocol daily for 3 months. To determine the logistical and financial effects we compared the healthcare utilization of all patients with SSIs three months before and after implementation. Patient satisfaction and the shift in treatment towards primary care were determined by means of questionnaires.In the three months before implementation 275 patients with an SSI presented to our ED, compared with 318 in the same period after implementation; 304 of the 318 patients were directly discharged (protocol compliance 95.6%). We found a significant reduction in follow-up appointments (-91%), radiological imaging (-72%), and costs. Patient satisfaction was comparable. There was no shift towards primary care in healthcare utilisation.In the Netherlands, direct discharge from the ED seems to be an effective and safe alternative to traditional treatment with outpatient follow-up. Further studies on patient-reported outcomes should determine if this process is in concordance with the principle of Value Based Health Care.

Prescription of medication is one of the most common medical interventions. Just half of patients use a prescribed preventative medication in accordance with the doctor's instructions; this leads to a smaller effect from the medication, side effects and higher care costs. Therapy-non-compliant patients are hardly recognisable on the basis of clinical, demographic or medication-related characteristics. The prescriber can make use of pharmacist data, questionnaires, or technical aids, or broach the subject with the patient to discover whether or not the patient is therapy-compliant. Reasons for non-compliance with therapy can be roughly divided into unintentional or practical reasons and intentional reasons. Tailored intervention can be offered on the basis of the underlying reasons.

Different fields of study have revealed discrepancies between the reported medication use presented by patients and medical records held by their doctor or apothecary. These also appear to have clinically relevant consequences. At present only two studies have explored medication discrepancies in psychiatry.br/AIM: To investigate the occurrence of discrepancies in the reported medication use of a psychiatric elderly out-patient population.br/METHOD: Comparing 40 medication records of patients to their respective general practitioner and pharmacy records. Information on their social situation, Mini-Mental State Examination score and diagnosis was collected.br/RESULTS: One or more discrepancies were present in 80 percent of cases. Patients living alone had a higher percentage of discrepancies. Patients with cognitive problems or a low score on the Mini-Mental State Examination had less discrepancies.br/CONCLUSION: Medication discrepancies are also common in a psychiatric elderly outpatient population.

During their specialty training program residents are stimulated to think and work in a goal-oriented way. Patient 'no shows' are quite common in the mental healthcare system, consequently causing the ineffective use of healthcare services.br/AIM: To reduce the amount of 'no shows' in an outpatient clinic for hospital psychiatry by sending reminders via text messaging.br/METHOD: A quasi-experimental study was conducted at an outpatient clinic for hospital-psychiatry in 2016, in which 101 patients were included. Eventually, 50 patients received a text message to remind them of their appointment, while 46 did not. We used a χ2 test to evaluate group differences. The effect size was expressed in the 'number needed to cash' (nnc), similar to the number needed to treat (nnt). Routinely available hospital-data was used to estimate lost revenue per year.br/RESULTS: A significant group difference was found in the number of outpatient clinic visits in favour of sending a text message reminder (74% vs. 92%, p = 0.018). This corresponded to a nnc of 5.53, i.e. 6 text messages need to be sent in order to accomplish one extra patient showing up for their intake. Based on hospital-data from 2016 the estimated lost revenue was € 53.017,38 / year at our outpatient clinic.br/CONCLUSION: Sending reminders via text messaging is effective in reducing the number of 'no shows' at an outpatient clinic for hospital psychiatry.

Almost all the literature dictates a period of non-weight-bearing after surgical treatment of articular and peri-articular fractures of the pelvis and lower extremities. This is followed by partial weight-bearing which is based on the number of weeks after surgery. However, none of these recommendations are based on evidence. When taking muscle force and gravity into account, non-weight-bearing is actually impossible. In addition, lack of patient compliance, lack of muscle force in the elderly and four-fold energy expenditure make it almost impossible to ensure that patients will adhere to their surgeon's restrictions. Based on our experiences in a large cohort of patients with fractures of the pelvis and lower extremities, we see no drawbacks in permissive weight-bearing and early recovery in most cases. We strongly believe that most patients are able to listen to their body and understand body awareness, while the creation of a safe environment makes more personalised follow-up treatment possible.

Non-adherence occurs at any age, in all chronic diseases, and has a major impact on clinical outcomes. Non-adherence is primarily determined by perceptions of illness and medication beliefs. During puberty, adolescents attain independence from their parents and attach to their peers. This complicates successful self-management of chronic illness, because the adolescents avoid standing out from their peers. Discussion of barriers hindering successful self-management in adolescents can be promoted by seeing the patient alone, without the parents being present, and by acknowledging the patient's independence and responsibilities.

To examine if Dutch physicians adhere to the national guidelines on the treatment of depression in children and adolescents.Retrospective database research.Data on children and adolescents aged between 6 and 17 years were selected from the IADB, a Dutch database of filled prescriptions. We examined whether children and adolescents were prescribed fluoxetine as recommended by the guideline, and whether the starting dose was in accordance with the guideline.Of 2942 children and adolescents in whom antidepressant treatment was initiated, the proportion prescribed fluoxetine increased from 10.1% in 1994-2003 to 19.7% in 2010-2014. However, paroxetine (1994-2003) and citalopram (2004-2014) were the most frequently prescribed antidepressants. Starting doses were guideline-concordant in 58% of children, 31% of preadolescents and 16% of adolescents. Sixty percent of all adolescents were prescribed an adult starting dose.Guideline adherence was poor. In contrast to the guidelines, physicians preferred citalopram to fluoxetine in children and adolescents with depression. Furthermore, adolescents often received an adult starting dose. These results suggest that dedicated effort is necessary to improve guideline adherence.

Cognitive impairment associated with dementia is characterized by a continuous decline. Cognitive training is a method to train specific brain functions such as memory and attention to prevent or slow down cognitive decline. A small number of studies has shown that cognitive training on a computer has a positive effect on both cognition and mood in people with cognitive impairment. This pilot study tested if serious games could be integrated in a psychogeriatric rehabilitation center. Fourteen psychogeriatric patients participated twice weekly in cognitive training sessions on a computer. Both the participants and the facilitator reported positive interactions and outcomes. However, after five weeks only half of the sample still participated in the training. This was partly because of patient turn-over as well as incorporating this new task in the facilitators' daily work. Fear of failure, physical limitations and rapidly decreasing cognitive function led to drop out according to the facilitator. The engagement of patients in the games and the role of the facilitator seemed essential for success, especially monitoring (and adjusting) the difficulty level of the program for every individual participant.

Non-adherence occurs at any age, in all chronic diseases, and has a major impact on clinical outcomes. Non-adherence is primarily determined by perceptions of illness and medication beliefs. During puberty, adolescents attain independence from their parents and attach to their peers. This complicates successful self-management of chronic illness, because the adolescents avoid standing out from their peers. Discussion of barriers hindering successful self-management in adolescents can be promoted by seeing the patient alone, without the parents being present, and by acknowledging the patient's independence and responsibilities.

Non-adherence occurs at any age, in all chronic diseases, and has a major impact on clinical outcomes. Non-adherence is primarily determined by perceptions of illness and medication beliefs. During puberty, adolescents attain independence from their parents and attach to their peers. This complicates successful self-management of chronic illness, because the adolescents avoid standing out from their peers. Discussion of barriers hindering successful self-management in adolescents can be promoted by seeing the patient alone, without the parents being present, and by acknowledging the patient's independence and responsibilities.

OBJECTIVE: A common side-effect of angiotensin-converting enzyme inhibitors (ACEi) is a persistent dry cough. Physicians and pharmacists who fail to recognise a dry cough to be ACEi-related may attempt to treat it with antitussives, instead of recommended ACEi substitution. The aim of this study was to quantify such prescription behaviour, as well as its influence on therapy compliance. DESIGN AND METHODS: Drug dispensing data were retrieved from the IADB.nl database in The Netherlands. A prescription sequence symmetry analysis was used to determine whether antitussive agents were prescribed more often following ACEi initiation than the other way around. Therapy compliance in both groups was assessed using the proportion of days covered (PDC) method; patients with a PDC ≥ 80% were considered compliant. RESULTS: 1601 patients were incident users of both ACEi and antitussives within a half-year time span. There was a significant excess of patients prescribed antitussive agents after ACEi initiation (1075 versus 526), yielding a sequence ratio of 2.0 (95% confidence interval 1.8-2.3). Therapy compliance in patients receiving antitussives after ACEi initiation was 58%, significantly lower than therapy compliance in control patients, which was 77% (P

Poor adherence to medication is one of the most important determinants in the treatment of patients with chronic disorders. e-Health-based interventions may be able to improve treatment adherence. This article gives an overview of the available e-Health interventions and the extent to which they can improve adherence. We searched in the PubMed, Cinahl, PsycInfo, and Embase databases for e-Health interventions that aimed at improving adherence to treatment. Of the 16 included studies, 15 used a website and one used an app. Ten studies showed a significant improvement in treatment adherence by using the intervention. e-Health interventions were generally complex. Simple interventions were the most successful in improving treatment adherence.

Objective. To gain insight into the vaccination behaviour of elderly people if they are offered a pneumococcal vaccine together with the annual vaccination against influenza. Design. Cross-sectional study. Method. In October 1999 in Amersfoort, a group of general practitioners offered a pneumococcal vaccine together with the yearly influenza vaccination to all 3,365 patients aged 65 years or over. A questionnaire was then mailed to a stratified sample (n = 972) of these patients. Vaccine acceptance and the determinants of non-compliance were then assessed by means of polytomous logistic regression analysis. Results. A total of 2,529 patients (75%) received the pneumococcal vaccine and 2,812 (84%) received the influenza vaccine. Predictors of non-acceptance of the pneumococcal vaccine were a perceived lack of recommendation by the general practitioner (odds ratio (OR): 4.6, 95% confidence interval (CI): 2.6-8.3) and fear of local side effects (OR: 2.8; 95% CI: 1.6-4.6). Predictors of refusal to accept either vaccination also included unwillingness to comply with the doctor's advice (OR: 6.1; 95% CI: 2.4-15.4), the belief that vaccinations weaken one's natural defences (OR: 2.7; 95% CI: 1.4-5.3 or that influenza is not dangerous (OR: 2.9; 95% CI: 1.5-5.4), and the fear of being made ill by pneumococcal vaccination (OR: 2.9; 95% CI: 1.1-7.9). People who felt healthy, found it difficult to come to the doctor's office, had private medical insurance, or were younger than 75 years of age remained unvaccinated more often. Conclusion. Addition of a pneumococcal vaccine to the existing influenza immunisation program resulted in high acceptance rates for both vaccinations. The role of the general practitioner was important in this connection.

In people with diabetes mellitus, foot ulcers are a major problem because they increase the risk of a foot infection and amputation and reduce quality of life. After a foot ulcer has healed, the risk of recurrence is high. Orthopaedic shoes and orthotics are often prescribed to high risk patients and aim to reduce the mechanical pressure on the plantar surface of the foot. Orthopaedic footwear that is modified to reduce pressure is not much more effective in preventing foot ulcer recurrence than orthopaedic footwear that did not undergo such modification, unless the shoes are worn as recommended. In that case, the risk of ulcer recurrence is reduced by 46%. In patients with a history of ulceration, compliance in wearing orthopaedic shoes at home is low, while these patients walk more inside the house than outside the house. Foot pressure measurements should be part of the prescription and evaluation of orthopaedic footwear for patients at high risk for foot ulceration.

Non-compliance with medication constitutes a large problem in medicine. Recently the results of a cluster randomised controlled trial were published in which financial incentives were offered to patients with psychotic disorders. The objective of this study was to test if financial incentives effectively improved adherence to maintenance treatment with depot antipsychotics. The financial incentives increased acceptance of depot medication but did not lead to any clinical benefits. Therefore, the implementation of contingency management using financial incentives is not yet desirable.

Elderly patients with multimorbidity treated in accordance with disease-specific guidelines use a large number of drugs. As this approach may harm the patient's wellbeing, our care should evolve from disease-oriented to patient-oriented. A simple tool has been introduced to facilitate this type of consultation. On a visual analogue scale (VAS; 0-100) four generic treatment goals are presented to the patient: extending life, maintaining independence, pain relief and relief of other symptoms. The patient is invited to weigh the importance of these outcomes using the 'trade-off' principle, and asked to rank these goals in such a way that the score reflects the patient's preference profile. With the help of this decision aid, the medication of two female patients aged 85 and 94 was reviewed. Embedding this tool in the first step of the medication review process may help to shift the focus from the disease to the patient.

Pectus carinatum occurs in one of 1500-1700 people and may lead to physical, cosmetic and psychosocial problems. Surgical treatment of pectus carinatum is performed using the 'Ravitch procedure'. An alternative and less invasive treatment consists of external compression with a brace. Results are often disappointing because of skin complications, a low level of comfort of the brace and low compliance. Nowadays a new brace (dynamic compression brace) exists with which the comfort and thus the compliance can be increased by measuring and regulating the pressure of correction during the treatment. This leads to better results and fewer complications. In 80-90% of patients the results are good to excellent and an operation can be avoided. This new brace is therefore a less invasive, cheap and safe alternative to the Ravitch procedure in the treatment of pectus carinatum in children.

Plasma levels can be used to monitor the clinical efficacy of tricyclic antidepressants (TCAs). In practice, the interpretation of plasma levels can be problematical, for several reasons: varying time-intervals between ingestion and blood sampling, the number of times per day a particular antidepressant is administered, the presence of active metabolites and the use of slow-release substances.To present realistic recommendations regarding the interpretation of plasma levels of TCA in clinical practice.We studied the relevant literature.On the basis of the literature we make the following recommendations

The term 'difficult-to-treat asthma' indicates that the asthma is not sufficiently controlled despite prescription of high doses of asthma medication. The term 'severe asthma' is used when the asthma is still insufficiently controlled after exclusion or treatment of any complicating factors; an important complicating factor is poor compliance. Recent studies have focused on the heterogeneous character of asthma and on the definition of specific phenotypes, with the aim of developing phenotype-specific treatments. Treatment options for severe asthma are only partly evidence based. The decision to implement additional therapy for severe asthma depends on the individual patient, the asthma phenotype, and the adverse-event profile of the treatment. Many of the additional therapies should be given as a trial treatment under strict control, especially when efficacy has not been convincingly scientifically proven.

The Netherlands has approximately 20,000 registered HIV-infected patients. The current HIV prevention policy consisting of condom use and active HIV testing does not effectively mitigate the HIV epidemic in all risk groups. In July of 2012, tenofovir/emtricitabine (TDF/FTC) was approved by the American Food and Drug Administration (FDA) for pre-exposure prophylaxis (PrEP) for long-term use in persons who exhibit frequent risky and unsafe sexual behaviour. With once-daily use and good therapy compliance, TDF/FTC has proved to be effective as PrEP, and few side effects are reported. Drawbacks in the use of TDF/FTC as PrEP are the potential risk of viral resistance and reduced condom use, the relatively high cost and the intensive counselling required. In special cases, long-term PrEP could enhance the current Dutch preventive policy. Further research is needed into the practical feasibility and protective efficacy of the ad hoc use of TDF/FTC as PrEP before a high-risk contact occurs.

Psychiatrists treating patients with drug and alcohol addiction currently consider these afflicions to be mental disorders. If patients are so mentally disturbed that they are a danger to themselves or others, then compulsory hospitalisation seems to be an acceptable treatment option. However, it would seem that at present this solution is not normal practice in addiction care.To describe the indications for compulsory hospitalisation when mental disorders associated with addiction and withdrawal cause risks and dangers.Discussion of the indications for compulsory enforced hospitalisation supported by literature.Compulsory hospitalisation is based on the acceptance of the principle that addiction and substance abuse are mental disorders. Indications for emergency hospitalisation include intoxications, acute withdrawal symptoms and other disorders associated with substance use. Indications for longer-term measures are (self)-protection, societal isolation and the need to protect other people from danger. Factors influencing the decision-making process regarding emergency hospitalisation are motivation and treatment perspectives, mental incompetence, contraindications and conflicts between criminal law and patients’ rights.Compulsory hospitalisation deserves serious consideration as the ultimate step in treatment of intoxication, drug and alcohol dependence and withdrawal symptoms. In addition, emergency hospitalisation can be a way of averting danger, facilitating diagnosis and motivating abstinence or at least a reduction in substance use.

Bij het maken van behandelkeuzen voor oudere patiënten met multimorbiditeit zouden hun voorkeuren centraal moeten staan. Die mening zijn veel huisartsen toegedaan en ook de multidisciplinaire richtlijn ‘Polyfarmacie bij ouderen’ benadrukt het belang van het verhelderen van de verwachtingen van de patiënt. In de praktijk blijken artsen echter om uiteenlopende redenen nauwelijks naar deze voorkeuren te vragen. Een visueel hulpmiddel, de voorkeurenschuif, kan een gesprek vergemakkelijken. Oudere patiënten met multimorbiditeit die volgens de geldende richtlijnen behandeld worden, gebruiken dagelijks gemiddeld 10 verschillende geneesmiddelen.1 Daarmee lopen zij een verhoogd risico op ongewenste effecten. Ook kan de kwaliteit van leven nadelig worden beïnvloed door de ‘gestapelde’ behandeling.2 Klachten over of onvrede met de behandeling, van de patiënt of de arts, kunnen aanleiding zijn om het beleid te herzien. Bij een dergelijke bezinning moet worden bepaald welke behandeldoelen de patiënt belangrijk vindt.

Iron deficiency is a frequent cause of anaemia in pregnancy and often results in fatigue and malaise. To prevent complications during labour, timely iron suppletion is important.A 30-year-old multiparous female presented at the outpatient clinic in her 38th week of this pregnancy because of fatigue and lightheadedness. She had been prescribed oral iron suppletion a month earlier but had not taken the tablets. Because her haemoglobin level had decreased to 6.3 mmol/l, it was decided to start her on intravenous iron dextran treatment. During administration of the test dose, the patient experienced acute dyspnoea and severe abdominal and back pain. Foetal bradycardia was observed and the patient underwent an emergency caesarean section. She delivered a healthy boy whose arterial pH was 7.05 (base excess: -7.6 mmol/l) and venous pH was 7.18 (base excess: -6.8 mmol/l).This case demonstrates that dextran anaphylaxis can occur, with potentially lethal consequences, even when no known underlying risk factors are present.

In the Dutch Standard of Care for chronic obstructive pulmonary disease (COPD) the patient, not the illness, is now central. Additionally, treatment is no longer exclusively guided by the degree of airway obstruction but by the burden of disease (also called 'integral health status'). Consequently, COPD care will be more intensive and more complex. The Nijmegen Clinical Screening Instrument (NCSI) method offers a guide for the patient and the caregiver to help execute the standard of care effectively and efficiently. Using this method, the burden of disease is assessed in detail. An integral intervention helps in formulating treatment goals (patient-tailored treatment), and in motivating patients to adhere to these treatment goals. A special condensed version of the NCSI is suitable for monitoring the patient. The method is web-based, which facilitates the assessment and monitoring of the patient.

OBJECTIVE: A common side-effect of angiotensin-converting enzyme inhibitors (ACEi) is a persistent dry cough. Physicians and pharmacists who fail to recognise a dry cough to be ACEi-related may attempt to treat it with antitussives, instead of recommended ACEi substitution. The aim of this study was to quantify such prescription behaviour, as well as its influence on therapy compliance. DESIGN AND METHODS: Drug dispensing data were retrieved from the IADB.nl database in The Netherlands. A prescription sequence symmetry analysis was used to determine whether antitussive agents were prescribed more often following ACEi initiation than the other way around. Therapy compliance in both groups was assessed using the proportion of days covered (PDC) method; patients with a PDC ≥ 80% were considered compliant. RESULTS: 1601 patients were incident users of both ACEi and antitussives within a half-year time span. There was a significant excess of patients prescribed antitussive agents after ACEi initiation (1075 versus 526), yielding a sequence ratio of 2.0 (95% confidence interval 1.8-2.3). Therapy compliance in patients receiving antitussives after ACEi initiation was 58%, significantly lower than therapy compliance in control patients, which was 77% (P

The treatment of children with type 1 diabetes mellitus has improved dramatically over the last few decades. The maintenance of acceptable metabolic control, nevertheless, remains challenging because the success of treatment is so dependent on patient compliance. Children with type 1 diabetes and poor metabolic control are at risk of developing Mauriac syndrome, a condition characterised by hepatomegaly, growth retardation and cushingoid features. A similar complication may occur in type-1 or type-2 adult diabetics; namely, glycogenic hepatopathy. We describe two children, a 12-year-old girl and a 16-year-old boy, who presented with classic symptoms of Mauriac syndrome. After metabolic control was achieved, reduction of hepatomegaly and the disappearance of cushingoid features were observed, proving the reversibility of the syndrome. Awareness that this syndrome still exists despite improved insulin therapy is crucial for earlier recognition and treatment.

The initial theoretical concept of a polypill was a fixed-dosed combination pill containing an antiplatelet agent, a cholesterol-lowering agent and multiple blood pressure-lowering agents aimed at the prevention of atherosclerotic vascular disease in the population aged 55 years and up. The reduction in the risk of cardiovascular disease does not depend on the cholesterol level and blood pressure at the start of treatment. The pharmacological reduction in risk factors in individuals with a high risk of atherosclerotic vascular disease is often suboptimal, partly due to the complexity of the guidelines and low adherence to the therapy. A polypill may offer opportunities for improvement. Research has shown that the use of combination products leads to a greater reduction in risk factors than the use of separate substances, possibly through improved adherence to the therapy. The use of a polypill in the prevention of vascular disease in high-risk patients may lead to a more effective reduction in risk, a decrease in costs and a reduction in pharmacological expenditure.

Caries is a dynamic process which can develop either progressively or regressively under the all-determining influence of oral health behaviour. Management of caries therefore involves first of all: diagnostics, monitoring and preventive care and treatment which result in good oral health behaviour. The oral care provider should recognize all phases ofprogression of the caries process, and should be able to differentiate the symptoms which indicate an active or inactive process. A well maintained patient dossier is necessary to monitor this process over time. Following this procedure, the oral care provider is in a position to guide the patient with relevant information in order to achieve the final objective, good oral health.

A 25-year-old male and a 41-year-old male presented at the Emergency Department with a hand injury. Although both patients received immediate surgical care and specialized rehabilitation care, outcomes were better in the first patient, who had sustained the more severe hand injury. Outcomes were influenced not only by injury severity, but also by personal and external factors. Personal factors, such as age, motivation and compliance, were more favourable in the first patient. External factors, such as complications, delayed care, language problems and social problems, mainly affected the second patient, who was less severely injured. As a result, outcomes on all functional levels of the WHO's International Classification of Functioning, Disability and Health (body functions and structure, and activity and participation) were better in the patient with the more severe injury. Specialized hand care is required in hand injuries, but professionals should also be aware that personal and external factors have a substantial influence on outcomes after hand injuries.

Patients of non-Western origin quite often fail to complete their course of treatment. The reasons are generally unclear. aim To suggest ways of tackling the problems in transcultural psychiatric practice.A theoretical model is presented, derived from clinical practice. The model provides insight into essentials of transcultural psychiatry. The model is based on the following: two interpretations of the concept of culture, an elaboration of the university-relativity dichotomy and a subdivision of the clinician’s work into three sections. These sections are: building a trusting relationship, making a diagnosis and carrying out treatment suited to the patient’s needs.The psychiatrist’s attitude to his patient varies according to the phase of treatment, sometimes it is more relativistic, at other times it is more universalistic.The compliance of non-Western patients will probably increase when the clinician adopts a more relativistic approach during the phase of building a relationship with the patient and probably also during some parts of the treatment phase so that he can come closer to meeting the patient’s expectations.

Medication compliance is generally suboptimal, particularly in patients with complex polypharmacy. This generic treatment problem is described here for Parkinson's disease (PD). We would expect patients with PD to have good medication compliance, since missed doses immediately result in worsening of symptoms. However, recent research has revealed that PD patients demonstrate poor medication compliance. Poor medication compliance is particularly undesirable for patients with PD because regular intake of medication is required for optimal treatment effect. Possible ways of improving medication compliance are pharmacotherapeutic measures and behavioural interventions. Modern methods of communication (text message reminders) and 'smart' pill dispensers may be beneficial, but the advantages of such interventions have not yet been scientifically studied.

Since the 'Diabetes Complications and Control Trial' results were published in 1993, intensive insulin therapy has been the standard treatment for paediatric patients with insulin-dependent diabetes mellitus. This therapy significantly lowers the risk of long term complications of diabetes. The intensive therapy occurs by either continuous insulin infusion via a pump or a 4-times daily injection regime. In three young patients--two girls of 16 and a boy aged 12 years--the intensive treatment option appeared to be inadequate due to a variety of factors including lack of parental support and an eating disorder. All patients were put on a 2 or 3-times daily regime, which resulted in great improvements to their HbA1c levels and sense of well being. To the boy and one of the girls, extra support was given by a home care nurse. We recommend an individualized approach to the paediatric diabetic patient when it comes to the degree of intensity of the treatment.

People suffering from a psychotic disorder show limited compliance with the prescribed regimen of antipsychotics. Insufficient compliance and insufficient insight into their illness are important contributing factors predicting recurrence of psychotic symptoms.To discuss what contribution long-acting, mainly intramuscular (depot) antipsychotics can make in reducing the chance of a psychotic relapse. Also, we suggest procedures for switching from oral to depot antipsychotics.The currently available depot antipsychotics in the Netherlands are compared with each other, desired and undesired treatment effects are discussed. Also, the possible role of depot antipsychotics in limiting compliance problems is discussed. Expected developments in depot antipsychotics in the near future are presented.A review of the literature shows that there are insufficient studies supporting an evidence-based choice for oral versus depot antipsychotics in different clinical situations. A choice for depot antipsychotics does not solve all compliance problems, but it does make them manifest.The choice for oral or depot administration of an antipsychotic will have to be based on the patient's particular circumstances, including the medical history and insight in his/ her illness, risks to patients and others and the personal preferences of both patient and clinician. The choice for switching to depot antipsychotics in order to reduce compliance problems needs to be part of an overall treatment plan that includes psychosocial support.

Chronic anal fissures are a painful condition frequently seen in general practice, with an incidence of 2,5/1000 per year. According to the practice guidelines of the Dutch College of General Practitioners, isosorbide dinitrate 1% ointment (ISDN) is the treatment of first choice for chronic anal fissures. Systemic side-effects such as headache are reported in 27% of all cases. This side effect in combination with the frequent application of ISDN (4-6 times daily) leads to a low compliance for this therapy. A meta-analysis of the Cochrane Collaboration showed similar efficacy of diltiazem compared to ISDN. Diltiazem has several advantages: the application frequency is only twice daily, no systemic side-effects have been reported, the total costs of treatment are lower than the costs of ISDN and a standard preparation of diltiazem ointment is available. Therefore, diltiazem 2% ointment should be the first line treatment for chronic anal fissures.

Most mental health providers in the Netherlands have implemented programmes of care. However, little is known about the extent to which care programmes are adhered to in routine clinical practice.To investigate the extent to which care programmes are adhered to in routine clinical practice.For three consecutive years we randomly selected 100 patients with a unipolar mood disorder, anxiety disorder or somatoform disorder and investigated retrospectively the extent to which care programmes were actually implemented in the first phase of treatment. We used a set of clinical process indicators based on the care programmes. The investigation took place on the premises of one of the 'Rivierduinen' mental health providers. We used patient records and data collected by means of routine outcome monitoring (ROM).Over the three years under study scores for most of the indicators ranged from fair to good. Scores were lower for the indicators 'ROM follow-up measurements' and 'frequency of psychotherapy'. Only the number of routine measurements of the severity of the psychopathology in the diagnostic phase appeared to have increased significantly over the three years under study.On the premises of the mental health care provider Rivierduinen where the study was conducted, care programmes during the first phase of treatment for mood disorder, anxiety disorder and somatoform disorders were adhered to reasonably well. Further research will have to concentrate on the subsequent phases of treatment. Another important matter that requires investigation is the relationship between the use of care programmes in daily practice and treatment outcomes.

About 50% of HIV patients have one or more mental disorders such as depression, addiction, anxiety disorders or personality disorders. Two patients, a 58-year-old male and a 38-year-old female, suffered from HIV infection with comorbid mental disorders. The mental disorders interfered with the treatment and outcome of their HIV infection. The first patient attempted suicide and was diagnosed with severe depression. He had stopped taking his antiretroviral combination therapy and had occasionally had unsafe sex. The woman suffered from posttraumatic stress disorder, alcohol abuse and depression. She took her antiretroviral combination therapy irregularly. Both patients received psychiatric treatment. Subsequently, medication adherence improved and the male patient no longer had unsafe sexual contacts. For optimal treatment of HIV infection it is important that comorbid mental disorders are recognized, diagnosed and treated.