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Diensten die opvang en bescherming bieden aan slachtoffers van mensenhandel hebben als ultieme doelstelling vaak een duurzame integratie van slachtoffers in de gastsamenleving voor ogen. Gelet op de complexe en uitgebreide noden van deze doelgroep is deze opdracht echter niet evident. Het vraagt een intensief en langdurig engagement van deze organisaties, die hiervoor niet steeds de middelen hebben. Dit artikel evalueert op verzoek van vereniging zonder winstoogmerk (vwz) Payoke1 een Europees gefinancierd pilootproject voor slachtoffers van mensenhandel in Antwerpen. Dit transitieprogramma is erop gericht om met ondersteunende maatregelen de overgang van opvanghuis naar zelfstandig wonen te vergemakkelijken.Op basis van de CAIMeR theorie van Blom & Morén (2009) werd een programmatheorieontwikkeld over dit transitieprogramma. De CAIMeR theorie beoogt te verklaren waarom en hoe sociaal werk werkt. Het biedt zowel inzicht in de context, actoren, interventies en voorlopige resultaten van een programma, als in de onderliggende werkzame mechanismen. In dit onderzoek leggen de resultaten bloot welke randvoorwaarden en mechanismen in het pilootproject kansrijk zijn om bij te dragen aan een duurzame integratie.[1] In België zijn er drie niet-gouvernementele organisaties actief die erkend zijn door de overheid voor bijstand aan en bescherming van de rechten van slachtoffers van mensenhandel, waaronder vwz Payoke in Antwerpen.

At present, two-thirds of the medical students in The Netherlands are women. However, the problems of combining a medical education with the responsibilities of motherhood, and the inaccessibility of medical top positions for women, are as serious as they were ten years ago at the 65th anniversary of the Dutch Association of Medical Women (VNVA). There is a serious need for medical education to become more 'woman-friendly'--and 'man-friendly' for that matter. For healthcare workers, it should be feasible to combine having children with a career. In addition, research into gender-specific health differences should be facilitated. Women, in particular, should take their responsibility in this respect, and be aware of the achievements of their pioneering predecessors. Last but not least: the Dutch Journal of Medicine needs to adapt. It needs to address a new audience, in which the male readers aged 50 and over have been largely replaced by female physicians in their thirties with children.

From the 1st of July 2008 the Dutch smoking ban for public spaces will be extended to hotels, restaurants and bars. The ban is a result of a 2003 Health Council report in which it was concluded that the annual incidence of deaths due to passive smoking is considerable. Based on these numbers, smoking in public spaces is prohibited since 2004. In a society where smoking in public spaces is prohibited, the harm of passive smoking will decrease. In this issue of The Nederlands Tijdschrit voor Geneeskunde (Dutch Journal of Medicine) a number of articles are dedicated to the subject of smoking.

At the end of their studies, physicians take the Hippocratic Oath. Medical and societal changes have meant that the oath has been altered over time. The oath still stipulates that the privacy of the patient should be respected. These days there is increased pressure on physicians and institutions to breach the duty of professional confidentiality. However, physicians themselves should also consider being more careful when talking about their patients outside the consulting room. They should definitely be aware oftheir responsibilities when participating in a reality series on television. In addition, medical information that is disclosed on Internet videos may negatively affect patients and physicians. Medical openness is commendable, but negligence may lead to loss of respect.

The results of self-measurements of blood pressure predict the risk of developing cardiovascular disease better than those of blood pressure measurements taken at the GP surgery or hospital. In spite of the increasing availability of devices for home measurement, exactly how, by whom, with what and when, blood pressure should be measured at home remains unclear. Self-measurement is to be recommended as a supplement to conventional blood pressure measurement, as, in this way, the white-coat effect and masked hypertension can be recognized. Self-measurement is only useful if it is carried using a validated, automatic, sphygmomanometer and measured in the correct way. It is essential that the patient be clearly instructed on how to do this. A limit for home measurement of 135/85 mmHg should be adhered to. When blood pressure measurements taken at home lead to a different conclusion than those taken at hospital or GP surgery (and if there is no white-coat or masked hypertension), it is recommended that the procedure be repeated. If after this, there is still a discrepancy between the results of these two methods of blood pressure measurement, ambulatory 24-hour blood pressure measurement will perhaps provide the definitive answer to the 'real' level of the patient's blood pressure.

The editor in chief, J. van Gijn, has retired. His main emphasis on the generalist capacities of the physician and on meticulous anamnesis and thorough physical examination is as relevant as ever. However a new challenge is unfolding: how to serve the modern physician who was brought up with digital information and the Internet revolution, with relevant, independent, and objective medical information. The web presence of this journal (www.ntvg.nl) will be brought up to the level of the demanding modern physician. This will include the possibilities of e-learning, podcasts and web videos. The British mathematician and physicist Sir Roger Penrose argues in his book The emperor's new mind: concerning computers, minds, and the laws of physics that the human spirit will never be equalled or replaced by a computer. If he is right--which he probably is--the plans of the new editors should not be seen as a foreseeable algorithmic reaction to the digitalising world, but as a genuinely new perspective.

Cognitive deterioration and its sequelae of vascular or Alzheimer's dementia is rapidly increasing all over the world. This is primarily caused by the worldwide increase of the ageing population. Additional causes may be sought in factors such as genetics and a habitually unhealthy life style. The significance of high blood pressure in the process leading to cognitive deterioration is relatively unknown. However, timely detection and treatment of hypertension seems to contribute to the preservation of cognition. Experience has shown that this applies in particular to dihydropyridine calcium antagonists. Medical care tends to make insufficient use of the existing possibilities for treating hypertension.

The recommendation to measure, at least once, the blood pressure in both arms is not without dispute. Several observations argue against such a recommendation. These include left-to-right asymmetry in cases of vascular rigidity and atherosclerotic lesions in both arms, and the variability of blood pressure. The latter may preclude any meaningful comparison between measurements taken in the left and right arm if these measurements are not obtained simultaneously.

Recently, an important study was published concerning the possible teratogenic effects of angiotensin converting enzyme (ACE) inhibitors. Non-diabetic women who had used an ACE inhibitor during the first trimester of pregnancy had a significantly greater chance of giving birth to an infant with congenital malformations than women who had used no or other antihypertensive agents. The excess risk remained even after adjusting for several potential confounders. The results indicate that ACE inhibitors should not be prescribed to women who are likely to become pregnant during the course of treatment.

The European Society of Hypertension in conjunction with the European Society of Cardiology has published new guidelines on the management of hypertension. At about the same time, the Joint National Committee in the United States updated the American hypertension guidelines. Both guidelines agree on a number of issues, such as the importance of systolic blood pressure, the necessity to take into account additional risk factors and the growing emphasis on combination treatment. As far as pharmacotherapy is concerned, however, there are major differences between the guidelines. Whereas the European report permits a choice from among several classes of drugs for initial treatment, the American guidelines still consider diuretics to be the first choice.

During the past few years, several randomised trials have compared the effects of older blood-pressure lowering drugs (diuretics, beta-blockers) with those of newer ones (angiotensin converting enzyme (ACE) inhibitors, calcium entry blockers) on the long-term prognosis. In general, no significant differences were found between these regimes. Recently, the ALLHAT trial, which was the largest hypertension trial ever and in which over 40,000 patients with hypertension participated, was completed. The initial treatment consisted of either the diuretic chlorthalidone, the calcium entry blocker amlodipine, the ACE inhibitor lisinopril, or the alpha-blocker doxazosin. The latter arm was prematurely discontinued because of a higher incidence of the secondary endpoint heart failure and stroke. Based on an intention-to-treat analysis, the other types of treatment proved to be equivalent in terms of the primary endpoint, a composite of fatal coronary heart disease and non-fatal myocardial infarction. Although the investigators conclude that ALLHAT suggests that thiazide diuretics should be first choice in the treatment of hypertension, there are several caveats that tend to lessen the strength of this conclusion.

According to the 'Australian burden of disease study', physical inactivity appears to be a leading risk factor in the population at large, accounting for no less than 6.7% of the total loss of disability-adjusted life years. In women it is even the most important risk factor. Regular physical mobility and exercise can reduce this negative influence. The effects are: improvement of cardiovascular fitness, prevention of coronary events, and the reduction of excess mortality. The mortality risk may be reduced by 47% by physical activity, depending on the energy expenditure. Especially the studies of the last two years have so convincingly proven a robust effect of daily physical exercise that on this point permissiveness is no longer acceptable in the advice to the population at large.

The prevalence and incidence of both degenerative (Alzheimer) and vascular dementias rise exponentially with aging. In both forms of dementia hypertension is a predisposing factor. The interval between the onset of hypertension and the manifestation of dementia amounts to 12-15 years. A complicating factor is the observation that initial dementia may be accompanied by secondary decrease in blood pressure. A preventive effect of current antihypertensive treatment is likely, according to preliminary evidence (particularly with regard to the use of the calcium antagonist nitrendipine), but the hopeful perspective of protection against dementias through antihypertensive treatment remains to be confirmed by further prospective comparative trials.

Angiotensin-II antagonists act on the terminus of the renin-angiotensin cascade, i.c. the angiotensin II subtype I (AT1) receptor. As a result, the receptor is reversibly blocked for the action of circulating angiotensin II, usually for 24 hours after a single dose. The consequence of this is that the blood pressure decreases, to the extent that this is dependent upon the action of this hormone. This action has various components, namely, vasoconstriction, sodium retention (mainly via aldosterone) and the promotion of cell growth in the cardiovascular system. The decrease in blood pressure is comparable to that achieved with the conventional antihypertensive drugs. The most striking difference is the almost total absence of the adverse effects know to be produced by the established agents. In vivo, there is no significant difference between the activity of the various AT1-receptor blockers. Their ultimate effect on the cardiovascular prognosis in the hypertensive population is still under investigation.

Even in an early phase of pregnancy marked haemodynamic changes occur, including a fall in vascular resistance and blood pressure and a rise in cardiac output. To compensate for the increased intravascular capacity the kidney retains more sodium and water. Apparently, the set point of sodium homeostasis shifts to a higher level at the expense of an expansion of extracellular volume. Studies during the normal menstrual cycle have shown that these changes, albeit smaller, also occur during the luteal phase. These fluctuations with the menstrual cycle are less apparent if salt intake is low, suggesting that a high salt intake is needed to facilitate the process of sodium retention. In pregnancies complicated by hypertension and/or pre-eclampsia body fluid volumes are low with an enhanced tendency to retain sodium after a volume challenge. These data, together with the lack of an apparent benefit of sodium restriction, suggest that the practice of prescribing a low-salt diet to hypertensive pregnant women should be abandoned.

By measuring central venous pressure during physical examination one quickly obtains information about the patient's volume status and cardiac function. For such measurements to be reliable there must be a free communication between the jugular vein (usually the right external or internal) and the right atrium. Venous pulsations must be visible and the point of venous collapse has to be clearly identified. During measurement the flow of blood through the vein must be halted. The sternal angle of the second rib is used as reference point. It is recommendable to use an instrument rather than the eye to estimate venous pressure. Although several studies have been performed to validate the external measurement of venous pressure, most of these are methodologically unsound.

The role of molecular genetics in the pathophysiology of various diseases is becoming clearer and clearer. In the field of cardiovascular diseases, molecular genetic aspects have been shown to play a definite role in the aetiology of these diseases. Several molecular-genetic variations called polymorphisms, occur in the population. The genes encoding the different components of the reninangiotensin-aldosterone system (RAAS), an important system in the regulation of the function and structure of the heart and vascular wall, also display polymorphisms. For some of these polymorphisms associations with various cardiovascular and renal diseases have been described. At present, this is particularly clear for the relation between angiotensin-converting-enzyme (ACE) polymorphism and the incidence of atherosclerotic complications and diabetic nephropathy, and for the relation between so-called M235 T-variant of the angiotensinogen gene and hypertension. Future research will have to show where it is worthwhile to use these and other polymorphisms as a marker for genetic risk. In what way the different RAAS-polymorphisms relate to functional abnormalities is as yet unclear, as are the potential therapeutic implications.

The relationship between (excessive) use of sodium chloride and the blood pressure is still equivocal. Blood pressure responses to alterations in dietary salt consumption vary greatly between individuals, which has led to the concept of salt sensitivity. Although the mechanisms which determine the degree of salt sensitivity are not fully understood, the renin-angiotensin system seems to play a key role. A relative inability of this system to respond promptly to alterations in salt intake may underlie the development of salt sensitivity. By administering drugs which block the renin-angiotensin system to patients with essential hypertension, blood pressure is rendered more sensitive to the effects of salt restriction and (or) diuretic treatment.

A 19-year-old female patient with cocaine and heroin intoxication is described in whom several life threatening complications such as hypovolemic shock, cardiopulmonary insufficiency, rhabdomyolysis, diffuse intravascular coagulation and multiple organ failure occurred. The patient survived the intoxication after quick intensive treatment.

A standardized test model for Aujeszky disease (AD) vaccines in pigs is described. The first two vaccines tested, a modified live virus (MLV) vaccine and an inactivated vaccine, failed to produce satisfactory results. The inactivated vaccine induced a short-lived, but clear-cut increase in body temperature in some of the vaccinated pigs; the MLV-vaccine was shown to spread. Complete protection against intranasal (i.n.) challenge was not achieved with either vaccine in five-month-old pigs that had been vaccinated once or even twice two to three months previously. However, the vaccinated pigs were less severely affected, and for shorter periods, than were the control animals; losses from death did not occur. In the control groups, at least thirty per cent died, the average growth of the remainder was arrested for more than three weeks. The mean period of arrested growth after challenge of pigs vaccinated once with the MLV-vaccine was slightly shorter than that following a single vaccination with the inactivated vaccine: 5.8 and 9.5 days respectively. The average virus excretion of vaccinated pigs after challenge was less and was not as protracted as in unvaccinated controls. In pigs from sows hyperimmunized with the inactivated vaccine, maternal antibodies afforded partial protection against i.n. challenge at the age of two months. However, five-month-old pigs were fully susceptible, although most of them continued to show low levels of neutralizing antibody. The average virus excretion after challenge in the two age-groups was comparable with that in control pigs. Cattle were effectively protected by vaccination with the inactivated vaccine against i.n. challenge with AD-virus. It is recommended to vaccinate "threatened" cattle twice, for instance in the autumn when they are removed from the pastures for indoor housing. The possibility that temperature reactions may occur should be taken into account.

In the autumn of 1979, approximately, 400 animals on twenty farms were inoculated twice against Aujeszky's disease using an inactivated vaccine in a practice in the Achterhoek (province of Gelderland). The animals vaccinated were mainly yearlings and heifers on farms on which cattle and pigs could not be effectively separated. Adverse reactions to vaccination, other than a slight to moderate increase in body temperature, were not observed. Outbreaks did not occur in vaccinated cattle during the 1979-1980 winter season; on the other hand, Aujeszky's disease was observed in the pigs on a number of farms. The serological effects of vaccination were followed up in forty-one animals on sixteen farms. Very high antibody titres were attained, particularly after the second vaccination. Antibody titres continued to be recorded after twelve months in a number of the animals followed.