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Abstract Background There is growing body of evidence of an association between cardiovascular risk factors and depressive and anxiety symptoms. The purpose of this study was to investigate whether these associations are similar in ethnic minority groups. Methods A random urban population sample, aged 18+, stratified by ethnicity (484 native Dutch subjects, 383 Turkish-Dutch subjects, and 316 Moroccan-Dutch subjects), in Amsterdam, the Netherlands, was interviewed with the Kessler Psychological Distress scale (K10) in combination with measurements of several cardiovascular risk factors. The association of psychological distress (defined as a K10 score above cut-off of 20) with cardiovascular risk factors (obesity, abdominal obesity, hypertension, hypercholesterolemia, low HDL cholesterol levels or diabetes), ethnicity and their interaction was analyzed using logistic regression analyses, stratified by gender and adjusted for age. Results Cardiovascular risk factors were not significantly associated with psychological distress in any of the gender/ethnic groups, with the exception of a positive association of obesity and hypertension with psychological distress in native Dutch women and a negative association of hypertension and psychological distress in Turkish men. Interaction terms of cardiovascular risk factors and ethnicity were approaching significance only in the association of obesity with the K10 in women. Conclusion In this cross-sectional multi-ethnic adult population sample the majority of the investigated cardiovascular risk factors were not associated with psychological distress. The association of obesity with psychological distress varies by gender and ethnicity. Our findings indicate that the prevention of obesity and psychological distress calls for an integrated approach in native Dutch women, but not necessarily in Turkish-Dutch and Moroccan-Dutch women, in whom these problems may be targeted separately.

Abstract Background Prevalence of type 2 diabetes mellitus is increasing due to lifestyle changes, particularly affecting those genetically at risk. We developed DiAlert as a targeted group-based intervention aimed to promote intrinsic motivation and action planning for lifestyle changes and weight loss in first degree relatives of patients with type 2 diabetes mellitus. The main objective of the pilot of the DiAlert intervention was to assess fidelity, feasibility and acceptability prior to starting the randomized controlled trial. Methods Individuals with a family history of type 2 diabetes mellitus were self-identified and screened for eligibility. DiAlert consists of two group sessions. Feasibility, fidelity, acceptability and self-reported perceptions and behavioral determinants were evaluated in a pre-post study using questionnaires and observations. Determinants of behavior change were analyzed using paired-samples t tests and Wilcoxon signed rank tests. Results DiAlert was delivered to two groups of first degree relatives of patients with type 2 diabetes mellitus (N = 9 and N = 12). Feasibility and fidelity were confirmed. Overall, the DiAlert group sessions were positively evaluated (8.0 on a scale of 1 to 10) by participants. The intervention did not impact perceived susceptibility or worry about personal diabetes risk. Action planning with regard to changing diet and physical activity increased. Conclusions DiAlert proved feasible and was well-accepted by participants. Positive trends in action planning indicate increased likelihood of actual behavior change following DiAlert. Testing the effectiveness in a randomized controlled trial is imperative. Trial registration Netherlands National Trial Register (NTR): NTR2036

Abstract Mesial temporal lobe epilepsy (mTLE) is a chronic and often treatment-refractory brain disorder characterized by recurrent seizures originating from the hippocampus. The pathogenic mechanisms underlying mTLE remain largely unknown. Recent clinical and experimental evidence supports a role of various inflammatory mediators in mTLE. Here, we performed protein expression profiling of 40 inflammatory mediators in surgical resection material from mTLE patients with and without hippocampal sclerosis, and autopsy controls using a multiplex bead-based immunoassay. In mTLE patients we identified 21 upregulated inflammatory mediators, including 10 cytokines and 7 chemokines. Many of these upregulated mediators have not previously been implicated in mTLE (for example, CCL22, IL-7 and IL-25). Comparing the three patient groups, two main hippocampal expression patterns could be distinguished, pattern I (for example, IL-10 and IL-25) showing increased expression in mTLE + HS patients compared to mTLE-HS and controls, and pattern II (for example, CCL4 and IL-7) showing increased expression in both mTLE groups compared to controls. Upregulation of a subset of inflammatory mediators (for example, IL-25 and IL-7) could not only be detected in the hippocampus of mTLE patients, but also in the neocortex. Principle component analysis was used to cluster the inflammatory mediators into several components. Follow-up analyses of the identified components revealed that the three patient groups could be discriminated based on their unique expression profiles. Immunocytochemistry showed that IL-25 IR (pattern I) and CCL4 IR (pattern II) were localized in astrocytes and microglia, whereas IL-25 IR was also detected in neurons. Our data shows co-activation of multiple inflammatory mediators in hippocampus and neocortex of mTLE patients, indicating activation of multiple pro- and anti-epileptogenic immune pathways in this disease.

Abstract Background The development and use of performance indicators (PI) in the field of public mental health care (PMHC) has increased rapidly in the last decade. To gain insight in the current state of PI for PMHC in nations and regions around the world, we conducted a structured review of publications in scientific peer-reviewed journals supplemented by a systematic inventory of PI published in policy documents by (non-) governmental organizations. Methods Publications on PI for PMHC were identified through database- and internet searches. Final selection was based on review of the full content of the publications. Publications were ordered by nation or region and chronologically. Individual PI were classified by development method, assessment level, care domain, performance dimension, diagnostic focus, and data source. Finally, the evidence on feasibility, data reliability, and content-, criterion-, and construct validity of the PI was evaluated. Results A total of 106 publications were included in the sample. The majority of the publications (n = 65) were peer-reviewed journal articles and 66 publications specifically dealt with performance of PMHC in the United States. The objectives of performance measurement vary widely from internal quality improvement to increasing transparency and accountability. The characteristics of 1480 unique PI were assessed. The majority of PI is based on stakeholder opinion, assesses care processes, is not specific to any diagnostic group, and utilizes administrative data sources. The targeted quality dimensions varied widely across and within nations depending on local professional or political definitions and interests. For all PI some evidence for the content validity and feasibility has been established. Data reliability, criterion- and construct validity have rarely been assessed. Only 18 publications on criterion validity were included. These show significant associations in the expected direction on the majority of PI, but mixed results on a noteworthy number of others. Conclusions PI have been developed for a broad range of care levels, domains, and quality dimensions of PMHC. To ensure their usefulness for the measurement of PMHC performance and advancement of transparency, accountability and quality improvement in PMHC, future research should focus on assessment of the psychometric properties of PI.

Abstract Background Family history is a known risk factor for type 2 diabetes (T2DM), and more so in the presence of overweight. This study aims to develop and evaluate the effectiveness of a new lifestyle education programme 'DiAlert' targeted at 1st degree relatives of people with T2DM and overweight. In view of the high risk for diabetes and cardiovascular disease in immigrants from Turkish origin living in Western Europe, a culturally appropriate Turkish version of DiAlert will be developed and tested. Methods/design In this RCT, 268 (134 Dutch and 134 Turkish) overweight 1st degree relatives of patients with T2DM will be allocated to either the intervention or control group (leaflet). The intervention DiAlert aims to promote intrinsic motivation to change lifestyle, and sustain achieved behaviour changes during follow-up. Primary outcome is weight loss. Secondary outcomes include biological, behavioural and psychological indices, along with process indicators. Measurements will take place at baseline and after 3 and 9 months. Changes in outcomes are tested between intervention and control group at 3 months; effects over time are tested within and between both ethnic groups at 3 and 9 months. Discussion The DiAlert intervention is expected to be more effective than the control condition in achieving significant weight loss at 3 months, in both Dutch and Turkish Dutch participants. Trial registration Netherlands National Trial Register (NTR): NTR2036

Abstract Background Injecting drug users (IDU) remain an important population at risk for blood-borne infections such as human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV). In the Netherlands, a program is being implemented to offer annual voluntary screening for these infections to opioid drug users (ODUs) screened in methadone care. At two care sites where the program is now operating, our study aimed to estimate the seroprevalence among ODUs screened for HIV, HBV and HCV; to evaluate HBV vaccination coverage; and to assess the feasibility of monitoring seroprevalence trends by using routine annual screening data. Methods Opioid drug users on methadone treatment are routinely offered voluntary screening for infectious diseases such as HIV, HBV and HCV. Data on uptake and outcome of anti-HIV, anti-HBc, and anti-HCV screening among ODUs receiving methadone were obtained from two regions: Amsterdam from 2004 to 2008 and Heerlen from 2003 to 2009. Findings Annual screening uptake for HIV, HBV and HCV varied from 34 to 69%, depending on disease and screening site. Of users screened, 2.5% were HIV-positive in Amsterdam and 11% in Heerlen; 26% were HCV-positive in Amsterdam and 61% in Heerlen. Of those screened for HBV, evidence of current or previous infection (anti-HBc) was found among 33% in Amsterdam and 48% in Heerlen. In Amsterdam, 92% were fully vaccinated for HBV versus 45% in Heerlen. Conclusion Annual screening for infectious diseases in all ODUs in methadone care is not fully implemented in the Netherlands. On average, more than half of the ODUs in methadone care in Heerlen and Amsterdam were screened for HIV, HBV and HCV. In addition, screening data indicate that HBV vaccination uptake was rather high. While the HIV prevalence among these ODUs was relatively low compared to other drug-using populations, the high HCV prevalence among this group underscores the need to expand annual screening and interventions to monitor HIV, HBV and HCV in the opioid drug-using population.

Abstract Background Adequate support for homeless populations includes shelter and care to recuperate from illness and/or injury. This is a descriptive analysis of diagnoses and use of shelter-based convalescence in a cohort of homeless adults in Amsterdam. Methods Demographics of ill homeless adults, diagnoses, referral pattern, length of stay, discharge locations, and mortality, were collected by treating physicians during outreach care provision in a shelter-based convalescence care facility in Amsterdam, from January 2001 through October 2007. Results 629 individuals accounted for 889 admissions to the convalescence care facility. 83% were male and 53% were born in the Netherlands. The mean age was 45 years (SD 10 years). The primary physical problems were skin disorders (37%), respiratory disorders (33%), digestive disorders (24%) and musculoskeletal disorders (21%). Common chronic conditions included addictions 78%, mental health disorders 20%, HIV/AIDS 11% and liver cirrhosis 5%. Referral sources were self-referred (18%), general hospitals (21%) and drug clinics (27%). The median length of stay was 20 days. After (self)discharge, 63% went back to the previous circumstances, 10% obtained housing, and 23% went to a medical or nursing setting. By March 2008, one in seven users (n = 83; 13%) were known to have died, the Standard Mortality Ratio was 7.5 (95% CI: 4.1-13.5). Over the years, fewer men were admitted, with significantly more self neglect, personality disorders and cocaine use. Lengths of stay increased significantly during the study period. Conclusion Over the last years, the shelter-based convalescence care facility users were mainly homeless single males, around 45 years of age, with chronic problems due to substance use, mental health disorders and a frail physical condition, many of whom died a premature death. The facility has been flexible and responsive to the needs of the users and services available.

Abstract Background Migration and ethnic minority status have been associated with higher occurrence of common mental disorders (CMD), while mental health care utilisation by non-Western migrants has been reported to be low compared to the general population in Western host countries. Still, the evidence-base for this is poor. This study evaluates uptake of mental health services for CMD and psychological distress among first-generation non-Western migrants in Amsterdam, the Netherlands. Methods A population-based survey. First generation non-Western migrants and ethnic Dutch respondents (N = 580) participated in structured interviews in their own languages. The interview included the Composite International Diagnostic Interview (CIDI) and the Kessler psychological distress scale (K10). Uptake of services was measured by self-report. Data were analysed using weighting techniques and multivariate logistic regression. Results Of subjects with a CMD during six months preceding the interview, 50.9% reported care for mental problems in that period; 35.0% contacted specialised services. In relation to CMD, ethnic groups were equally likely to access specialised mental health services. In relation to psychological distress, however, Moroccan migrants reported less uptake of primary care services (OR = 0.37; 95% CI = 0.15 to 0.88). Conclusion About half of the ethnic Dutch, Turkish and Moroccan population in Amsterdam with CMD contact mental health services. Since the primary purpose of specialised mental health services is to treat "cases", this study provides strong indications for equal access to specialised care for these ethnic groups. The purpose of primary care services is however to treat psychological distress, so that access appears to be lower among Moroccan migrants.

Abstract Background To improve homelessness prevention practice, we met with recently homeless adults, to explore their pathways into homelessness, problems and service use, before and after becoming homeless. Methods Recently homeless adults (last housing lost up to two years ago and legally staying in the Netherlands) were sampled in the streets, day centres and overnight shelters in Amsterdam. In April and May 2004, students conducted interviews and collected data on demographics, self reported pathways into homelessness, social and medical problems, and service use, before and after becoming homeless. Results among 120 recently homeless adults, (male 88%, Dutch 50%, average age 38 years, mean duration of homelessness 23 weeks), the main reported pathways into homelessness were evictions 38%, relationship problems 35%, prison 6% and other reasons 22%. Compared to the relationship group, the eviction group was slightly older (average age 39.6 versus 35.5 years; p = 0.08), belonged more often to a migrant group (p = 0.025), and reported more living single (p < 0,001), more financial debts (p = 0.009), more alcohol problems (p = 0.048) and more contacts with debt control services (p = 0.009). The relationship group reported more domestic conflicts (p < 0.001) and tended to report more drug (cocaine) problems. Before homelessness, in the total group, contacts with any social service were 38% and with any medical service 27%. Despite these contacts they did not keep their house. During homelessness only contacts with social work and benefit agencies increased, contacts with medical services remained low. Conclusion the recently homeless fit the overall profile of the homeless population in Amsterdam: single (Dutch) men, around 40 years, with a mix of financial debts, addiction, mental and/or physical health problems. Contacts with services were fragmented and did not prevent homelessness. For homelessness prevention, systematic and outreach social medical care before and during homelessness should be provided.

Abstract Background The Pictorial Representation of Illness and Self Measure (PRISM) has been introduced as a visual measure of suffering. We explored the validity of a revised version, the PRISM-RII, in diabetes patients as part of the annual review. Methods Participants were 308 adult outpatients with either type 1 or type 2 diabetes. Measures: (1) the PRISM-RII, yielding Self-Illness Separation (SIS) and Illness Perception Measure (IPM); (2) the Problem Areas in Diabetes (PAID) scale, a measure of diabetes-related distress; (3) the WHO-5 Well-Being Index; (4) and a validation question on suffering (SQ). In addition, patients' complication status, comorbidity and glycemic control values(HbA1c) were recorded. Results Patients with complications did have marginally significant higher scores on IPM, compared to patients without complications. Type 2 patients had higher IPM scores than Type 1 patients. SIS and IPM showed low intercorrelation (r = -.25; p < .01). Convergent validity of PRISM-RII was demonstrated by significant correlations between IPM and PAID (r = 0.50; p < 0.01), WHO-5 (r = -.26; p < 0.01) and SQ (r = 0.36; p < 0.01). SIS showed only significant correlations with PAID (r = -0.28; p < 0.01) and SQ (r = -0.22; p < 0.01). Neither IPM nor SIS was significantly associated with HbA1c. The PRISM-RII appeared easy to use and facilitated discussion with care providers on coping with the burden of diabetes. Conclusion PRISM-RII appears a promising additional tool to assess the psychological burden of diabetes.

Abstract Background Experience suggests that patients with alcohol and other drug use disorders (AOD) are commonly cared for in our intensive care units (ICU's) and require more sedation. We sought to determine the impact of AOD on sedation requirement and mechanical ventilation (MV) duration. Methods Retrospective review of randomly selected records of adult patients undergoing MV in the medical ICU. Diagnoses of AOD were identified using strict criteria in Diagnostic and Statistical Manual of Mental Disorders, and through review of medical records and toxicology results. Results Of the 70 MV patients reviewed, 27 had AOD (39%). Implicated substances were alcohol in 22 patients, cocaine in 5, heroin in 2, opioids in 2, marijuana in 2. There was no difference between AOD and non-AOD patients in age, race, or reason for MV, but patients with AOD were more likely to be male (21 versus 15, p < 0.0001) and had a lower mean Acute Physiology and Chronic Health Evaluation II (22 versus 26, p = 0.048). While AOD patients received more lorazepam equivalents (0.5 versus 0.2 mg/kg.day, p = 0.004), morphine equivalents (0.5 versus 0.1 mg/kg.day, p = 0.03) and longer duration of infusions (16 versus 10 hours/day. medication, p = 0.002), they had similar sedation levels (Richmond Agitation-Sedation Scale (RASS) -2 versus -2, p = 0.83), incidence of agitation (RASS ≥ 3: 3.0% versus 2.4% of observations, p = 0.33), and duration of MV (3.6 versus 3.9 days, p = 0.89) as those without AOD. Conclusion The prevalence of AOD among medical ICU patients undergoing MV is high. Patients with AOD receive higher doses of sedation than their non-AOD counterparts to achieve similar RASS scores but do not undergo longer duration of MV.

Abstract Background To determine physical and psychosocial well-being of adolescents with type 1 diabetes by self-report and parent report and to explore associations with glycemic control and other clinical and socio-demographic characteristics. Methods Demographic, medical and psychosocial data were gathered from 4 participating outpatient pediatric diabetes clinics in the Netherlands. Ninety-one patients completed the Child Health Questionnaire-CF87 (CHQ-CF87), Centre for Epidemiological Studies scale for Depression (CES-D), and the DFCS (Diabetes-specific Family Conflict Scale). Parents completed the CHQ-PF50, CES-D and the DFCS. Results Mean age was 14.9 years (± 1.1), mean HbA1c 8.8% (± 1.7; 6.2–15.0%). Compared to healthy controls, patients scored lower on CHQ subscales role functioning-physical and general health. Parents reported less favorable scores on the behavior subscale than adolescents. Fewer diabetes-specific family conflicts were associated with better psychosocial well-being and less depressive symptoms. Living in a one-parent family, being member of an ethnic minority and reporting lower well-being were all associated with higher HbA1c values. Conclusion Overall, adolescents with type 1 diabetes report optimal well-being and parent report is in accordance with these findings. Poor glycemic control is common, with single-parent families and ethnic minorities particularly at risk. High HbA1c values are related to lower social and family functioning.

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Background: Patients experiencing severe mental illnesses (SMI) need continuing support and remain vulnerable in many domains. Crisis interventions and compulsory admissions are common, causing a huge burden on police, health workers, the community and patients. The aim of this retrospective case-file study is to determine profiles of SMI-patients and their pathways through care among those experiencing multiple public crisis events., Methods: Data from a larger study of 323 SMI-patients in Amsterdam were used. These data were linked to data of the public mental health care (PMHC) in order to identify persons that experienced crisis interventions (CI's) between January 2004 and November 2012. The cut-off point for inclusion in the study population was set on three CI's, resulting in a group of 47 SMI-patients. PMHC and mental health care (MHC) data were linked in order to identify profiles in patterns of care. Qualitative content analysis was used to gather and analyze chronological timelines., Results: Three profiles were identified: SMI-patients with CI's during continuous MHC, SMI-patients with CI's after discharge and SMI-patients with CI's during unstable MHC. For each profile events prior to, during and after a CI were identified., Conclusions: PMHC and MHC can possibly identify cases with a high risk of CI's and predict these events based on the results of this study. CI's seem inevitable for a group of SMI-patients in care but they do not only require acute psychiatric care. The collaboration between MHC, PMHC and police could be further developed in a quick and effective triage in order to tackle the complexity of problems of the SMI-patients.

Background: Turkish migrants in the Netherlands have a high prevalence of depressive and/or anxiety disorders. Acculturation has been shown to be related to higher levels of psychological distress, although it is not clear whether this also holds for depressive and anxiety disorders in Turkish migrants. This study aims to clarify the relationship between acculturation strategies (integration, assimilation, separation and marginalization) and the prevalence of depressive and anxiety disorders as well as utilisation of GP care among Turkish migrants., Methods: Existing data from an epidemiological study conducted among Dutch, Turkish and Moroccan inhabitants of Amsterdam were re-examined. Four scales of acculturation strategies were created in combination with the bi-dimensional approach of acculturation by factor analysis. The Lowlands Acculturation Scale and the Composite International Diagnostic Interview were used to assess acculturation and mood and anxiety disorders. Socio-demographic variables, depressive, anxiety and co-morbidity of both disorders and the use of health care services were associated with the four acculturation strategies by means of Chi-Squared and Likelihood tests. Three two-step logistic regression analyses were performed to control for possible, confounding variables., Results: The sample consisted of 210 Turkish migrants. Significant associations were found between the acculturation strategies and age (p < .01), education (p < .01), daily occupation (p < .01) and having a long-term relationship (p = .03). A significant association was found between acculturation strategies and depressive disorders (p = .049): integration was associated with a lower risk of depression, separation with a higher risk. Using the axis separately, participation in Dutch society showed a significant relationship with a decreased risk of depressive, anxiety and co-morbidity of both disorders (OR = .15; 95% CI: .024 - .98). Non-participation showed no significant association. No association was found between the acculturation strategies and uptake of GP care., Conclusions: Turkish migrants who integrate may have a lower risk of developing a depressive disorder. Participation in Dutch culture is associated with a decreased risk of depressive, anxiety and co-morbidity of both disorders. Further research should focus on the assessment of acculturation in the detection of depression.

Objectives: To aid public health policy in preventing severe social exclusion (like homelessness) and promoting social inclusion (like labour market participation), we aimed to quantify (unmet) health needs of an expectedly vulnerable population on which little was known about: single male welfare recipients (SIM-welfare). One of the main policy questions was: is there need to promote access to healthcare for this specific group?, Design: A cross-sectional study incorporating peer-to-peer methodology to approach and survey SIM-welfare. Sociodemographics, prevalence of ill health, harmful drug use and healthcare utilisation for subgroups of SIM-welfare assessed with a different distance to the labour market and exposed to different reintegration policy were described and compared against single employed men (SIM-work)., Setting: Men between the age of 23 and 64, living in single person households in Amsterdam., Participants: A random and representative sample of 472 SIM-welfare was surveyed during 2009-2010. A reference sample of 212 SIM-work was taken from the 2008 Amsterdam Health Survey., Outcome Measures: Standardised instruments were used to assess self-reported ill somatic and mental health, harmful drug use and service use., Results: SIM-welfare are mostly long-term jobless, low educated, older men; 70% are excluded from re-employment policy due to multiple personal barriers. Health: 50% anxiety and depression; 47% harmful drug use; 41% multiple somatic illnesses. Health differences compared with SIM-work: (1) controlled for background characteristics, SIM-welfare report more mental (OR 4.0; 95% CI 2.1 to 4.7) and somatic illnesses (OR 3.1; 95% CI 2.7 to 6.0); (2) SIM-welfare assessed with the largest distance to the labour market report most combined health problems. Controlled for ill health, SIM-welfare are more likely to have service contacts than SIM-work., Conclusions: SIM-welfare form a selection of men with disadvantaged human capital and health. Findings do not support a need to improve access to healthcare. The stratification of welfare clients distinguishes between health needs.

The Kessler Psychological Distress scale (K10) is an instrument that is widely used to screen for mental disorders, but information is lacking on its psychometric qualities in non-Western samples. This study used a population-based sample (N = 725) to assess the reliability and validity of the K10 across ethnic groups in an urban area. The results were generally supportive of the K10 as a reliable and valid instrument to screen for anxiety and depression in all three groups. Cronbach's alpha was high (0.93) and the results indicated the existence of a solid single factor structure. Item bias in relation to ethnic background was minor. In each group, there was good criterion validity with respect to one-month DSM-IV diagnosis for depressive and/or anxiety disorder. The results nevertheless highlight the importance of cross-cultural validation, as we found different cut-off values for ethnic subgroups to obtain optimal sensitivity and specificity for detecting depressive and/or anxiety disorders., ((c) 2009 John Wiley & Sons, Ltd.)

Background: To improve homelessness prevention practice, we met with recently homeless adults, to explore their pathways into homelessness, problems and service use, before and after becoming homeless., Methods: Recently homeless adults (last housing lost up to two years ago and legally staying in the Netherlands) were sampled in the streets, day centres and overnight shelters in Amsterdam. In April and May 2004, students conducted interviews and collected data on demographics, self reported pathways into homelessness, social and medical problems, and service use, before and after becoming homeless., Results: among 120 recently homeless adults, (male 88%, Dutch 50%, average age 38 years, mean duration of homelessness 23 weeks), the main reported pathways into homelessness were evictions 38%, relationship problems 35%, prison 6% and other reasons 22%. Compared to the relationship group, the eviction group was slightly older (average age 39.6 versus 35.5 years; p = 0.08), belonged more often to a migrant group (p = 0.025), and reported more living single (p < 0,001), more financial debts (p = 0.009), more alcohol problems (p = 0.048) and more contacts with debt control services (p = 0.009). The relationship group reported more domestic conflicts (p < 0.001) and tended to report more drug (cocaine) problems. Before homelessness, in the total group, contacts with any social service were 38% and with any medical service 27%. Despite these contacts they did not keep their house. During homelessness only contacts with social work and benefit agencies increased, contacts with medical services remained low., Conclusion: the recently homeless fit the overall profile of the homeless population in Amsterdam: single (Dutch) men, around 40 years, with a mix of financial debts, addiction, mental and/or physical health problems. Contacts with services were fragmented and did not prevent homelessness. For homelessness prevention, systematic and outreach social medical care before and during homelessness should be provided.

In order to target the most important cost components of gastroenteritis in The Netherlands and to indicate which change of policy yields the largest decrease in costs, the cost of illness of gastroenteritis and the number of Disability Adjusted Life Years (DALYs) in the Dutch population in 1999 were determined. The costs of gastroenteritis were estimated using data mainly from a community-based cohort study. For calculating DALYs, data on the number of deaths due to gastroenteritis were used from Statistics Netherlands. On average, the costs for gastroenteritis were 77 Euro (euros) per case. For all patients in The Netherlands, the costs were estimated at 345 million euros (ranging between 252 and 531 million euros). Indirect costs made up 82% of this total. An estimate of costs for patients with campylobacter, salmonella or norovirus infections was, in total, 10-17% of the costs of gastroenteritis. Gastroenteritis was associated with a loss of approximately 67,000 DALYs.

Viral pathogens are the most common causes of gastroenteritis in the community. To identify modes of transmission and opportunities for prevention, a case-control study was conducted and risk factors for gastroenteritis attributable to norovirus (NV), Sapporo-like virus (SLV), and rotavirus were studied. For NV gastroenteritis, having a household member with gastroenteritis, contact with a person with gastroenteritis outside the household, and poor food-handling hygiene were associated with illness (population attributable risk fractions [PAR] of 17%, 56%, and 47%, respectively). For SLV gastroenteritis, contact with a person with gastroenteritis outside the household was associated with a higher risk (PAR 60%). For rotavirus gastroenteritis, contact with a person with gastroenteritis outside the household and food-handling hygiene were associated with a higher risk (PAR 86% and 46%, respectively). Transmission of these viral pathogens occurs primarily from person to person. However, for NV gastroenteritis, foodborne transmission seems to play an important role.

Results of the Dutch laboratory surveillance of bacterial gastroenteritis between 1991 and 2001 are presented and compared with recent findings in general practices and in the community. Between 1996 and 2000 the mean annual number of stools screened by sentinel laboratories was about 1000 samples/100,000 inhabitants, which is 4% of the estimated annual incidence of gastroenteritis in the Dutch population. Campylobacter (36/100,000 inhabitants) and salmonella (24/100,000 inhabitants) were the main pathogens isolated. Since 1996, the incidence of laboratory confirmed salmonellosis decreased by 30%, predominantly among young children. The incidence of campylobacter was highest in urban areas and Salmonella Enteritidis emerged as the predominant serotype in urban areas. Between 1991 and 2001, multi-resistant Salmonella Typhimurium DT104 emerged to comprise up to 15% of all salmonella isolates in 2001. Reported rates of Shigella spp. and Yersinia spp. varied little, with average annual incidences of 3.2 and 1.2 cases/100,000 inhabitants, respectively. Escherichia coli O157 (90% STEC) was scarcely found (0.26/100,000).

We compared gastroenteritis cases that consulted a general practitioner (GP) with those who did not in a community-based study and also with those in a GP-based study. We aimed to identify factors associated with consultation, and with inclusion of cases by GPs, and secondly to study the effects on the frequency of detection of pathogens. Furthermore, we estimated the under-ascertainment by GPs. Both studies were performed in The Netherlands in the same population in an overlapping time-period. Overall, 5% of community cases consulted a GP. Cases who consulted suffered from more severe episodes than non-consulting cases. Inclusion of cases by GPs, instead of a study team, caused a selection of more severe cases with more chronic symptoms. When extrapolating data from GP-based studies, it should be taken into account that, in general practice, gastroenteritis due to bacteria and Giardia lamblia is a relatively large proportion of that in the community and gastroenteritis due to Norwalk-like viruses is a relatively small proportion. The incidence of gastroenteritis in general practices was estimated between 14 and 35 per 1000 person years.

A prospective population-based cohort study with a nested case-control study was conducted to estimate the incidence of gastroenteritis and the associated pathogens in the general Dutch population. Follow-up of two consecutive cohorts was performed by weekly reporting cards from December 1998 to December 1999. Cases and controls in the case-control study supplied a questionnaire and stool samples. The standardized gastroenteritis incidence was 283 per 1,000 person-years. The incidence rose with increasing level of education and was higher for persons with a history of diarrhea and for young children. Bacterial pathogens accounted for 5% of cases, bacterial toxins for 9%, parasites for 6%, and viral pathogens for 21%, with Norwalk-like virus (NLV) as the leading pathogen in 11% of cases. The gastroenteritis incidence was higher than that reported for England, but lower than for the United States. In community cases, viral pathogens are the leading cause of gastroenteritis, with NLV being the number one cause of illness in all age groups but one. In many countries, preventive measures are implemented to decrease bacterial infections. However, additional prevention of viral infections, especially NLV, might significantly decrease the number of gastroenteritis cases in the community.

Data from a general practice-based, case-control study on gastroenteritis and the pathogens related to this disease were used to study the association between specific pathogens and the infected patients' ages and symptoms. For comparison, the occurrence of these pathogens in control patients, stratified by age, also is presented. In children with gastroenteritis who were <5 years of age, rotavirus (in 21% of patients) and Norwalk-like virus (NLV; in 15%) were the most common pathogens. Among patients who were 5-14 years of age, Campylobacter species (in 16% of patients) and Giardia lamblia (in 10%) were the most common pathogens. In the older patients, Campylobacter species was also the most common pathogen (8% to 15% of patients). In addition, several symptoms in case patients were associated with specific pathogens. Blood in the stool was associated with infection with Campylobacter species. In patients with fever, Salmonella species, Campylobacter species, and rotavirus were detected relatively often. Vomiting was associated with NLV and rotavirus. This is the first study in The Netherlands and one of the first studies in the world that has investigated a broad range of pathogens recovered from an unselected population of patients who had consulted general practitioners because of gastroenteritis.

From 1996 to 1999, the incidence of gastroenteritis in general practices and the role of a broad range of pathogens in the Netherlands were studied. All patients with gastroenteritis who had visited a general practitioner were reported. All patients who had visited a general practitioner for gastroenteritis (cases) and an equal number of patients visiting for nongastrointestinal symptoms (controls) were invited to participate in a case-control study. The incidence of gastroenteritis was 79.7 per 10,000 person years. Campylobacter was detected most frequently (10% of cases), followed by Giardia lamblia (5%), rotavirus (5%), Norwalk-like viruses (5%) and Salmonella (4%). Our study found that in the Netherlands (population 15.6 million), an estimated 128,000 persons each year consult their general practitioner for gastroenteritis, slightly less than in a comparable study in 1992 to 1993. A pathogen could be detected in almost 40% of patients (bacteria 16%, viruses 15%, parasites 8%).

Infection with thermophilic Campylobacter spp. usually leads to an episode of acute gastroenteritis. Occasionally, more severe diseases may be induced, notably Guillain Barré syndrome and reactive arthritis. For some, the disease may be fatal. We have integrated available data in one public health measure, the Disability Adjusted Life Year (DALY). DALYs are the sum of Years of Life Lost by premature mortality and Years Lived with Disability, weighted with a factor between 0 and 1 for the severity of illness. The mean health burden of campylobacter-associated illness in the Dutch population in the period 1990-5 is estimated as 1400 (90% CI 900-2000) DALY per year. The main determinants of health burden are acute gastroenteritis (440 DALY), gastroenteritis related mortality (310 DALY) and residual symptoms of Guillain-Barré syndrome (340 DALY). Sensitivity analysis demonstrated that alternative model assumptions produced results in the above-mentioned range.

The development of a vaccine against rotavirus (RV) infection has necessitated the estimation of the number of hospitalizations for RV infection in the Netherlands. During 1998, pediatricians have reported all hospitalizations with RV infection and supplied information on the duration of admission, clinical picture, indication for admission, and treatment. Also, data from the National Disease Registry on hospitalizations for gastroenteritis (International Classification of Disease codes 006.6. 006.8, 009, and 558.9) and laboratory surveillance data for 1996-1998 were combined in a linear regression model to indirectly estimate the incidence and proportion of hospitalizations attributable to RV infection. The direct estimate of admissions for RV infection in children aged <5 years was 0.9 per 1000, and the indirect estimate was 2.7 per 1000 in 1998 (1996, 3.4; 1997, 1.6). The proportion of hospitalizations for gastroenteritis attributable to RV ranged from 32% in 1997 to 58% in 1996.

The aim of this study was to estimate the incidence of gastroenteritis and Campylobacter and Salmonella infection in the Dutch population, the disease burden, and the percentage of patients with gastroenteritis that consults a general practitioner. A sample of 6243 persons was invited to participate in the study, i.e. completing a questionnaire and submitting stool samples. The follow-up period was 17 weeks. In total, 2206 persons participated (= 35%), contributing 660 person years. The incidence (standardised by age and gender) of first episodes of gastroenteritis was 45 per 100 person years. Among patients with gastroenteritis, Salmonella and Campylobacter were cultured in 1.6 and 4.5%, respectively. The standardised incidence of first Campylobacter infections was 9 per 100 person years, of first Salmonella infections 4 per 100 person years. For 22% of the episodes of gastroenteritis, a general practitioner was consulted (either by phone or by practice visit). For 52% of the episodes, medicine were used. For 34% of the episodes, absence from school was reported and for 15%, absence from work was reported. Despite of possible biases, we can conclude that the incidence of gastroenteritis is very high and causes considerable use of medication, consultation of general practitioners and absence from work and school.