51
|
Diesfeldt HFA. [Interpreting change scores of the Behavioural Rating Scale for Geriatric Inpatients (GIP)]. Tijdschr Gerontol Geriatr 2014; 44:166-74. [PMID: 23921986 DOI: 10.1007/s12439-013-0035-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The Behavioural Rating Scale for Geriatric Inpatients (GIP) consists of fourteen, Rasch modelled subscales, each measuring different aspects of behavioural, cognitive and affective disturbances in elderly patients. Four additional measures are derived from the GIP: care dependency, apathy, cognition and affect. The objective of the study was to determine the reproducibility of the 18 measures. A convenience sample of 56 patients in psychogeriatric day care was assessed twice by the same observer (a professional caregiver). The median time interval between rating occasions was 45 days (interquartile range 34-58 days). Reproducibility was determined by calculating intraclass correlation coefficients (ICC agreement) for test-retest reliability. The minimal detectable difference (MDD) was calculated based on the standard error of measurement (SEM agreement). Test-retest reliability expressed by the ICCs varied from 0.57 (incoherent behaviour) to 0.93 (anxious behaviour). Standard errors of measurement varied from 0.28 (anxious behaviour) to 1.63 (care dependency). The results show how the GIP can be applied when interpreting individual change in psychogeriatric day care participants.
Collapse
Affiliation(s)
- H F A Diesfeldt
- PgD De Stichtse Hof, Naarderstraat 81, 1251 BG, Laren, The Netherlands,
| |
Collapse
|
52
|
Borsje P, Wetzels RB, Lucassen PLBJ, Pot AM, Koopmans RTCM. Neuropsychiatric symptoms in patients with dementia in primary care: a study protocol. BMC Geriatr 2014; 14:32. [PMID: 24628730 PMCID: PMC3995579 DOI: 10.1186/1471-2318-14-32] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 03/11/2014] [Indexed: 12/05/2022] Open
Abstract
Background Neuropsychiatric symptoms (NPS) frequently occur in patients with dementia. To date, prospective studies on the course of NPS have been conducted in patients with dementia in clinical centers or psychiatric services. The primary goal of this study is to investigate the course of NPS in patients with dementia and caregiver distress in primary care. We also aim to detect determinants of both the course of NPS in patients with dementia and informal caregiver distress in primary care. Methods/design This is a prospective observational study on the course of NPS in patients with dementia in primary care. Thirty-seven general practitioners (GPs) in 18 general practices were selected based on their interest in participating in this study. We will retrieve electronic medical files of patients with dementia from these general practices. Patients and caregivers will be followed for 18 months during the period January 2012 to December 2013. Patient characteristics will be collected at baseline. Time to death or institutionalization will be measured. Co-morbidity will be assessed using the Charlson index. Psychotropic drug use and primary and secondary outcome measures will be measured at 3 assessments, baseline, 9 and 18 months. The primary outcome measures are the Neuropsychiatric Inventory score for patients with dementia and the Sense of Competence score for informal caregivers. In addition to descriptive analyses frequency parameters will be computed. Univariate analysis will be performed to identify determinants of the course of NPS and informal caregiver distress. All determinants will then be tested in a multivariate regression analysis to determine their unique contribution to the course of NPS and caregiver distress. Discussion The results of this study will provide data on the course of NPS, which is clinically important for prognosis. The data will help GPs and other professionals in planning follow-up visits and in the timing for offering psycho-education, psychosocial interventions and the provision of care. In addition, these data will enlarge health professionals’ awareness of NPS in their patients with dementia.
Collapse
Affiliation(s)
- Petra Borsje
- Department of Primary and Community Care, Radboud university medical centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands.
| | | | | | | | | |
Collapse
|
53
|
van der Spek K, Gerritsen DL, Smalbrugge M, Nelissen-Vrancken MHJMG, Wetzels RB, Smeets CHW, Zuidema SU, Koopmans RTCM. PROPER I: frequency and appropriateness of psychotropic drugs use in nursing home patients and its associations: a study protocol. BMC Psychiatry 2013; 13:307. [PMID: 24238392 PMCID: PMC3840691 DOI: 10.1186/1471-244x-13-307] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Accepted: 11/13/2013] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Nursing home patients with dementia use psychotropic drugs longer and more frequently than recommended by guidelines implying psychotropic drugs are not always prescribed appropriately. These drugs can have many side effects and effectiveness is limited. Psychotropic drug use between nursing home units varies and is not solely related to the severity of neuropsychiatric symptoms. There is growing evidence indicating that psychotropic drug use is associated with environmental factors, suggesting that the prescription of psychotropic drugs is not only related to (objective) patient factors. However, other factors related to the patient, elderly care physician, nurse and the physical environment are only partially identified. Using a mixed method of qualitative and quantitative research, this study aims to understand the nature of psychotropic drug use and its underlying factors by identifying: 1) frequency and appropriateness of psychotropic drug use for neuropsychiatric symptoms in nursing home patients with dementia, 2) factors associated with (appropriateness of) psychotropic drug use. METHODS A cross-sectional mixed methods study. For the quantitative study, patients with dementia (n = 540), nursing staff and elderly care physicians of 36 Dementia Special Care Units of 12 nursing homes throughout the Netherlands will be recruited. Six nursing homes with high average rates and six with low average rates of psychotropic drug use, based on a national survey about frequency of psychotropic drug use on units, will be included. Psychotropic drugs include antipsychotics, anxiolytics, hypnotics, antidepressants, anticonvulsants and anti-dementia drugs. Appropriateness will be measured by an instrument based on the Medication Appropriateness Index and current guidelines for treatment of neuropsychiatric symptoms. Factors associated to psychotropic drug use, related to the patient, elderly care physician, nurse and physical environment, will be explored using multilevel regression analyses. For the qualitative study, in depth interviews with staff will be held and analyzed to identify and explore other unknown factors. DISCUSSION This study will provide insight into factors that are associated with the frequency and appropriateness of psychotropic drug use for neuropsychiatric symptoms. Understanding psychotropic drug use and its associations may contribute to better dementia care.
Collapse
Affiliation(s)
- Klaas van der Spek
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboudumc, Huispost 117 ELG, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Debby L Gerritsen
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboudumc, Huispost 117 ELG, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Martin Smalbrugge
- Department of General Practice and Elderly Care Medicine/EMGO + Institute for Health and Care Research, VU Medical Center, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands
| | | | - Roland B Wetzels
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboudumc, Huispost 117 ELG, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Claudia HW Smeets
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboudumc, Huispost 117 ELG, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Sytse U Zuidema
- Department of General Practice, University of Groningen, University Medical Center Groningen, HPC FA21, PO Box 196, 9700 AD Groningen, The Netherlands
| | - Raymond TCM Koopmans
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboudumc, Huispost 117 ELG, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| |
Collapse
|
54
|
Smeets CHW, Smalbrugge M, Gerritsen DL, Nelissen-Vrancken MHJMG, Wetzels RB, van der Spek K, Zuidema SU, Koopmans RTCM. Improving psychotropic drug prescription in nursing home patients with dementia: design of a cluster randomized controlled trial. BMC Psychiatry 2013; 13:280. [PMID: 24180295 PMCID: PMC3840636 DOI: 10.1186/1471-244x-13-280] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 10/23/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Neuropsychiatric symptoms are highly prevalent in nursing home patients with dementia. Despite modest effectiveness and considerable side effects, psychotropic drugs are frequently prescribed for these neuropsychiatric symptoms. This raises questions whether psychotropic drugs are appropriately prescribed. The aim of the PROPER (PRescription Optimization of Psychotropic drugs in Elderly nuRsing home patients with dementia) II study is to investigate the efficacy of an intervention for improving the appropriateness of psychotropic drug prescription in nursing home patients with dementia. METHODS/DESIGN The PROPER II study is a multi-center cluster randomized controlled, pragmatic trial using parallel groups. It has a duration of eighteen months and four six-monthly assessments. Six nursing homes will participate in the intervention and six will continue care as usual. The nursing homes will be located throughout the Netherlands, each participating with two dementia special care units with an average of fifteen patients per unit, resulting in 360 patients. The intervention consists of a structured and repeated multidisciplinary medication review supported by education and continuous evaluation. It is conducted by pharmacists, physicians, and nurses and consists of three components: 1) preparation and education, 2) conduct, and 3) evaluation/guidance. The primary outcome is the proportion of patients with appropriate psychotropic drug use. Secondary outcomes are the overall frequency of psychotropic drug use, neuropsychiatric symptoms, quality of life, activities of daily living, psychotropic drug side effects and adverse events (including cognition, comorbidity, and mortality). Besides, a process analysis on the intervention will be carried out. DISCUSSION This study is expected to improve the appropriateness of psychotropic drug prescription for neuropsychiatric symptoms in nursing home patients with dementia by introducing a structured and repeated multidisciplinary medication review supported by education and continuous evaluation. TRIAL REGISTRATION Netherlands Trial Registry (NTR): NTR3569.
Collapse
Affiliation(s)
- Claudia HW Smeets
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud university medical center, Code 117 ELG, P.O. Box 9101, 6500, HB Nijmegen, the Netherlands
| | - Martin Smalbrugge
- Department of General Practice and Elderly Care Medicine/EMGO + Institute for Health and Care Research, VU Medical Center, P.O Box 7057, 1007, MB Amsterdam, The Netherlands
| | - Debby L Gerritsen
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud university medical center, Code 117 ELG, P.O. Box 9101, 6500, HB Nijmegen, the Netherlands
| | | | - Roland B Wetzels
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud university medical center, Code 117 ELG, P.O. Box 9101, 6500, HB Nijmegen, the Netherlands
| | - Klaas van der Spek
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud university medical center, Code 117 ELG, P.O. Box 9101, 6500, HB Nijmegen, the Netherlands
| | - Sytse U Zuidema
- Department of General Practice, University of Groningen, University Medical Center Groningen, HPC FA21, P.O. Box 196, 9700, AD Groningen, the Netherlands
| | - Raymond TCM Koopmans
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud university medical center, Code 117 ELG, P.O. Box 9101, 6500, HB Nijmegen, the Netherlands
| |
Collapse
|
55
|
Vink AC, Zuidersma M, Boersma F, de Jonge P, Zuidema SU, Slaets JPJ. The effect of music therapy compared with general recreational activities in reducing agitation in people with dementia: a randomised controlled trial. Int J Geriatr Psychiatry 2013; 28:1031-8. [PMID: 23280604 DOI: 10.1002/gps.3924] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Accepted: 12/03/2012] [Indexed: 11/10/2022]
Abstract
OBJECTIVE This study aimed to compare the effects of music therapy with general recreational day activities in reducing agitation in people with dementia, residing in nursing home facilities. METHODS In a randomised controlled design, residents with dementia (n = 94) were allocated to either music therapy or recreational activities. Both music therapy and general activities were offered twice weekly for 4 months. Changes in agitation were measured with a modified Cohen-Mansfield Agitation Inventory (CMAI) at four intervals on each intervention day. A mixed model analysis was used to evaluate the effectiveness of music therapy, compared with general activities, on CMAI scores at 4 h after the intervention, controlled for CMAI scores at 1 h before the session and session number. RESULTS Data were analysed for 77 residents (43 randomised to music therapy and 34 to general activities). In both groups, the intervention resulted in a decrease in agitated behaviours from 1 h before to 4 h after each session. This decrease was somewhat greater in the music therapy group than in the general activities group, but this difference was statistically not significant (F = 2.885, p = 0.090) and disappeared completely after adjustment for Global Deterioration Scale stage (F = 1.500; p = 0.222). CONCLUSIONS Both music therapy and recreational activities lead to a short-term decrease in agitation, but there was no additional beneficial effect of music therapy over general activities. More research is required to provide insight in the effects of music therapy in reducing agitation in demented older people.
Collapse
Affiliation(s)
- A C Vink
- Department of Internal Medicine, University of Groningen, University Medical Center Groningen, The Netherlands; Department of Music Therapy, ArtEZ School of Music, Enschede, The Netherlands; KenVaK Research Centre Art Therapies, The Netherlands
| | | | | | | | | | | |
Collapse
|
56
|
Cannon RL, Baldwin DR, Shaw TL, Diloreto DJ, Phillips SM, Scruggs AM, Riehl TC. Reliability of quantitative EEG (qEEG) measures and LORETA current source density at 30 days. Neurosci Lett 2012; 518:27-31. [DOI: 10.1016/j.neulet.2012.04.035] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Revised: 04/10/2012] [Accepted: 04/16/2012] [Indexed: 11/26/2022]
|
57
|
Efficacy of memantine for agitation in Alzheimer's dementia: a randomised double-blind placebo controlled trial. PLoS One 2012; 7:e35185. [PMID: 22567095 PMCID: PMC3342281 DOI: 10.1371/journal.pone.0035185] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Accepted: 03/08/2012] [Indexed: 12/11/2022] Open
Abstract
Background Agitation in Alzheimer’s disease (AD) is common and associated with poor patient life-quality and carer distress. The best evidence-based pharmacological treatments are antipsychotics which have limited benefits with increased morbidity and mortality. There are no memantine trials in clinically significant agitation but post-hoc analyses in other populations found reduced agitation. We tested the primary hypothesis, memantine is superior to placebo for clinically significant agitation, in patients with moderate-to-severe AD. Methods and Findings We recruited 153 participants with AD and clinically significant agitation from care-homes or hospitals for a double-blind randomised-controlled trial and 149 people started the trial of memantine versus placebo. The primary outcome was 6 weeks mixed model autoregressive analysis of Cohen-Mansfield Agitation Inventory (CMAI). Secondary outcomes were: 12 weeks CMAI; 6 and 12 weeks Neuropsychiatric symptoms (NPI), Clinical Global Impression Change (CGI-C), Standardised Mini Mental State Examination, Severe Impairment Battery. Using a mixed effects model we found no significant differences in the primary outcome, 6 weeks CMAI, between memantine and placebo (memantine lower −3.0; −8.3 to 2.2, p = 0.26); or 12 weeks CMAI; or CGI-C or adverse events at 6 or 12 weeks. NPI mean difference favoured memantine at weeks 6 (−6.9; −12.2 to −1.6; p = 0.012) and 12 (−9.6; −15.0 to −4.3 p = 0.0005). Memantine was significantly better than placebo for cognition. The main study limitation is that it still remains to be determined whether memantine has a role in milder agitation in AD. Conclusions Memantine did not improve significant agitation in people with in moderate-to-severe AD. Future studies are urgently needed to test other pharmacological candidates in this group and memantine for neuropsychiatric symptoms. Trial Registration ClinicalTrials.gov NCT00371059 Trial Registration International Standard Randomised Controlled Trial 24953404
Collapse
|
58
|
van Os AJ, Aziz L, Schalkwijk D, Schols JMGA, de Bie RA. Effectiveness of Physio Acoustic Sound (PAS) therapy in demented nursing home residents with nocturnal restlessness: study protocol for a randomized controlled trial. Trials 2012; 13:34. [PMID: 22495093 PMCID: PMC3349520 DOI: 10.1186/1745-6215-13-34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Accepted: 04/11/2012] [Indexed: 12/03/2022] Open
Abstract
Background Many older people with neuropsychiatric disorders such as Alzheimer's disease and frontotemporal dementia suffer from sleeping problems and often show nocturnal restlessness. Professionals and informal carers face considerable problems in solving these problems. Attempts to diminish these problems with medication in a safe and responsible manner have proven hardly effective or not effective at all. Therefore, nowadays the focus lies more on non-pharmacological solutions, for example by influencing environmental factors. There are indications that treatment with low-frequency acoustic vibrations, that is Physio Acoustic Sound (PAS) therapy, has a positive effect on sleeping problems. Therefore we study the effectiveness of PAS therapy in demented patients with nocturnal restlessness. Methods In a randomized clinical trial, 66 nursing home patients will be divided into two groups: an intervention group and a control group. For both groups nocturnal restlessness will be measured with actiwatches during a period of six weeks. In addition, a sleep diary will be filled in. For the intervention group the baseline will be assessed, in the first two weeks, reflecting the existing situation regarding nocturnal restlessness. In the next two weeks, this group will sleep on a bed identical to their own, but with a mattress containing an in-built PAS device. As soon as the patient is lying in bed, the computer programme inducing the vibrations will be switched on for the duration of 30 min. In the last two weeks, the wash-out period, the measurements of the intervention group are continued, without the PAS intervention. During the total study period, other relevant data of all the implied patients will be recorded systematically and continuously, for example patient characteristics (data from patient files), the type and seriousness of the dementia, occurrence of neuropsychiatric symptoms during the research period, and the occurrence of intermittent co-morbidity. Discussion If PAS therapy turns out to be effective, it can be of added value to the treatment of nocturnal restlessness in demented patients. Non-pharmacological PAS therapy is not only safe and patient-friendly, but it can also be widely used in a simple and relatively inexpensive way, both in institutions such as nursing homes and residential homes for the elderly, and at home. Ultimately, this may lead to a decrease in the frequent and still common use of psychotropic drugs. In addition, care needs of demented patients also may decrease as well as the number of preventable admissions to care institutions. Trial registration Netherlands Trial Register (NTR): NTR3242
Collapse
Affiliation(s)
- Arnoldien J van Os
- Zorgspectrum Het Zand, Hollewandsweg 17, Zwolle 8014BE, The Netherlands.
| | | | | | | | | |
Collapse
|
59
|
Mannu P, Rinaldi S, Fontani V, Castagna A. Radio electric asymmetric brain stimulation in the treatment of behavioral and psychiatric symptoms in Alzheimer disease. Clin Interv Aging 2011; 6:207-11. [PMID: 21822377 PMCID: PMC3147052 DOI: 10.2147/cia.s23394] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Behavioral and psychiatric symptoms of dementia (BPSD) are common in Alzheimer's disease (AD) and disrupt the effective management of AD patients. The present study explores the use of radio electric asymmetric brain stimulation (REAC) in patients who have had a poor response to pharmacological treatment. PATIENTS AND METHODS Eight patients (five females and three males; mean [±standard deviation] age at study baseline: 69.9 ± 3.0 years) diagnosed with AD according to the DSM-IV-TR criteria (mean onset age of AD: 65.4 ± 3.5 years) were cognitively and psychometrically assessed with the Mini-Mental State Examination (MMSE), the Activity of Daily Living (ADL), the Instrumental Activity of Daily Living (IADL), and the Neuropsychiatric Inventory (NPI), prior to and after each of 2 REAC treatment cycles. RESULTS Scores on the MMSE and all subscales of the NPI (frequency, severity, and distress), the ADL, and the IADL were significantly improved following the initial REAC treatment. There was further significant improvement in all measurements (with a tendency for improvement in the IADL) after the second REAC treatment cycle. CONCLUSION The improvement of cognitive and behavioral/psychiatric functioning following REAC treatment suggests that this innovative approach may be an effective, safe, and tolerable alternative to pharmacological treatment of AD patients, especially in the area of BPSD. Elderly patients suffering from other types of dementia may also benefit from REAC treatment.
Collapse
Affiliation(s)
- Piero Mannu
- Rinaldi Fontani Institute, Department of Neuro Psycho Physio Pathology, Florence, Italy
| | | | | | | |
Collapse
|
60
|
Zwijsen SA, Smalbrugge M, Zuidema SU, Koopmans RTCM, Bosmans JE, van Tulder MW, Eefsting JA, Gerritsen DL, Pot AM. Grip on challenging behaviour: a multidisciplinary care programme for managing behavioural problems in nursing home residents with dementia. Study protocol. BMC Health Serv Res 2011; 11:41. [PMID: 21338502 PMCID: PMC3051882 DOI: 10.1186/1472-6963-11-41] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2010] [Accepted: 02/21/2011] [Indexed: 11/25/2022] Open
Abstract
Background Behavioural problems are common in nursing home residents with dementia and they often are burdensome for both residents and nursing staff. In this study, the effectiveness and cost-effectiveness of a new care programme for managing behavioural problems will be evaluated. Methods/Design The care programme is based on Dutch national guidelines. It will consist of four steps: detection, analysis, treatment and evaluation. A stepped wedge design will be used. A total of 14 dementia special care units will implement the care programme. The primary outcome is behavioural problems. Secondary outcomes will include quality of life, prescription rate of antipsychotics, use of physical restraints and workload and job satisfaction of nursing staff. The effect of the care programme will be estimated using multilevel linear regression analysis. An economic evaluation from a societal perspective will also be carried out. Discussion The care programme is expected to be cost-effective and effective in decreasing behavioural problems, workload of nursing staff and in increasing quality of life of residents. Trial registration The Netherlands National Trial Register (NTR). Trial number: NTR 2141
Collapse
Affiliation(s)
- Sandra A Zwijsen
- Department of Nursing Home Medicine/EMGO + Institute for Health and Care Research, VU Medical Center, Amsterdam, The Netherlands.
| | | | | | | | | | | | | | | | | |
Collapse
|