Taenia martis Neurocysticercosis-Like Lesion in Child, Associated with Local Source, the Netherlands.

A neurocysticercosis-like lesion in an 11-year-old boy in the Netherlands was determined to be caused by the zoonotic Taenia martis tapeworm. Subsequent testing revealed that 15% of wild martens tested in that region were infected with T. martis tapeworms with 100% genetic similarity; thus, the infection source was most likely local.

Emergence of Bluetongue Virus Serotype 3, the Netherlands, September 2023.

Since 1998, notifiable bluetongue virus (BTV) serotypes 1-4, 6, 8, 9, 11, and 16 have been reported in Europe. In August 2006, a bluetongue (BT) outbreak caused by BTV serotype 8 began in northwestern Europe. The Netherlands was declared BT-free in February 2012, and annual monitoring continued. On September 3, 2023, typical BT clinical manifestations in sheep were notified to the Netherlands Food and Product Safety Consumer Authority. On September 6, we confirmed BTV infection through laboratory diagnosis; notifications of clinical signs in cattle were also reported. We determined the virus was serotype 3 by whole-genome sequencing. Retrospective analysis did not reveal BTV circulation earlier than September. The virus source and introduction route into the Netherlands remains unknown. Continuous monitoring and molecular diagnostic testing of livestock will be needed to determine virus spread, and new prevention strategies will be required to prevent BTV circulation within the Netherlands and Europe.

Link between Monkeypox Virus Genomes from Museum Specimens and 1965 Zoo Outbreak.

We used pathogen genomics to test orangutan specimens from a museum in Bonn, Germany, to identify the origin of the animals and the circumstances of their death. We found monkeypox virus genomes in the samples and determined that they represent cases from a 1965 outbreak at Rotterdam Zoo in Rotterdam, the Netherlands.

Effect of 2020-21 and 2021-22 Highly Pathogenic Avian Influenza H5 Epidemics on Wild Birds, the Netherlands.

The number of highly pathogenic avian influenza (HPAI) H5-related infections and deaths of wild birds in Europe was high during October 1, 2020-September 30, 2022. To quantify deaths among wild species groups with known susceptibility for HPAI H5 during those epidemics, we collected and recorded mortality data of wild birds in the Netherlands. HPAI virus infection was reported in 51 bird species. The species with the highest numbers of reported dead and infected birds varied per epidemic year; in 2020-21, they were within the Anatidae family, in particular barnacle geese (Branta leucopsis) and in 2021-22, they were within the sea bird group, particularly Sandwich terns (Thalasseus sandvicensis) and northern gannet (Morus bassanus). Because of the difficulty of anticipating and modeling the future trends of HPAI among wild birds, we recommend monitoring live and dead wild birds as a tool for surveillance of the changing dynamics of HPAI.

Bridging the gap between scientific discoveries and clinical application at the Utrecht Science Park.

Associate Professor Victor Peperzak from the University Medical Center (UMC) Utrecht in the Netherlands discusses the opportunities and challenges of building a research group in the Netherlands. Victor highlights the scientific strengths of UMC Utrecht in juxtaposition with other universities and centers around the Netherlands, and highlights the collaborative nature of the Dutch research scene.

Which men benefit from prostate cancer screening? Prostate cancer mortality by subgroup in the European Randomised Study of Screening for Prostate Cancer.

OBJECTIVE: To evaluate whether a subgroup of men can be identified that would benefit more from screening than others. MATERIALS AND METHODS: This retrospective cohort study was based on three European Randomised Study of Screening for Prostate Cancer (ERSPC) centres, Finland, the Netherlands and Sweden. We identified 126 827 men aged 55-69 years in the study who were followed for maximum of 16 years after randomisation. The primary outcome was prostate cancer (PCa) mortality. We analysed three age groups 55-59, 60-64 and 65-69 years and PCa cases within four European Association of Urology (EAU) risk groups: low, intermediate, high risk, and advanced disease. RESULTS: The hazard ratio (HR) for PCa mortality in the screening arm relative to the control arm for men aged 55-59 years was 0.96 (95% confidence interval [CI] 0.75-1.24) in Finland, 0.70 (95% CI 0.44-1.12) in the Netherlands and 0.42 (95% CI 0.24-0.73) in Sweden. The HR for men aged 60-64 years was 1.03 (95% CI 0.77-1.37) in Finland, 0.76 (95% CI 0.50-1.16) in the Netherlands and 0.97 (95% CI 0.64-1.48) in Sweden. The HR for men aged 65-69 years was 0.80 (95% CI 0.62-1.03) in Finland and 0.57 (95% CI 0.38-0.83) in the Netherlands, and this age group was absent in Sweden. In the EAU risk group analysis, PCa mortality rates were materially lower for men with advanced disease at diagnosis in all three countries: 0.67 (95% CI 0.56-0.82) in Finland, 0.28 (95% CI 0.18-0.44) in the Netherlands, and 0.48 (95% CI 0.30-0.78) in Sweden. CONCLUSION: We were unable to unequivocally identify the optimal age group for screening, as mortality reduction differed among centres and age groups. Instead, the screening effect appears to depend on screening duration, and the number and frequency of screening rounds. PCa mortality reduction by screening is largely attributable to stage shift.

Cross-border differences in the prevalence and risk factors for carriage of antimicrobial resistance in children attending daycare centers: a point prevalence study in the Netherlands and Belgium.

BACKGROUND: Day care centres (DCCs) are ideal settings for drug-resistant bacteria to emerge. Prevalence numbers of faecal carriage of antimicrobial resistant bacteria in these settings are rare. We aimed to determine the prevalence of faecal antimicrobial resistant bacteria carriage in children attending DCCs and to assess and identify infection risk factors within DCCs in The Netherlands and Belgium. METHODS: A point-prevalence study was conducted in 28 Dutch (499 children) and 18 Belgian (448 children) DCCs. Stool samples were taken from the children's diapers and a questionnaire was filled in by their parents. Hygiene related to stool and toilet use, hygiene related to food, environmental contamination, hand hygiene and hygiene guidelines were assessed conform a standardized questionnaire by the infection prevention and control expert visiting the DCC. Multilevel logistical regression analyses were used to define which characteristics predicted the presence of extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-E), carbapenemase-producing Enterobacterales (CPE), vancomycin-resistant enterococci (VRE), and ciprofloxacin-resistant Enterobacterales (CipR-E). RESULTS: The ESBL-E prevalence was 16% (n = 71) in Belgium and 6% (n = 30) in the Netherlands. The CipR-E prevalence was 17% (n = 78) in Belgium and 8% (n = 38) in the Netherlands. Antimicrobial use (RR: 0.30; 95% CI: 0.33-0.48) and hospital admissions (RR: 0.37; 95% CI: 0.25-0.54) were lower in the Netherlands. Children travelling to Asia were at higher risk of being an ESBL-E carrier. Children using antimicrobials were at higher risk of being a CipR-E carrier. Cleaning the changing mat after each use was found as a protective factor for CipR-E carriage. CONCLUSIONS: We established a significant difference in ESBL-E and CipR-E carriage and antimicrobial use and hospital admissions between the Netherlands and Belgium among children attending DCCs. The differences between both countries should be further studied to improve the policy on anti-microbial use and hospital admissions in children.

Implementing group care in Dutch and Surinamese maternity and child care services: the vital importance of addressing outer context barriers.

BACKGROUND: By addressing physical and psychosocial needs, group care (GC) improves health-related behaviours, peer support, parent-provider interactions and may improve birth outcomes. Hence, global implementation of GC is encouraged. Context analyses prior to implementation are vital to elucidate which local factors may support or hinder implementation. METHODS: Contextual analyses conducted in the Netherlands and Suriname were compared to identify the factors relevant to the implementability of GC as perceived by healthcare professionals (HCPs). 32 semi-structured interviews were conducted with Dutch and Surinamese healthcare professionals. Audio recordings were transcribed verbatim and coded using the Framework approach. The Consolidated Framework for Implementation Research guided the development of the interview guide and of the coding tree. RESULTS: Outer setting: Concerns regarding funding surfaced in both countries. Due to limited health insurance coverage, additional fees would limit accessibility in Suriname. In the Netherlands, midwives dreaded lower revenue due to reimbursement policies that favour one-on-one care. Inner setting: Appropriate space for GC was absent in one Dutch and three Surinamese facilities. Role division regarding GC implementation was clearer in the Netherlands than in Suriname. INNOVATION: HCPs from both countries expected increased social support, health knowledge among women, and continuity of care(r). Individuals/innovation deliverers: Self-efficacy and motivation emerged as intertwined determinants to GC implementation in both countries. Individuals/innovation recipients: Competing demands can potentially lower acceptability of GC in both countries. While Dutch HCPs prioritised an open dialogue with mothers, Surinamese HCPs encouraged the inclusion of partners. PROCESS: Campaigns to raise awareness of GC were proposed. Language barriers were a concern for Dutch but not for Surinamese HCPs. CONCLUSIONS: While the most striking differences between both countries were found in the outer setting, they trickle down and affect all layers of context. Ultimately, at a later stage, the process evaluation will show if those outer setting barriers we identified prior to implementation actually hindered GC implementation. Changes to the health care systems would ensure sustained implementation in both countries, and this conclusion feeds into a more general discussion: how to proceed when contextual analyses reveal barriers that cannot be addressed with the time and resources available.

Comparison of the nutritional composition and calculated Nutri-score classifications of the Dutch food retail supply in 2018 and 2020.

OBJECTIVE: In the Netherlands, reformulation strategies have been established for several years, whereas Nutri-Score was implemented in 2024. Besides being a helpful tool for consumers to make healthier food choices, Nutri-Score also aims to stimulate food reformulation by food manufacturers. The present study investigates whether changes in food composition could have led to different calculated Nutri-Score classifications. DESIGN: Food compositions and Nutri-Score classifications were calculated using the updated Nutri-Score algorithm. Food groups with the largest change in the distribution of Nutri-Score classifications were analysed in-depth by plotting frequency distributions and calculating median contents for nutrient contents that relatively changed the most in 2020. SETTING: Food composition data were available from the Dutch Branded Food database in 2018 (n 38 295) and 2020 (n 48 091). PARTICIPANTS: Not applicable. RESULTS: In general, median nutrient contents and calculated Nutri-Score classifications were similar for 2018 and 2020. The median sugar and SFA contents were lower for some food groups (e.g. breakfast cereals, meat preserves, sweets and sweet goods) in 2020 compared to 2018. The median SFA content for meat preserves and sweets and sweet goods was relatively low in Nutri-Score classification A ascending towards higher median content in Nutri-Score classification E. CONCLUSIONS: Although food reformulation was not substantial in the Dutch food retail supply in 2018 and 2020, some differences in Nutri-Score classifications were observed. When implemented, Nutri-Score may encourage food manufacturers to increase their reformulation efforts. Repeated monitoring of food compositions and Nutri-Score classifications is recommended to establish reformulation efforts by food manufacturers.

Establishing Outcome Parameters for Helicopter Emergency Medical Services Research in the Netherlands: Results of a Mixed-Methods Delphi Consensus Study.

OBJECTIVES: Physician staffed Helicopter Emergency Medical Services (P-HEMS) care in the Netherlands has transitioned from predominantly trauma management to handling a variety of medical conditions. Relevant outcome parameters for Dutch P-HEMS research have not been previously defined. National consensus was sought to identify relevant long term patient outcome parameters, process outcome parameters and performance outcome parameters for Dutch P-HEMS care. METHODS: This was a mixed methods Delphi consensus study. A list of potentially relevant outcome parameters was identified using a systematic literature review. These parameters were subsequently surveyed in a Delphi consensus study. Helicopter Emergency Medical Services physicians and relevant stakeholders were invited to participate in this Delphi survey, where they were allowed to suggest additional outcome parameters. Descriptive analysis was performed on all data sets. RESULTS: Forty-nine potential outcome parameters for Dutch P-HEMS care were surveyed. Of 71 invited participants, 53 (75%), 40 (56%), and 20 (28%) participated in the first, second, and third round of the Delphi study, respectively. Consensus was reached on 25 (51%) of 49 outcome parameters as being important. These consisted of seven long term patient related outcome parameters, four short term patient related outcome parameters, five process outcome parameters and nine performance outcome parameters. CONCLUSIONS: In conclusion, this study identified 25 outcome parameters relevant for Dutch physician staffed HEMS care. These parameters should be considered when designing future studies and should be routinely collected for each dispatch if possible.

Adoption of C-reactive protein rapid tests for the management of acute childhood infections in hospitals in the Netherlands and England: a comparative health systems analysis.

BACKGROUND: The adoption of C-reactive protein point-of-care tests (CRP POCTs) in hospitals varies across Europe. We aimed to understand the factors that contribute to different levels of adoption of CRP POCTs for the management of acute childhood infections in two countries. METHODS: Comparative qualitative analysis of the implementation of CRP POCTs in the Netherlands and England. The study was informed by the non-adoption, abandonment, spread, scale-up, and sustainability (NASSS) framework. Data were collected through document analysis and qualitative interviews with stakeholders. Documents were identified by a scoping literature review, search of websites, and through the stakeholders. Stakeholders were sampled purposively initially, and then by snowballing. Data were analysed thematically. RESULTS: Forty-one documents resulted from the search and 46 interviews were conducted. Most hospital healthcare workers in the Netherlands were familiar with CRP POCTs as the tests were widely used and trusted in primary care. Moreover, although diagnostics were funded through similar Diagnosis Related Group reimbursement mechanisms in both countries, the actual funding for each hospital was more constrained in England. Compared to primary care, laboratory-based CRP tests were usually available in hospitals and their use was encouraged in both countries because they were cheaper. However, CRP POCTs were perceived as useful in some hospitals of the two countries in which the laboratory could not provide CRP measures 24/7 or within a short timeframe, and/or in emergency departments where expediting patient care was important. CONCLUSIONS: CRP POCTs are more available in hospitals in the Netherlands because of the greater familiarity of Dutch healthcare workers with the tests which are widely used in primary care in their country and because there are more funding constraints in England. However, most hospitals in the Netherlands and England have not adopted CRP POCTs because the alternative CRP measurements from the hospital laboratory are available in a few hours and at a lower cost.

Orthopaedic surgeons' attitude toward physical activity for people after total hip or knee replacement: Northern vs Southern European country.

BACKGROUND: Regular physical activity (PA) is a key factor of lifestyle behavior enhancing general health and fitness, especially in people after total hip or knee replacement (THR and TKR). Orthopaedic surgeons can play a primary role in advocating the benefits of an active lifestyle. Aim of the study was 1) to assess the attitude of orthopaedic surgeons towards PA for people after THR/TKR and 2) to compare the attitude between a Northern European (the Netherlands) and a Southern European (Italy) country and analyze which factors influence the attitude towards PA. METHODS: A cross-cultural study. An (online) survey was distributed among orthopaedic surgeons in Italy and the Netherlands. Chi-square and Mann-Whitney tests were used to compare surgeons' and clinics' characteristics, and questionnaires' scores, respectively. A linear regression analysis was conducted to assess which surgeon characteristics influence attitude towards PA. RESULTS: A cohort of 159 surgeons (103 Italians and 56 Dutch) was analyzed. The median score of overall orthopaedic surgeons' attitude towards PA was positive (57 out of 72). Dutch surgeons showed a more positive attitude compared to Italian surgeons (p < 0.01). Main difference was found in the "Physical activity concern" factor, where Italian surgeons showed more concern about the negative effects of PA on the survival of the prosthesis. The regression analyses showed that "Country" and "Type of clinic" were associated with the surgeons' attitude. CONCLUSIONS: Overall, the orthopaedic surgeons' attitude towards PA for people with THR and TKR was positive. However, Dutch surgeons seem to be more positive compared to the Italian. The country of residence was the item that most influenced attitude. Further investigations are needed to untangle specific factors, such as cultural, socioeconomic, or contextual differences within the variable "country" that may influence orthopaedic surgeons' attitudes towards PA.

Risk factors for introduction of BVDV in the context of a mandatory control program in Dutch dairy herds.

Bovine Viral Diarrhea Virus (BVDV) is a common viral disease in cattle, causing economic losses in naive herds where the virus is introduced. In the Netherlands, a BVDV control program has been in place since 1998, evolving from voluntary to mandatory participation for dairy herds since April 2018. Participation in the BVDV control program is not mandatory for non-dairy farms. The aim of this study was to determine risk factors for new introduction of BVDV into certified BVDV-free herds in the context of a national BVDV control program in dairy herds. In this retrospective case-control study, survey data were collected from 149 dairy farms that lost their BVDV-free status (case herds) and 148 matched dairy farms that maintained their BVDV-free status (control herds) between 2018 and 2021. The survey captured information about potential risk factors and herd characteristics in the 2 years leading up to the loss of BVDV-free status (case herds, virus detection in at least one animal or when seroconversion was detected) or remaining BVDV-free (control herds). Descriptive statistics and logistic regression with a backward selection and elimination procedure were used to identify potential risk factors associated with losing BVDV-free status. Risk factors were quantified as an Odds Ratio (OR) with the associated 95% confidence interval (CI). The risk factor with the highest OR for losing BVDV-free status was purchasing cattle from herds without BVDV-free status (OR 1.25, CI 1.10-1.41), followed by the farmer having another profession that resulted in contact with other cattle (OR 1.25, CI 1.06-1.47), housing young calves and adult cows in the same barn (OR 1.22, CI 1.08-1.38), having a permanent employee on the farm (OR 1.17, CI 1.04-1.31), having a group calving pen (OR 1.16, CI 1.03-1.32), escaped cattle from other farms that mingled with own cattle (OR 1.16, CI 1.01-1.33), and nearest distance to a non-dairy farm (OR 1.15, CI 1.03-1.28). Although the BVDV status of most dairy herds can be checked in an open register, approximately half of the farmers indicated that they purchased cattle from BVDV-free herds while they were actually purchasing from non-BVDV-free farms. Farmers should be stimulated to actively check the true BVDV status of the herd from which cattle are purchased to further reduce the risk of introduction. In addition, indirect contact with cattle from other farms through either the farmer or other on-farm staff should be avoided. It is strongly advised to work in these situations with proper biosecurity measures such as changing boots and coveralls. The results can be used to improve BVDV control programs to further decrease the prevalence.

Increased incidence of Mycoplasma pneumoniae infections and hospital admissions in the Netherlands, November to December 2023.

Mycoplasma pneumoniae is an important cause of pneumonia and extra-pulmonary manifestations. We observed a rise in admissions due to M. pneumoniae infections starting October 2023 in a regional hospital in the Netherlands and an increased incidence in national surveillance data. The incidence in the Netherlands has not been that high since 2011. The patients had a lower median age compared with 2019 and 2020 (28 vs 40 years). M. pneumoniae should be considered in patients with respiratory symptoms, especially children.

Nosocomial transmission of tet(x3), bla NDM-1 and bla OXA-97-carrying Acinetobacter baumannii conferring resistance to eravacycline and omadacycline, the Netherlands, March to August 2021.

Carbapenem-resistant Acinetobacter baumannii (CRAb) is an important pathogen causing serious nosocomial infections. We describe an outbreak of CRAb in an intensive care unit in the Netherlands in 2021. During an outbreak of non-resistant A. baumannii, while infection control measures were in place, CRAb isolates carrying highly similar bla NDM-1 - and tet(x3)-encoding plasmids were isolated from three patients over a period of several months. The chromosomal and plasmid sequences of the CRAb and non-carbapenemase-carrying A. baumannii isolates cultured from patient materials were analysed using hybrid assemblies of short-read and long-read sequences. The CRAb isolates revealed that the CRAb outbreak consisted of two different strains, carrying similar plasmids. The plasmids contained multiple antibiotic resistance genes including the tetracycline resistance gene tet(x3), and the bla NDM-1 and bla OXA-97 carbapenemase genes. We determined minimal inhibitory concentrations (MICs) for 13 antibiotics, including the newly registered tetracycline antibiotics eravacycline and omadacycline. The CRAb isolates showed high MICs for tetracycline antibiotics including eravacycline and omadacycline, except for minocycline which had a low MIC. In this study we show the value of sequencing multidrug-resistant A. baumannii for outbreak tracking and guiding outbreak mitigation measures.

Large outbreak of typhoid fever on a river cruise ship used as accommodation for asylum seekers, the Netherlands, 2022.

On 6 April 2022, the Public Health Service of Kennemerland, the Netherlands, was notified about an outbreak of fever and abdominal complaints on a retired river cruise ship, used as shelter for asylum seekers. The diagnosis typhoid fever was confirmed on 7 April. An extensive outbreak investigation was performed. Within 47 days, 72 typhoid fever cases were identified among asylum seekers (n = 52) and staff (n = 20), of which 25 were hospitalised. All recovered after treatment. Consumption of food and tap water on the ship was associated with developing typhoid fever. The freshwater and wastewater tanks shared a common wall with severe corrosion and perforations, enabling wastewater to leak into the freshwater tank at high filling levels. Salmonella Typhi was cultured from the wastewater tank, matching the patient isolates. In the freshwater tank, Salmonella species DNA was detected by PCR, suggesting the presence of the bacterium and supporting the conclusion of contaminated freshwater as the probable source of the outbreak. Outbreaks of uncommon infections may occur if persons from endemic countries are accommodated in crowded conditions. Especially when accommodating migrants on ships, strict supervision on water quality and technical installations are indispensable to guarantee the health and safety of the residents.

Organization of head and neck cancer rehabilitation care: a national survey among healthcare professionals in Dutch head and neck cancer centers.

PURPOSE: Head and neck cancer (HNC) treatment often leads to physical and psychosocial impairments. Rehabilitation can overcome these limitations and improve quality of life. The aim of this study is to obtain an overview of rehabilitation care for HNC, and to investigate factors influencing rehabilitation provision, in Dutch HNC centers, and to some extent compare it to other countries. METHODS: An online survey, covering five themes: organizational structure; rehabilitation interventions; financing; barriers and facilitators; satisfaction and future improvements, among HNC healthcare- and financial professionals of Dutch HNC centers. RESULTS: Most centers (86%) applied some type of rehabilitation care, with variations in organizational structure. A speech language therapist, physiotherapist and dietitian were available in all centers, but other rehabilitation healthcare professionals in less than 60%. Facilitators for providing rehabilitation services included availability of a contact person, and positive attitude, motivation, and expertise of healthcare professionals. Barriers were lack of reimbursement, and patient related barriers including comorbidity, travel (time), low health literacy, limited financial capacity, and poor motivation. CONCLUSION: Although all HNC centers included offer rehabilitation services, there is substantial practice variation, both nationally and internationally. Factors influencing rehabilitation are related to the motivation and expertise of the treatment team, but also to reimbursement aspects and patient related factors. More research is needed to investigate the extent to which practice variation impacts individual patient outcomes and how to integrate HNC rehabilitation into routine clinical pathways.

Accountability in healthcare in the Netherlands: A scoping review.

For better serving people's complex needs the subsequent movement to person-centred integrated care, requires inter-organisational cooperation and service provision by domain-overarching networks and alliances. In the development to these networks, it is relevant to explore which accountability approaches are appropriate for local inter-organisational healthcare governance. Therefore, in a scoping review we studied the current state of knowledge and practice of accountability in healthcare in the Netherlands. We found that two of the included 41 studies show characteristics of accountability towards healthcare with characteristics of integration care components, such as integration of services with accompanying accountability arrangements and development of networked accountability. The first studies are found in the literature which report on accountability in integrated care. With this we add to the international discussion about accountability as an aspect of integrated care governance, by providing insight into the current state of art of accountability in Dutch healthcare.

Assessing runners' exposure to natural and built environments in the Netherlands: A descriptive assessment based on GPS tracking.

Running is a convenient physical activity that has gained popularity. However, little is known about runners' running environments and how they differ from their residential environments. To fill this gap, this study examines runners' exposure to natural and built environments along their running routes and assesses the difference between running and residential environments. We collected running track data from Endmondo, a fitness data platform, and used it to determine runners' residency. Moreover, we used open geographical data to calculate a range of environmental variables within their residential areas and along their running trajectories. We applied t-tests to assess differences across objectively measured environmental variables between urban and rural runners, considering geographic, temporal and track-specific strata. We found that the running environments of urban and rural runners were diverse and had distinct characteristics. The results suggest policies to promote running acknowledging these differences between running environments in urban and rural areas.

A Disputed Hegemony: Negotiating Neurosurgical Patient Care in the Netherlands, 1930-1952.

The emergence of the neurosurgical patient as a novel clinical entity in the Netherlands was marked by a lingering conflict between neurologists and neurosurgeons, in which both types of specialists sought to assume the clinical and institutional leadership of neurosurgical patient care. In the 1920s and 1930s, neurologists had facilitated the establishment of the first generation of neurosurgeons in the country, and in the process, had managed to clinically and institutionally subordinate neurosurgery to neurology. As the demand for neurosurgical patient care grew, the neurosurgeons began to challenge this hegemonic relationship. The neurologists, however, were unwilling to give up their control, fearing that they would be bypassed in the diagnosis of patients eligible to neurosurgery. These conflicting aims and interests resulted in an intricate demarcation battle, in which the boundary work between neurologists and neurosurgeons was directly played out at the local workplace and at the meetings of the Study Club for Neuro-Surgery, and indirectly at various other sites of contestation, such as medical journals and academic lecture halls, as both parties sought to rally external stakeholders to their cause. During these negotiations, local, national, and international forces increasingly intertwined to shape the particular organization of Dutch neurosurgery in the middle of the twentieth century. By analyzing this multilayered demarcation process, this article draws attention to the complexity of medical boundary work, and to the way in which, despite pervasive international influences, specialist practice was ultimately negotiated at the local and national levels.