Developing a prenatal nursing care International Classification for Nursing Practice catalogue.

AIM: This study aimed to develop a prenatal nursing care catalogue of International Classification for Nursing Practice. BACKGROUND: As a programme of the International Council of Nurses, International Classification for Nursing Practice aims to support standardized electronic nursing documentation and facilitate collection of comparable nursing data across settings. This initiative enables the study of relationships among nursing diagnoses, nursing interventions and nursing outcomes for best practice, healthcare management decisions, and policy development. The catalogues are usually focused on target populations. Pregnant women are the nursing population addressed in this project. METHODS: According to the guidelines for catalogue development, three research steps have been adopted: (a) identifying relevant nursing diagnoses, interventions and outcomes; (b) developing a conceptual framework for the catalogue; (c) expert's validation. RESULTS: This project established a prenatal nursing care catalogue with 228 terms in total, including 69 nursing diagnosis, 92 nursing interventions and 67 nursing outcomes, among them, 57 nursing terms were newly developed. All terms in the catalogue were organized by a framework with two main categories, i.e. Expected Changes of Pregnancy and Pregnancy at Risk. Each category had four domains, representing the physical, psychological, behavioral and environmental perspectives of nursing practice. IMPLICATIONS FOR NURSING PRACTICE: This catalogue can ease the documentation workload among prenatal care nurses, and facilitate storage and retrieval of standardized data for many purposes, such as quality improvement, administration decision-support and researches. The documentations of prenatal care provided data that can be more fluently communicated, compared and evaluated across various healthcare providers and clinic settings.

Electrical waterbath stunning: influence of different waveform and voltage settings on the induction of unconsciousness and death in male and female broiler chickens.

Stunning effectiveness of male and female broiler chickens was analyzed in response to different waveforms at 3 constant voltage levels. In total, 180 male and female broiler chickens were stunned using a sine wave alternating current (AC) of 50 Hz, rectangular AC of 70 Hz, and pulsed direct current (DC) of 70 Hz (duty-cycle 1:1) with a constant voltage of 60, 80, or 120 V, respectively. In each stunning group, 10 male and 10 female birds were stunned for 4 s. The current obtained by every bird was recorded. For stunning efficiency, the electroencephalogram (EEG) and physical reflexes were recorded and analyzed. The EEG was recorded for 120 s poststun. Simultaneously, the occurrence of spontaneous eye blinking, wing flapping, and breathing was assessed, and the corneal reflex was tested every 20 s poststun. The EEG was analyzed regarding the occurrence of a profound suppression to less than 10% of the prestun level in the 2 to 30 Hz and 13 to 30 Hz bands. Female broilers obtained a significantly lower stunning current compared with that of the males. This resulted in a lower stunning efficiency for females, when the same constant voltage was applied to males and females. The waveforms required different amounts of currents to achieve a 90% stunning efficiency. A minimum necessary stunning current of 70, 90, and 130 mA could be established for sine wave AC, rectangular AC, and pulsed DC, respectively. The low stunning efficiency of pulsed DC might be caused by the short stunning time of 4 s. This effect should be further investigated for DC stunning. Very few birds stunned with AC resumed breathing following stunning, indicating stun to kill. Pulsed DC stunning showed a lower effect on the induction of death. The level of wing flapping, indicating convulsions and possible meat quality defects, was higher for the AC treatments.

Evaluation of the content coverage of SNOMED CT representing ICNP seven-axis version 1 concepts.

OBJECTIVES: The purpose of this study is to evaluate the ability of SNOMED CT (Systematized Nomenclature of Medicine Clinical Terms) to represent the concepts of the ICNP version 1--the seven-axis model. METHODS: The first author mapped 1658 concepts of the ICNP version 1 to SNOMED CT using CLUE browser 5.0. The second author from SNOMED Terminology Solutions--with a team of SNOMED CT experts--and the third author from the ICN with a team of ICNP experts validated the mapping result. If there was any disagreement during the validation process, the three of us convened online meetings to reach a consensus. RESULTS: In total, SNOMED CT covered 1331 out of 1658 (80%) ICNP seven-axis model concepts ranging from a 61% coverage rate of the Actions Axis concepts to a 94% coverage rate of the Judgment axis concepts. CONCLUSIONS: SNOMED CT can represent most (80%) of the ICNP version 1 concepts. However, improvements in the ICNP version 1 in terms of concept naming and definition, and the addition of missing concepts to SNOMED CT, would lead to a greater harmonization of the ICNP seven-axis model version 1 concepts with SNOMED CT.

Electroencephalograms and physical reflexes of broilers after electrical waterbath stunning using an alternating current.

Stunning efficiency of broilers after electrical waterbath stunning with an alternating current was assessed using electroencephalograms (EEG) and physical reflexes. Four hundred eighty-nine broilers (246 males and 243 females) were stunned in an electrical waterbath with a rectangular alternating stunning current of 60, 80, 100, 120, and 150 mA and frequencies of 70, 100, 200, 400, 800, and 1,500 Hz. Stunning time was 10 s. The EEG was recorded for 120 s poststun. Occurrence of spontaneous breathing, eye blinking, and wing flapping and the corneal reflex were recorded. The EEG was analyzed regarding the occurrence of a profound suppression to less than 10% of the prestun level in the 2 to 30-Hz band and 13 to 30-Hz band. The occurrence of epileptiform patterns was assessed and the occurrence of clonic-tonic convulsions was recorded. Statistical analysis showed a highly significant effect of stunning frequency and stunning current for all groups in the EEG analysis. Stunning frequencies above 400 Hz or below 100 mA did not result in profound suppression of brain power to less than 10% of the prestun level in more than 90% of the broilers and can therefore not be recommended. More than 80% of the birds stunned with 70 or 100 Hz at 100 mA or 70, 100, and 200 Hz with 120 and 150 mA did not recover from stunning. The occurrence of epileptiform activity could only be observed in a few birds. It is assumed that this is due to the long stunning time of 10 s and epileptiform activity could have occurred just before EEG recording started. A maximum of 30% of birds with corneal reflexes and spontaneous eye blinking should not be exceeded, whereas at 15 s poststun, not more than 15% of birds should show spontaneous eye blinking. Wing flapping occurred in at least 50% of birds with adequate stunning results. This seems to be related to convulsions and could cause meat quality defects.

Effects of waterbath stunning on the electroencephalograms and physical reflexes of broilers using a pulsed direct current.

Stunning efficiency of a pulsed direct current was assessed regarding the effect on the electroencephalogram (EEG) and physical reflexes. Four hundred sixty-seven broilers (males and females) were stunned in an electrified waterbath with 60, 80, 100, 120, and 150 mA at frequencies of 70, 100, 200, 400, 800, and 1,500 Hz. Stunning time was 10 s. The EEG recordings lasted for 120 s poststun and simultaneously the occurrence of breathing, spontaneous eye blinking, corneal reflex, and wing flapping was recorded. The EEG records were assessed regarding a profound suppression to less than 10% of the prestun brain power in 2 brain frequency bands, 2 to 30 Hz and 13 to 30 Hz. The EEG results showed a significant effect of stunning frequency for all analyzed parameters. Stunning frequencies of 800 and 1,500 Hz did not achieve adequate stunning results. With a minimum stunning current of 120 mA at frequencies of 70 or 100 Hz or 150 mA at 200 Hz, more than 80% of the animals did not resume breathing. Currents of 80 and 100 mA at 70 or 100 Hz achieved unconsciousness in more than 90% of the birds and birds recovered within 30 to 40 s poststun. Epileptiform activity was found in a relatively low proportion of EEG traces. This could be explained by the long stunning time of 10 s, in which epileptiform activity might have occurred already before the start of EEG recording. Direct current stunning causes less cardiac arrest during stunning, but occurrence of breathing seems more related to cardiac function than to consciousness. A maximum of 30% corneal reflexes and spontaneous eye blinking seems acceptable with a maximum of 15% spontaneous blinking at 15 s poststun. Fourty percent of wing flapping occurred in all effectively stunned groups. Direct current seems to have a different effect on male and female broilers because significantly more male broilers showed reflexes, whereas simultaneously the likelihood of profound EEG suppression was higher. Further investigation of this effect is necessary.

Electroencephalogram functional connectivity between rat hippocampus and cortex after pilocarpine treatment.

The muscarinic agonist pilocarpine has been shown to increase the duration and total number of episodes presenting theta rhythm-simultaneously in hippocampus and cortex-in rats during the waking states. Theta waves are suggested to be involved in the flow of information between hippocampus and cortex during memory processes. This work investigates this functional interdependence using the spectral and phase synchronization analysis of the electroencephalogram (EEG) theta band recorded in these brain structures of rats after pilocarpine treatment. Pilocarpine was used at doses devoid of epilepticus-like seizures effects in conscious freely moving rats. The results showed that pilocarpine administration significantly increased the relative theta power during the waking states in the cortex, but not in the hippocampus of rats. Additionally, the EEG coherence between the hippocampal EEG theta band and that arising at the frontal cortex increased after pilocarpine treatment but only during the waking states. This result reveals an increase of the linear correlation between the theta waves of these two brain structures after pilocarpine treatment during the waking states. Moreover, phase synchronization results showed an effective phase locking with non-zero phase difference between hippocampus and frontal cortex theta waves that remained after pilocarpine treatment. Therefore, pilocarpine seems to reinforce the neural transmission waves from the hippocampus toward the cortex during waking. In conclusion, the present EEG study could suggest an effect of the muscarinic cholinergic agonist pilocarpine on the hippocampal-cortical functional connectivity.

Placental transfer of SSRI and SNRI antidepressants and effects on the neonate.

INTRODUCTION: We investigated placental transfer and neurobehavioural effects in neonates exposed to citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine or sertraline (SSRI's), or to venlafaxine (an SNRI). METHODS: Women receiving antidepressants during pregnancy and their neonates were studied. Cord and maternal drug concentrations were measured at birth and in the neonates plasma on day 3. Neonates were also assessed using a range of neurobehavioral tests and compared to controls. RESULTS: Median cord/maternal distribution ratio was 0.7-0.86 (range) for SSRIs, 0.72 for the SNRI venlafaxine and 1.08 for the O-desmethyl metabolite. Neonatal abstinence scores were significantly higher (p<0.05) in exposed infants than controls on day 1. Brazelton scores for habituation, social-interactive, motor and autonomic clusters, and serotonin scores were significantly greater (p<0.05) in exposed infants. DISCUSSION: Transfer of SSRIs and SNRIs across the placenta was substantial. Neonates developed mild behavioral symptoms in the early perinatal period but these were self-limiting and similar for both SSRIs and the SNRI venlafaxine.

Remote monitoring of electroencephalogram, electrocardiogram, and behavior during controlled atmosphere stunning in broilers: implications for welfare.

This study examined the welfare implications of euthanizing broilers with 3 gas mixtures relevant to the commercial application of controlled atmosphere stunning (CAS). Birds were implanted/equipped with electrodes to measure brain activity (electroencephalogram, EEG) and heart rate. These signals were recorded using a purpose-built telemetry-logging system, small enough to be worn by each bird in a spandex backpack. The birds were euthanized in a scaled-down CAS apparatus consisting of a conveyor belt passing through 2 compartments. Three gas environments were applied (8 birds per treatment): 1) anoxia (N(2) with <2% residual O(2), in both compartments), 2) hypercapnic anoxia (N(2) with 30% CO(2) and <2% residual O(2), in both compartments), and 3) a 2-phase approach with a hypercapnic hyperoxygenated anesthetic phase (40% CO(2), 30% O(2), and 30% N(2), in the first compartment, 80 s) followed by a second euthanasia phase (80% CO(2) in air, in the second compartment). All 3 CAS approaches effectively achieved nonrecovery states, and time to loss of consciousness for each bird was determined by visual determination of isoelectric EEG and by calculation of the correlation dimension of the EEG. Hypercapnic anoxia resulted in rapid unconsciousness and death; both anoxic treatments were associated with early onset prolonged wing flapping and sustained tonic convulsions as displayed in the electrophysiological recordings. These responses were seen in the period when consciousness remained a possibility. Hypercapnic hyperoxygenation (the 2-phase approach) was associated with respiratory disruption, but this treatment eliminated initial clonic convulsions in the stunning process, and tonic convulsions were not seen. These results suggest that the presence of O(2) in the first stage of CAS is associated with an absence of potentially distressing behavioral responses. The respiratory discomfort associated with hypercapnic hyperoxygenation is an issue. We propose that this may be compensated by a more gradual induction to unconsciousness, which eliminates the impact of other potentially negative experiences.

Achieving blood pressure goals globally: five core actions for health-care professionals. A worldwide call to action.

The prevalence of hypertension continues to rise across the world, and most patients who receive medical intervention are not adequately treated to goal. A Working Group including representatives of nine international health-care organizations was convened to review the barriers to more effective blood pressure control and propose actions to address them. The group concluded that tackling the global challenge of hypertension will require partnerships among multiple constituencies, including patients, health-care professionals, industry, media, health-care educators, health planners and governments. Additionally, health-care professionals will need to act locally with renewed impetus to improve blood pressure goal rates. The Working Group identified five core actions, which should be rigorously implemented by practitioners and targeted by health systems throughout the world: (1) detect and prevent high blood pressure; (2) assess total cardiovascular risk; (3) form an active partnership with the patient; (4) treat hypertension to goal and (5) create a supportive environment. These actions should be pursued with vigour in accordance with current clinical guidelines, with the details of implementation adapted to the economic and cultural setting.

N150 in amygdalar ERPs in the rat: is there modulation by anticipatory fear?

The hypothesis was tested whether the amygdalar N150 of rats, a slow, negative component in the event-related potential from the lateral amygdala, is sensitive to a state of anxious anticipation. A conditioning procedure was applied in which a series of six auditory stimuli was followed by a shock when presented alone, but not when the auditory stimuli were preceded by a visual stimulus. Heart rate recordings confirmed that the auditory stimulus train induced a state of increasing anticipatory fear and that this condition was modulated by the visual stimulus. During behavioral training, a N150 appeared in the amygdalar event-related potential evoked by the auditory stimuli, replicating previous findings. However, the amplitude of the N150 was not affected by whether or not the visual stimulus had been presented before. These results failed to support the idea that the N150 is related to the expectancy of an aversive event. An alternative interpretation, emphasizing the increase in arousal and attention that is inherent to aversive learning, is discussed.

Effects of pilocarpine on the cortical and hippocampal theta rhythm in different vigilance states in rats.

It has been suggested that theta rhythm gates the flow of information between the hippocampus and cortex during memory processes. The cholinergic system plays an important role in regulating vigilance states and in generating theta rhythm. This study aims to analyse the effects of the muscarinic agonist pilocarpine (120 and 360 microg, i.c.v.) on hippocampal and frontal cortical theta rhythm during several vigilance states in rats. Pilocarpine injection increased the duration and number of episodes with theta activity, particularly when theta rhythm appeared during waking states in the cortex and hippocampus simultaneously. It seems that the effects of pilocarpine are related to the appearance of cortical theta activity in waking states, and suggest that pilocarpine could modify the transference rate of information from the hippocampus to cortex in rats during wakefulness states, in relation to the postulated effect of cholinergic system modulating memory consolidation.

Are there different mechanisms of synchronization in the course of spike-wave discharges (SWDs) burst development in WAG/Rij rats?

In WAG/Rij rats the pair linear correlation r was calculated for bipolar recordings in fronto-temporal, fronto-occipital and occipito-temporal zones of both hemispheres as well as in paleocerebellar cortex (culmen). It was shown that development of SWD bursts resulted in interhemispheric decreases of correlation between the right occipito-temporal cortical region on one side, and left fronto-temporal on the contralateral side. Towards the end of SWD, we found an increased interhemispheric correlation between left fronto-temporal and right fronto-occipital cortical zones, as well as, between both fronto-temporal zones. Paleocerebellum correlates at a weak to moderate level during different periods of SWD burst generation.

An effective correlation dimension and burst suppression ratio of the EEG in rat. Correlation with sevoflurane induced anaesthetic depth.

BACKGROUND AND OBJECTIVE: Anaesthesiologists need parameters that measure the depth of anaesthesia. In the context of this need, the present study investigated in rats how two variables from the electroencephalogram, the burst suppression ratio and effective correlation dimension correlated with a measure of anaesthetic depth as measured in the strength of a noxious withdrawal reflex. METHODS: Eight rats were exposed to different inspiratory concentrations of sevoflurane, each rat in two separate experiments. In the first experiment, spontaneously breathing animals could move freely and no painful stimuli were applied. In the second experiment, in mechanically ventilated restrained anaesthetized rats, the withdrawal reflex was measured every 80 s. In both experiments the electroencephalogram was continuously recorded. The concentration in the effector compartment was estimated using a first order two compartment model. Correlation dimension was computed following the Grassberger/Procaccia/Takens approach with optimized parameter settings to achieve maximum sensitivity to anaesthetic drug effects and enable real-time computation. The Hill, equation was fitted to the data, describing the effect as a function of sevoflurane concentration. RESULTS: Good correlations of Depth of Anaesthesia with correlation dimension as well as burst suppression ratio were established in both types of experiments. Arousal by noxious stimuli decreased burst suppression ratio and increased correlation dimension. The effective sevoflurane concentration associated with 50% of the maximum effect (C50) was higher in experiment II (stimulation) than in experiment I (no stimulation): i.e. for correlation dimension 2.18% vs. 0.60% and for burst suppression ratio 3.07% vs. 1.73%. The slope factors were: gammaCD = 4.15 vs. gammaCD = 1.73 and gammaBSR = 5.2 vs. gammaBSR = 5.4. Correlation dimension and burst suppression ratio both correlated with the strength of the withdrawal reflex with correlation coefficients of 0.46 and 0.66 respectively (P < 0.001). CONCLUSIONS: Both correlation dimension and burst suppression ratio are related to anaesthetic depth and are affected by noxious stimuli. The relationship between anaesthetic depth and burst suppression ratio is confirmed and the potential of correlation dimension is demonstrated.

Dignified dying: phenomenon and actions among nurses in India.

PURPOSE: This study contributes to the ongoing efforts of the International Classification for Nursing Practice (ICNP) to describe the phenomenon of dignified dying, to describe nursing actions used to promote dignified dying, and to evaluate the validity of a dignified dying scale among practising nurses in India. DESIGN AND SAMPLE: This descriptive study surveyed 229 nurses who had cared for dying patients and were currently practising in government and private hospitals in India. METHODS: Nurses were recruited to complete a survey in either Hindi or English. The survey included demographic, open-ended questions, and a dignified dying scale of Likert-like items. Nurses also identified nursing interventions used in practice to promote dignified dying. FINDINGS: The descriptions of dignified dying phenomenon fit within the three major areas of the Dignity-Conserving Model of Care. A variety of interventions were reported, with more focusing on spiritual than physical factors. The 14 items selected reliably measured dignified dying, with a Cronbach's alpha of 0.79. Factor analysis yielded a 4-factor solution, with 11 items accounting for 56% of the variance. CONCLUSIONS: Nurses in India endorsed spirituality as an essential aspect of the phenomenon of dignified dying. Nursing actions to promote dignified dying supported finding spiritual comfort at end of life. These results contribute to an understanding of nursing phenomena and actions worldwide.

Lessons learned from a population-based chlamydia screening pilot.

We evaluated process organization and response optimization in a home-based Chlamydia trachomatis (Ct) screening project in the Netherlands among 15- to 29-year-old women and men. The method used was computer-supported data flow, from population sampling to informing participants of the result. A new test kit or a letter reminded non-respondents after six weeks. Fifteen-year olds required parental consent. Urine arrived at the laboratory within 29 days from invitation, and four (1-11) days after collection, indicating good specimen quality. Test kits had a higher response than letters (15 versus 10%). Response in 15-year olds was 33%; with 2% Ct infected sexually active 15 year olds. In Conclusion, purpose made computer software is essential for an efficient screening programme. Sending urine by mail does not impair diagnostics. Reminders are necessary and effective after four weeks. Necessary parental consent for under 16-year olds should not be a deterrent to offer Ct screening to this age group.

Audiogenic seizures associated with a cortical spreading depression wave suppress spike-wave discharges in rats.

To study the role of the cortex and sub-cortical structures in the generation of epileptic spike-wave discharges in more detail, cortical and striatal activity was eliminated by the induction of spreading depression in a non-invasive way. EEG and DC potentials were recorded from the cortex and striatum of WAG/Rij rats. Several of these rats show two forms of generalised epilepsy: spontaneously occurring non-convulsive absence seizures, together with convulsive audiogenic seizures. The latter can be evoked by a brief sound stimulation, provoking a fit of wild running, which is regarded as the first phase of an audiogenic seizure. In a majority of fits the cortical DC potential does not show main changes, while the spontaneously occurring spike-wave discharges are briefly suppressed for some minutes. In a minority of fits, however, audiogenic seizures are associated with a spreading depression wave, clearly expressed in the cortical DC potential. This wave is bilaterally initiated in the cortex and propagates to the caudate nucleus of the striatum. In these cases spontaneously occurring spike-wave discharges are fully suppressed for about 1 h. It is suggested that cortical spreading depression, triggered by a short audiogenic seizure, induces a long-lasting suppression of spike-wave discharges. These results are in line with the concept that spike-wave discharges are originally initiated in the cortex, as proposed by the 'cortical focus' theory. The precise role of the striatum remains less clear, although this structure seems not to play a pivotal role in spike-wave generation.

Management of Chlamydia cases and their partners: results from a home-based screening program organized by municipal public health services with referral to regular health care.

BACKGROUND: We evaluated the management of Chlamydia trachomatis cases and partners found in a systematic home-based chlamydia screening project in the Netherlands among 15- to 29-year-old women and men, organized by the Municipal Public Health Services (MHS). METHODS: Infected participants (165/8339 = 2%) were referred to regular curative services. The treating physician provided feedback on treatment and partner notification. RESULTS: Including the effect of a reminder, the treatment rate of all index cases was 91% (150/165); among persons with non-Dutch ethnicity, 81% (25/31). The majority of cases (82%) consulted the general practitioner for treatment as opposed to sexually transmitted disease/MHS clinics (18%). Eighty-five percent of cases were treated within 2 weeks. The confirmed treatment rate of partners in the last 6 months was 49% (86/176); 57% (81/141) for current versus 14% (5/35) for other partners. Patient referral was advised in an additional 18% (25/141) of current partners and in 9% (3/35) of other partners (potential treatment). CONCLUSION: Home-based chlamydia screening and treatment through regular treatment facilities has proven to be effective in the Netherlands. The necessity of a reminder to increase treatment rate and the lower treatment rate in non-Dutch high-risk groups deserve attention. Low confirmed treatment rate of current partners carries the potential of reinfection, and patient-delivered treatment should be expanded.

Acceptability and consequences of screening for chlamydia trachomatis by home-based urine testing.

OBJECTIVE: The objective of this study was to study the acceptability and consequences of home-based chlamydia (CT) screening by Municipal Health Services (MHS) among 15- to 29-year-old participants. STUDY: This study consisted of a cross-section of 156 CT-positives and 600 random sampled CT-negatives after receiving the result of their CT test. RESULTS: Thirty-eight percent of the men and 59% of the women responded. The screening method was well-accepted. Seventy percent (52) of the CT-positives were surprised about their result. Infected women more often than men reported a feeling of being dirty and of anxiety about infertility. Curiosity for the CT result was decisive for participation in 68% and perception of personal risk was poor. The willingness to be tested regularly was determined by present chlamydial infection, young age, multiple lifetime partners, short relationship, and earlier test for chlamydia. CONCLUSIONS: Chlamydia screening organised by MHS is acceptable for future screening. Participants with an elevated risk are interested in screening as long as test kits are easily available. Counseling with focus on effects of CT, especially on women, is essential. Alternative approaches are needed to motivate men and non-Dutch high-risk groups.

Prevalence of urogenital Chlamydia trachomatis increases significantly with level of urbanisation and suggests targeted screening approaches: results from the first national population based study in the Netherlands.

OBJECTIVES: Chlamydia trachomatis (Chlamydia) is the most prevalent sexually transmitted bacterial infection and can cause considerable reproductive morbidity in women. Chlamydia screening programmes have been considered but policy recommendations are hampered by the lack of population based data. This paper describes the prevalence of Chlamydia in 15-29 year old women and men in rural and urban areas, as determined through systematic population based screening organised by the Municipal Public Health Services (MHS), and discusses the implications of this screening strategy for routine implementation. METHODS: Stratified national probability survey according to "area address density" (AAD). 21 000 randomly selected women and men in four regions, aged 15-29 years received a home sampling kit. Urine samples were returned by mail and tested by polymerase chain reaction (PCR). Treatment was via the general practitioner, STI clinic, or MHS clinic. RESULTS: 41% (8383) responded by sending in urine and questionnaire. 11% (2227) returned a refusal card. Non-responders included both higher and lower risk categories. Chlamydia prevalence was significantly lower in rural areas (0.6%, 95% CI 0.1 to 1.1) compared with very highly urbanised areas (3.2%, 95% CI 2.4 to 4.0). Overall prevalence was 2.0% (95% CI 1.7 to 2.3): 2.5% (95% CI 2.0 to 3.0%) in women and 1.5% (95% CI 1.1 to 1.8) in men. Of all cases 91% were treated. Infection was associated with degree of urbanisation, ethnicity, number of sex partners, and symptoms. CONCLUSION: This large, population based study found very low prevalence in rural populations, suggesting that nationwide systematic screening is not indicated in the Netherlands and that targeted approaches are a better option. Further analysis of risk profiles will contribute to determine how selective screening can be done.