Surprisingly long body length of the lungworm Parafilaroides gymnurus from common seals of the Dutch North Sea.

Lungworms of the genera Parafilaroides and Otostrongylus are responsible for parasitic bronchopneumonia, the foremost disease of eastern Atlantic common seals (EACS, Phoca vitulina vitulina) in the Dutch North Sea. Recently, there have been increased reports of lungworm cases and observations of unusually long Parafilaroides sp. adults in this location. The initial aim of this study was to confirm the identity of the Parafilaroides species infecting this population. Parafilaroides are usually small and delicate, making them difficult to extract from host tissue, and there is often difficulty accessing fresh specimens for morphological study. The large size of the Dutch worms and the accessibility of specimens from numerous animals enabled the description and measurement of many intact specimens (N = 64) from multiple host animals (N = 20). Species identity was confirmed by targeted sequencing of ribosomal and mitochondrial DNA amplicons from a subset of worms. Worm morphology was consistent with descriptions for P. gymnurus, but the mature females were 1.9-fold and 3.4-fold longer than those recovered from French EACS (P ≤ 0.001) and Canadian western Atlantic common seals (Phoca vitulina concolor; P ≤ 0.0001). They were also significantly longer than mature female P. gymnurus described from other seal species, with the exception of those from harp seals of Les Escoumins, Quebec. We suggest that intraspecific genetic differences in P. gymnurus and the environment within the host could contribute to the variation reported here. This study is the first to describe P. gymnurus using morphological and molecular methods and should serve as a reference for identification of the species.

Development and feasibility of a web-based question prompt sheet to support information provision of health-related quality of life topics after oesophageal cancer surgery.

We developed a web-based question prompt sheet (QPS) to support information provision of health-related quality of life (HRQL) topics after oesophageal cancer surgery. The QPS was evaluated and updated in three consecutive studies. In Study 1, eight patients were guided in using the QPS. Feasibility was assessed by cognitive walkthrough, questionnaire and interview. We obtained 430 notes (217 negative, 213 positive) of patients' actions and or remarks, and 91 suggestions. With minor support, most patients were able to use the QPS. In Study 2, forty patients independently used and appraised a modified version of the QPS by questionnaire. All patients deemed the QPS to be usable and useful. In Study 3, 21 patients and three surgeons used the QPS in clinical practice. Clinical feasibility was assessed by the number of QPS sent to the researcher/surgeon. Patients and surgeons were surveyed and the follow-up consultation was audio-recorded. Surgeons were additionally interviewed. Twenty/fourteen patients sent their QPS to the researcher/surgeon. Five QPSs were read by the consultation surgeon. Patients considered the QPS usable and useful. Surgeons considered the QPS of added value and helpful in informing patients, but currently not clinically feasible due to increased consultation time.

How long do I have? Observational study on communication about life expectancy with advanced cancer patients.

OBJECTIVE: To examine how communication about life expectancy is initiated in consultations about palliative chemotherapy, and what prognostic information is presented. METHODS: Patients with advanced cancer (n=41) with a median life expectancy <1year and oncologists (n=6) and oncologists-in-training (n=7) meeting with them in consultations (n=62) to discuss palliative chemotherapy were included. Verbatim transcripts of audio-recorded consultations were analyzed using MAXqda10. RESULTS: Life expectancy was addressed in 19 of 62 of the consultations. In all cases, patients took the initiative, most often through direct questions. Estimates were provided in 12 consultations in various formats: the likelihood of experiencing a significant event, point estimates or general time scales of "months to years", often with an emphasis on the "years". The indeterminacy of estimates was consistently stressed. Also their potential inadequacy was regularly addressed, often by describing beneficial prognostic predictors for the specific patient. Oncologists did not address the reliability or precision of estimates. CONCLUSION: Oncologists did not initiate talk about life expectancy, they used different formats, emphasized the positive and stressed unpredictability, yet not ambiguity of estimates. PRACTICE IMPLICATIONS: Prognostic communication should be part of the medical curriculum. Further research should address the effect of different formats of information provision.

How can communication by oncologists enhance patients' trust? An experimental study.

BACKGROUND: Cancer patients need to trust their oncologist to embark in the process of oncologic treatment. Yet, it is unclear how oncologist communication contributes to such trust. The aim of this study was to investigate the effect of three elements of oncologists' communication on cancer patients' trust: conferring competence, honesty, and caring. METHODS: Eight videotaped consultations, 'vignettes', were created, reflecting an encounter between an oncologist and a patient with colorectal cancer. All vignettes were identical, except for small variations in the oncologist's verbal communication. Cancer patients (n = 345) were randomly assigned to viewing two vignettes, asked to identify with the patient and afterwards to rate their trust in the observed oncologist. The effects of competence, honesty, and caring on trust were established with multilevel analysis. RESULTS: Oncologist's enhanced expression of competence (ß = 0.17, 95% CI 0.08, 0.27; P < 0.001), honesty (ß = 0.30, 95% CI 0.20, 0.40; P < 0.001), as well as caring (ß = 0.36, 95% CI 0.26, 0.46; P < 0.001) resulted in significantly increased trust. Communication of honesty and caring also increased patients' expectation of operation success and reported willingness to recommend the oncologist. CONCLUSION(S): As hypothesized, oncologists can influence their patients' trust by enhanced conveyance of their level of competence, honesty, and caring. Caring behavior has the strongest impact on trust. These findings can be translated directly into daily clinical practice as well as in communication skills training.

Patterns of stranding and mortality in common seals (Phoca vitulina) and grey seals (Halichoerus grypus) in The Netherlands between 1979 and 2008.

Pathological examination of stranded marine mammals provides information on the causes of mortality in their populations. Patterns of stranding and causes of death of dead-stranded seals on the Dutch coast were analyzed over a 30-year period (1979-2008). Stranding data (n=1,286) and post-mortem data (n=379) from common seals (Phoca vitulina) and grey seals (Halichoerus grypus) found dead, or that died before admission to rehabilitation, were obtained from the Seal Rehabilitation and Research Centre database. Data for the years 1988 and 2002, when mass mortality occurred due to phocine distemper virus epidemics, were excluded. Common seal stranding increased from one to nearly 100 per year over this period. This coincides with the increase in the number of common seals in Dutch waters over recent decades. Grey seal stranding increased gradually from one to about 40 per year over the period, reflecting recolonization of Dutch waters by this species. For both species, the trend in stranding of dead seals was found to be in line with that of seals observed in Dutch waters during aerial surveys and did not provide any indications of a relative change in the stranding rate of dead seals. The total monthly stranding rates peaked at more than 120 in June and July for common seals and at nearly 60 in January for grey seals. This coincides with the pupping periods of the two species. Besides phocine distemper, the most common causes of death in investigated common seals (n=286) were by-catch (confirmed and inferred) (19%), pup starvation (7%), intestinal volvulus (7%) and parasitic bronchopneumonia (6%). The most common causes of death in investigated grey seals (n=93) were by-catch (confirmed and inferred) (15%), pup starvation (11%) and trauma (5%). The relative occurrence of by-catch significantly decreased over time for grey seals, but not for common seals. Common seals were affected by infectious disease significantly more often than grey seals, mainly because of a higher occurrence of parasitic pneumonia. Phocine distemper caused mass mortalities among common seals, but not among grey seals. These findings in dead-stranded seals differ in part from those reported elsewhere in live-stranded seals, for which pup starvation and parasitic bronchopneumonia were the main causes of stranding. A substantial proportion of seals in Dutch waters die from causes related to human activity. Continued monitoring of stranding patterns and causes of death is warranted for early detection of changes and the possibility of taking timely management actions.

Information gain in patients using a multimedia website with tailored information on anaesthesia.

BACKGROUND: The preoperative visit is an appropriate time to educate the patient on anaesthesia. The aim of this study was to determine if a website, as an information source for anaesthesia before the visit to the preoperative assessment clinic (PAC), increases patients' knowledge on anaesthesia. METHODS: A multimedia website was developed containing specific information about anaesthesia relevant to the patient. A questionnaire was developed to measure knowledge gain. Patients were divided into three groups: (i) those who read the existing brochure; (ii) those who looked at the new website; and (iii) a cluster of non-brochure and non-website users: those who did not read the brochure or website but had completed the questionnaire. An anaesthesiologist also informed all three groups during the preoperative visit at the PAC. RESULTS: Patients visiting the website had a higher educational level than others. A significant increase in knowledge was observed after using the website information compared with the other two groups (P<0.001). The group with higher education levels had higher knowledge gains, and the website independently contributed to the knowledge gain. CONCLUSIONS: A patient-tailored multimedia website is an effective way to support the information provided by the anaesthesiologist in order to inform patients about their upcoming anaesthetic procedure. The use of such a website gives a significant increase in knowledge compared with only spoken information, or spoken information combined with a brochure.

Under what conditions do patients want to be informed about their risk of a complication? A vignette study.

BACKGROUND: Discussing treatment risks has become increasingly important in medical communication. Still, despite regulations, physicians must decide how much and what kind of information to present. OBJECTIVE: To investigate patients' preference for information about a small risk of a complication of colonoscopy, and whether medical and personal factors contribute to such preference. To propose a disclosure policy related to our results. DESIGN: Vignettes study. SETTING: Department of Gastroenterology, Academic Medical Centre, the Netherlands. PATIENTS: 810 consecutive colonoscopy patients. INTERVENTION: A home-sent questionnaire containing three vignettes. Vignettes varied in the indication for colonoscopy, complication severity and level of risk. Patients were invited to indicate their wish to be informed and the importance of such information. In addition, sociodemograhic, illness-related and psychological characteristics were assessed. MAIN OUTCOME MEASUREMENTS: Wish to be informed and importance of information. RESULTS: Of 810 questionnaires, 68% were returned. Patients generally wished to be informed about low-risk complications, regardless of the indication for colonoscopy or the severity of the complication. The level of risk did matter, though (OR = 2.48, SE = 0.28, p = 0.001). The information was considered less important if done for population screening purposes or diagnosis of colon cancer, if the complication was less severe (bleeding) and if the risk was smaller (0.01% and 0.1%). Patients' information preference was also related to age, mood and coping style. LIMITATIONS: Difficulty of vignettes. CONCLUSIONS: Patients generally wish to be informed about all possible risks. However, this might become uninformative. A stepwise approach is suggested.

Legal constraints in EU product labelling to mitigate the environmental risk of veterinary medicines at use.

This paper summarises what possibilities and obligations are created by the EU Directive 2001/82/EC on the registration of veterinary medicines to mitigate the environmental impact of the use of a veterinary medicinal product. More specifically, an identified environmental risk may be mitigated to an acceptable level by special precautions in the information that accompanies the product in labelling and packaging. These precautions can address the fate of contaminated slurry and treated animals, but are only acceptable under the EU Directive if their effect can be demonstrated using the risk assessment methodology. Next, all possible keepers of the animals or the manure, including third parties, should be addressed, either in the precaution, or in the national regulation that should enforce the precautions. A number of examples illustrate that some precautions used are not quantifiable in the risk methodology, and that others are legally inadequate. To render risk mitigation measures effective, hence suitable for labelling and packaging, it is imperative that the risk assessment methodology is further developed and applied adequately, and that the legality of precautions is established in national regulation, harmonised between Member States.

Predictors of patients' choices for breast-conserving therapy or mastectomy: a prospective study.

A study was undertaken to describe the treatment preferences and choices of patients with breast cancer, and to identify predictors of undergoing breast-conserving therapy (BCT) or mastectomy (MT). Consecutive patients with stage I/II breast cancer were eligible. Information about predictor variables, including socio-demographics, quality of life, patients' concerns, decision style, decisional conflict and perceived preference of the surgeon was collected at baseline, before decision making and surgery. Patients received standard information (n=88) or a decision aid (n=92) as a supplement to support decision making. A total of 180 patients participated in the study. In all, 72% decided to have BCT (n=123); 28% chose MT (n=49). Multivariate analysis showed that what patients perceived to be their surgeons' preference and the patients' concerns regarding breast loss and local tumour recurrence were the strongest predictors of treatment preference. Treatment preferences in itself were highly predictive of the treatment decision. The decision aid did not influence treatment choice. The results of this study demonstrate that patients' concerns and their perceptions of the treatment preferences of the physicians are important factors in patients' decision making. Adequate information and communication are essential to base treatment decisions on realistic concerns, and the treatment preferences of patients.

Quality of life in goserelin-treated versus cyclophosphamide + methotrexate + fluorouracil-treated premenopausal and perimenopausal patients with node-positive, early breast cancer: the Zoladex Early Breast Cancer Research Association Trialists Group.

PURPOSE: To compare quality of life (QoL) in premenopausal and perimenopausal patients with node-positive, early breast cancer treated with the endocrine agent goserelin (Zoladex; AstraZeneca Pharmaceuticals LP, Wilmington, DE) or cyclophosphamide + methotrexate + fluorouracil (CMF). PATIENTS AND METHODS: Patients from 86 centers worldwide were randomly assigned to receive either goserelin (3.6 mg every 28 days for 2 years; n = 514) or CMF (six 28-day cycles; n = 496), and were included in the QoL study. QoL was assessed using a self-administered patient questionnaire that consisted of 39 items from the Rotterdam Symptom Checklist, including dimensions evaluating physical and psychological symptom distress, activities of daily living, hormonal effects, and an assessment of overall QoL. RESULTS: Early benefits were noted during months 3 to 6 of treatment, for goserelin compared with CMF. Significant differences were found for changes in overall QoL (eg, 6.96 +/- 0.88 v 0.69 +/- 0.92 at 6 months; P <.0001) and for physical symptom distress, activity levels, and "effort to cope with illness" dimensions. At 1, 2, and 3 years, there were no significant differences in overall QoL or specific QoL dimensions. Scores for hormonal symptoms were worse with goserelin during the 2-year goserelin treatment period; however, this trend was reversed at 3 years. CONCLUSION: Goserelin offers improved overall QoL during the first 6 months of therapy compared with CMF chemotherapy in premenopausal and perimenopausal patients with early breast cancer. Coupled with equivalent efficacy in estrogen receptor-positive patients, these data support the use of goserelin as an alternative to CMF in premenopausal and perimenopausal patients with estrogen receptor-positive, node-positive early breast cancer.

Environmental labelling in The Netherlands: a framework for integrated farming.

This article compares four Dutch environmental certification schemes for agricultural food crops, analysing their methodology and the completeness of their criteria on five aspects: pesticide use, nutrient use, water management, energy and materials consumption, and habitat management. The least stringent of the labels, the MBT ('Environmentally Aware Cultivation') certificate, serves mainly to increase farmers' awareness of nutrient and pesticide use. With regard to both administrative obligations and actual management practices, the MBT label largely mirrors the terms of standing Dutch legislation. The CC ('Controlled Cultivation') and AMK ('Agro-Environmental') labels comprise more and more stringent criteria. With their restrictions on nutrient and pesticide use, these two labels serve as the two principal labels in the field of integrated agriculture. There is little difference between the two and it is recommended that they be merged, on the basis of a standardised definition of integrated agriculture. The EKO ('Organic Agriculture') label proceeds from different principles, but as a minimum should also comply with Dutch legislation without exception. For both integrated and organic agriculture, in addition to criteria on pesticide and nutrient use, criteria should also be developed for water management, energy and materials use and habitat management. The relationship between the criteria and their respective thresholds and Dutch legislation is also addressed. Existing criteria are frequently specified in such a way that the environmental benefits cannot be ascertained. This is a serious drawback for the parties further down the chain: auctioneers, retailers and consumers. It is recommended to develop qualitative guidelines for an Agricultural Stewardship Council at international level, like the Forest Stewardship Council, and a separate label for integrated agriculture per country comprising quantitative criteria for all relevant aspects of farming operations.

The decisional conflict scale: further validation in two samples of Dutch oncology patients.

The importance of patient involvement in medical decision making is indisputable. Yet, decision making concerning medical treatment options is a difficult task for most patients. In order to study decision-making processes in health care, O'Connor developed the decisional conflict scale (DCS). The DCS assesses the level of 'decisional conflict' that patients experience while making health care decisions, and encompasses the following three subscales: (1) uncertainty about choosing among alternatives; (2) factors contributing to uncertainty; (3) perceived effectiveness of the decision. The aim of the present study is to investigate the reliability and validity of the Dutch version of the DCS. A written version of the DCS was administered in two samples of Dutch cancer patients. One sample consisted of cancer patients faced with the decision whether or not to undergo palliative chemotherapy (N=29). The other sample included women with early stage breast cancer who had to choose between mastectomy or lumpectomy followed by radiation therapy (N=141). The response rates were 76% and 91%, respectively. The reliability coefficients of the three subscales were 0.52, 0.80, 0.84, and 0.74, 0.83, 0.83 in the two samples, respectively. Construct validity was partly supported. Criterion validity was substantiated. In evaluating the factorial validity, it was found that the original three-factor model had to be rejected (chi(2)(87)=293, root mean square error of approximation (RMSEA)=0.137). A subsequent exploratory factor analysis suggested an alternative four-factor model. The psychometric properties of the DCS were partly confirmed in Dutch cancer patients. Improved 'wording' of certain items, e.g. to avoid double negatives, could further increase the factorial validity of the DCS. Then, this scale may be a valuable tool for studies that address the quality of medical decision making.

Development of a field bioassay for the side-effects of herbicides on vascular plants using Brassica napus and Poa annua.

A field bioassay method has been developed for assessing side-effects of herbicides on Brassica napus and Poa annua. The test method aims at effects outside the target area, up to 20 m from the treated parcel. Experiments were conducted in the field and in a glasshouse with the herbicides atrazin, bentazone, diquat, glyphosate, and r(4-chloro-2-methylphenoxyacetic acid) MCPA. An iterative procedure was used with the aim of developing a sound test procedure. The resulting method appeared to be very sensitive. Pesticide drift was measured using water-sensitive paper. Effects were sometimes found below the detection limit of this method (at 8 m from the treated parcel with moderate wind speeds of 3-5 m/s). The sensitivity of the test and the test conditions are discussed and an optimized method is presented.

Decision support for patients with early-stage breast cancer: effects of an interactive breast cancer CDROM on treatment decision, satisfaction, and quality of life.

PURPOSE: To investigate the effects of the Interactive Breast Cancer CDROM as a decision aid for breast cancer patients with a choice between breast conserving therapy (BCT) and mastectomy (MT). PATIENTS AND METHODS: Consecutive patients with stage I and II breast cancer were enrolled. A quasi-experimental, longitudinal, and pretest/posttest design was used. Follow-up was scheduled 3 and 9 months after discharge from the hospital. Control patients (n = 88) received standard care (oral information and brochures). The CDROM was provided to patients in the experimental condition (n = 92) as a supplement to standard procedures. Outcome variables were treatment decision, satisfaction, and quality of life (QoL). RESULTS: No effect on treatment decision was found. CDROM patients expressed more general satisfaction with information at 3 and 9 months (95% confidence interval for the difference (d) between the means (d: 4.1 to 12.5 and 5.7 to 14.2 respectively). CDROM patients were also more satisfied with their treatment decision at 3 and at 9 months (d: 0.1 to 0.4; 0.2 to 0.5). Moreover, at 9 months, CDROM patients were more satisfied with breast cancer-specific information (d: 0.9 to 16.5), the decision-making process (d: 0.1 to 0.4), and communication (d: 0.2 to 11.0). At 3 and 9 months, a positive effect was found on general health (d: 0.2 to 14.5 and 0.3 to 15.0). Moreover, at 9 months, CDROM patients reported better physical functioning (d: 5.1 to 19.8), less pain (d: -17.9 to -4.5), and fewer arm symptoms (d: -14.1 to -0.5). CONCLUSION: The Interactive Breast Cancer CDROM improved decision making in patients with early-stage breast cancer with a choice between BCT and MT, as evaluated in terms of patients' satisfaction and QoL.

Ecological compensation in Dutch highway planning.

The ecological compensation principle was introduced by the Dutch government in 1993. This principle is designed to enhance the input of nature conservation interests in decision-making on large-scale development projects and to counterbalance the ecological impacts of such developments when implemented. This article evaluates the application of the Dutch compensation principle in highway planning. Six current highway projects reveal consistent implementation of this principle, although provincial policies on compensation and a national method for identifying compensation measures are still under development. As the planning process has not yet been completed for all the projects, no general conclusions can be drawn on the impact of the compensation principle on highway decision-making. Nevertheless, several examples show that the principle stimulates project initiators to develop alternative routes or route sections in order to avoid or reduce ecological impacts and the need for coherent compensation measures. If the compensation principle is to be properly implemented in the context of highway planning, particular attention should be paid to the following aspects: (1) sequential assessment of overall project legitimacy and the necessity of intersecting protected areas and compensation measures. (2) the initiator's attempts to avoid and mitigate ecological impacts in developing alternative routes prior to compensation for impacts, and (3) the role of uncertain ecological impacts in identifying compensation measures, especially those concerning habitat isolation.

Which chronic conditions are associated with better or poorer quality of life?

The objective of the present study is to compare the QL of a wide range of chronic disease patients. Secondary analysis of eight existing data sets, including over 15,000 patients, was performed. The studies were conducted between 1993 and 1996 and included population-based samples, referred samples, consecutive samples, and/or consecutive samples. The SF-36 or SF-24 were employed as generic QL instruments. Patients who were older, female, had a low level of education, were not living with a partner, and had at least one comorbid condition, in general, reported the poorest level of QL. On the basis of rank ordering across the QL dimensions, three broad categories could be distinguished. Urogenital conditions, hearing impairments, psychiatric disorders, and dermatologic conditions were found to result in relatively favorable functioning. A group of disease clusters assuming an intermediate position encompassed cardiovascular conditions, cancer, endocrinologic conditions, visual impairments, and chronic respiratory diseases. Gastrointestinal conditions, cerebrovascular/neurologic conditions, renal diseases, and musculoskeletal conditions led to the most adverse sequelae. This categorization reflects the combined result of the diseases and comorbid conditions. If these results are replicated and validated in future studies, they can be considered in addition to information on the prevalence of the diseases, potential benefits of care, and current disease-specific expenditures. This combined information will help to better plan and allocate resources for research, training, and health care.

How response shift may affect the measurement of change in fatigue.

If patients experience extreme fatigue during treatment, they may judge the level of fatigue following this experience differently from how they would have judged it before. This change in internal standard is referred to as a response shift. We explored whether a response shift might have occurred in patients receiving radiotherapy (n = 199). Fatigue was assessed before and after radiotherapy. Following completion of the post-test, a thentest was administered where patients had to provide a renewed judgment of their pre-treatment level of fatigue. Response shift was assessed by the mean difference between the pre-test and thentest scores. Comparing the thentest with the pretest scores, patients retrospectively minimized their pre-treatment level of fatigue. The thentest-post-test difference was significant, whereas the conventional pretest-post-test difference was not. These results are in line with the occurrence of a response shift. Additional hypotheses regarding response shift were partially supported. It is concluded that the potentially large implications of response shift justify further research.

Feasibility and effects of decision aids.

Decision aids for patients have recently been introduced in health care. A literature review was conducted to address the following research questions: 1) which types of decision aids have been developed?; 2) to what extent are they feasible, and acceptable to patients and health care providers?; 3) do decision aids affect the decision-making process and patients' outcomes? Thirty non-controlled (e.g., one-group-only designs) and controlled studies (e.g., randomized experimental designs) were identified. Decision aids were found to be feasible and acceptable to patients and to increase the agreement between patients' values and decisions and patients' knowledge. The effects of decision aids on decisions and on patients' outcomes, including decision uncertainty, satisfaction, and health, have rarely been addressed. When studied, the beneficial effects of decision aids on these outcomes appear to be rather modest. Implications for future development of decision aids and the design of studies are discussed.

The effect of a single fraction compared to multiple fractions on painful bone metastases: a global analysis of the Dutch Bone Metastasis Study.

PURPOSE: To answer the question whether a single fraction of radiotherapy that is considered more convenient to the patient is as effective as a dose of multiple fractions for palliation of painful bone metastases. PATIENTS: 1171 patients were randomised to receive either 8 Gy x 1 (n = 585) or 4 Gy x 6 (n = 586). The primary tumour was in the breast in 39% of the patients, in the prostate in 23%, in the lung in 25% and in other locations in 13%. Bone metastases were located in the spine (30%), pelvis (36%), femur (10%), ribs (8%), humerus (6%) and other sites (10%). METHOD: Questionnaires were mailed to collect information on pain, analgesics consumption, quality of life and side effects during treatment. The main endpoint was pain measured on a pain scale from 0 (no pain at all) to 10 (worst imaginable pain). Costs per treatment schedule were estimated. RESULTS: On average, patients participated in the study for 4 months. Median survival was 7 months. Response was defined as a decrease of at least two points as compared to the initial pain score. The difference in response between the two treatment groups proved not significant and stayed well within the margin of 10%. Overall, 71% experienced a response at some time during the first year. An analysis of repeated measures confirmed that the two treatment schedules were equivalent in terms of palliation. With regard to pain medication, quality of life and side effects no differences between the two treatment groups were found. The total number of retreatments was 188 (16%). This number was 147 (25%) in the 8 Gy x 1 irradiation group and 41 (7%) in the 4 Gy x 6 group. It was shown that the level of pain was an important reason to retreat. There were also indications that doctors were more willing to retreat patients in the single fraction group because time to retreatment was substantially shorter in this group and the preceding pain score was lower. Unexpectedly, more pathological fractures were observed in the single fraction group, but the absolute percentage was low. In a cost-analysis, the costs of the 4 Gy x 6 and the 8 Gy x 1 treatment schedules were calculated at 2305 and 1734 Euro respectively. Including the costs of retreatment reduced this 25% cost difference to only 8%. The saving of radiotherapy capacity, however, was considered the major economic advantage of the single dose schedule. CONCLUSION: The global analysis of the Dutch study indicates the equality of a single fraction as compared to a 6 fraction treatment in patients with painful bone metastases provided that 4 times more retreatments are accepted in the single dose group. This equality is also shown in long term survivors. A more detailed analysis of the study is in progress.