Hospitalisation rates differed by city district and ethnicity during the first wave of COVID-19 in Amsterdam, The Netherlands.

BACKGROUND: It is important to gain insight into the burden of COVID-19 at city district level to develop targeted prevention strategies. We examined COVID-19 related hospitalisations by city district and migration background in the municipality of Amsterdam, the Netherlands. METHODS: We used surveillance data on all PCR-confirmed SARS-CoV-2 hospitalisations in Amsterdam until 31 May 2020, matched to municipal registration data on migration background. We calculated directly standardised (age, sex) rates (DSR) of hospitalisations, as a proxy of COVID-19 burden, per 100,000 population by city district and migration background. We calculated standardised rate differences (RD) and rate ratios (RR) to compare hospitalisations between city districts of varying socio-economic and health status and between migration backgrounds. We evaluated the effects of city district and migration background on hospitalisation after adjusting for age and sex using Poisson regression. RESULTS: Between 29 February and 31 May 2020, 2326 cases (median age 57 years [IQR = 37-74]) were notified in Amsterdam, of which 596 (25.6%) hospitalisations and 287 (12.3%) deaths. 526/596 (88.2%) hospitalisations could be matched to the registration database. DSR were higher in individuals living in peripheral (South-East/New-West/North) city districts with lower economic and health status, compared to central districts (Centre/West/South/East) (RD = 36.87,95%CI = 25.79-47.96;RR = 1.82,95%CI = 1.65-1.99), and among individuals with a non-Western migration background compared to ethnic-Dutch individuals (RD = 57.05,95%CI = 43.34-70.75; RR = 2.36,95%CI = 2.17-2.54). City district and migration background were independently associated with hospitalisation. CONCLUSION: City districts with lower economic and health status and those with a non-Western migration background had the highest burden of COVID-19 during the first wave of COVID-19 in Amsterdam.

Lessons learned from the Amsterdam Cohort Studies among people who use drugs: a historical perspective.

The Netherlands is well known for its early adoption of harm reduction (HR) programs at the height of its heroin crisis in the 1970s/1980s, including the implementation of the first needle and syringe program worldwide. In this manuscript, we describe how the Amsterdam Cohort Studies (ACS) among people who use drugs (PWUD) was conceived within the context of the Dutch HR approach, including the challenges scientists faced while establishing this cohort. This required striking a balance between public health and individual benefit, solving research dilemmas in the face of uncertainty, developing controversial innovative and cutting-edge interventions, which changed the prevention landscape for PWUD, and using longitudinal cohort data to provide unique insights. Studies from the ACS covering follow-up between 1985 and 2016 revealed that participation in both opioid agonist therapy and needle and syringe programs led to a major decrease in the risk of HIV and hepatitis B and C infection acquisition. ACS data have shown that the observed decrease in incidence also likely included shifts in drug markets and drug culture over time, selective mortality among those with the highest levels of risk behaviour, demographic changes of the PWUD population, and progression of the HIV and HCV epidemics. Moreover, HR programs in the Netherlands provided services beyond care for drug use, such as social support and welfare services, likely contributing to its success in curbing the HIV and viral hepatitis epidemics, increasing access and retention to HIV and HCV care and ultimately decreases in overdose mortality over time. Given the low coverage of HR programs in certain regions, it is unsurprising that continued HIV and HCV outbreaks occur and that transmission is ongoing in many countries worldwide. If we aim to reach the World Health Organization viral hepatitis and HIV elimination targets in 2030, as well as to improve the life of PWUD beyond infection risk, comprehensive HR programs need to be integrated as a part of prevention services, as in the Netherlands. We should use the evidence generated by longstanding cohorts, including the ACS, as a basis for which implementation and improved coverage of integrated HR services can be achieved for PWUD worldwide.

Psychometric properties of the Dutch version of the self-sufficiency matrix (SSM-D).

Measuring treatment outcomes can be challenging in patients who experience multiple interlinked problems, as is the case in public mental health care (PMHC). This study describes the development and psychometric properties of a Dutch version of the self-sufficiency matrix (SSM-D), an instrument that measures outcomes and originates from the US. In two different settings, clients were rated using the SSM-D in combination with the Health of the Nation Outcome Scales (HoNOS) and the Camberwell assessment of need short appraisal schedule (CANSAS). The results provided support for adequate psychometric properties of the SSM-D. The SSM-D had a solid single factor structure and internal consistency of the scale was excellent. In addition, convergent validity of the SSM-D was indicated by strong correlations between HoNOS and CANSAS, as well as between several subdomains. Further research is needed to establish whether the results presented here can be obtained in other PMHC settings.

The use of the Dutch Self-Sufficiency Matrix (SSM-D) to inform allocation decisions to public mental health care for homeless people.

The current study set out to develop a decision support tool based on the Self-Sufficiency Matrix (Dutch version; SSM-D) for the clinical decision to allocate homeless people to the public mental health care system at the central access point of public mental health care in Amsterdam, The Netherlands. Logistic regression and receiver operating characteristic-curve analyses were used to model professional decisions and establish four decision categories based on SSM-D scores from half of the research population (Total n = 612). The model and decision categories were found to be accurate and reliable in predicting professional decisions in the second half of the population. Results indicate that the decision support tool based on the SSM-D is useful and feasible. The method to develop the SSM-D as a decision support tool could be applied to decision-making processes in other systems and services where the SSM-D has been implemented, to further increase the utility of the instrument.

Composing a core set of performance indicators for public mental health care: a modified Delphi procedure.

Public mental health care (PMHC) systems are responsible for the wellbeing of vulnerable groups that cope with complex psychosocial problems. This article describes the development of a set of performance indicators that are feasible, meaningful, and useful to assess the quality of the PMHC system in Amsterdam, the Netherlands. Performance indicators were selected from an international inventory and presented to stakeholders of the PMHC system in a modified Delphi procedure. Characteristics of indicators were judged individually, before consensus on a core set was reached during a plenary discussion. Involving stakeholders at early stages of development increases support for quality assessment.

COVID-19 burden differed by city districts and ethnicities during the pre-vaccination era in Amsterdam, the Netherlands.

Background: During the first wave of COVID-19 in Amsterdam, the Netherlands, a disproportional number of COVID-19 hospitalizations occurred in individuals with an ethnic minority background and in individuals living in city districts with a lower socioeconomic status (SES). In this study, we assessed whether these disparities continued throughout the second wave, when SARS-CoV-2 testing was available to anyone with symptoms but prior to the availability of COVID-19 vaccination. Methods: Surveillance data on all notified SARS-CoV-2 cases in Amsterdam between 15 June 2020 and 20 January 2021 were matched to municipal registration data to obtain the migration background of cases. Crude and directly age- and sex-standardized rates (DSR) of confirmed cases, hospitalizations, and deaths per 100,000 population were calculated overall, and by city districts, and migration backgrounds. Rate differences (RD) and rate ratios (RR) were calculated to compare DSR between city districts and migration backgrounds. We used multivariable Poisson regression to assess the association of city districts, migration backgrounds, age, and sex with rates of hospitalization. Results: A total of 53,584 SARS-CoV-2 cases (median age 35 years [IQR = 25-74]) were notified, of whom 1,113 (2.1%) were hospitalized and 297 (0.6%) deceased. DSR of notified infections, hospitalization, and deaths per 100,000 population were higher in lower SES peripheral city districts (South-East/North/New-West) than higher SES central districts (Central/West/South/East), with almost a 2-fold higher hospitalization DSR in peripheral compared to central districts (RR = 1.86, 95%CI = 1.74-1.97). Individuals with a non-European migration background also had a higher COVID-19 burden, particularly with respect to hospitalization rates, with a 4.5-fold higher DSR for individuals with a non-European background compared to ethnic-Dutch (RR 4.51, 95%CI = 4.37-4.65). City districts, migration backgrounds, male gender, and older age were independently associated with COVID-19 hospitalization rates. Discussion: Individuals with a non-European background and individuals living in city districts with lower SES continued to independently have the highest COVID-19 burden in the second wave of COVID-19 in Amsterdam, the Netherlands.

Low prevalence of current and past SARS-CoV-2 infections among visitors and staff members of homelessness services in Amsterdam at the end of the second wave of infections in the Netherlands.

BACKGROUND: People experiencing homelessness (PEH) may be at increased risk of SARS-CoV-2 infection and severe COVID-19. The Dutch government established emergency shelters and introduced preventive measures for homelessness services. There were no major SARS-CoV-2 outbreaks noticed among PEH during the first two waves of infections. This study aimed to assess the prevalence of current and past infections among PEH and staff by conducting an on-site COVID-19 screening project at homelessness services in Amsterdam, the Netherlands. METHODS: We assessed the proportion of visitors and staff members of four homelessness services at two locations in Amsterdam with positive SARS-CoV-2 qPCR and antibody results (IgG/IgM Rapid Test/Biozek) in May 2021. We also assessed sociodemographic, clinical and lifestyle characteristics, compliance with basic prevention measures and intention to vaccinate against COVID-19 among PEH and staff. RESULTS: A total of 138 visitors and 53 staff members filled out a questionnaire and were tested. Among PEH, the SARS-CoV-2 positivity rate was 0% (0/133;95%CI = 0-1.9) and the antibody positivity rate was 1.6% (2/131;95%CI = 0.8-7.5) among those without prior COVID-19 vaccination. Among staff, these percentages were 3% (1/32;95%CI = 0.1-16.2) and 11% (5/53;95%CI = 3.6-23.6), respectively. Most participants were often compliant with the basic preventive measures 'not shaking hands', 'wearing a face mask' and 'washing hands', but not with 'physical distancing'. High vaccination intent was more common among staff members (55%) than among visitors (42%), while high trust in the governmental COVID-19 policies was more common among visitors (41%) than among staff (30%). CONCLUSIONS: We observed a low prevalence of past and current SARS-CoV-2 infections among PEH, which may be explained by instated shelter policies, limited daily activities of PEH and compliance with prevention measures. Vaccine hesitancy and mistrust among visitors and staff could hinder vaccination uptake, suggesting that interventions towards homelessness services are needed.

Performance indicators for public mental healthcare: a systematic international inventory.

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

Health care seeking among detained undocumented migrants: a cross-sectional study.

BACKGROUND: As in many European countries, access to care is decreased for undocumented migrants in the Netherlands due to legislation. Studies on the health of undocumented migrants in Europe are scarce and focus on care-seeking migrants. Not much is known on those who do not seek care. METHODS: This cross-sectional study includes both respondents who did and did not seek care, namely undocumented migrants who have been incarcerated in a detention centre while awaiting expulsion to their country of origin. A consecutive sample of all new arrivals was studied. Data were collected through structured interviews and reviews of medical records. RESULTS: Among the 224 male migrants who arrived at the detention centre between May and July 2008, 173 persons were interviewed. 122 respondents met inclusion criteria. Only half of the undocumented migrants in this study knew how to get access to medical care in the Netherlands if in need. Forty-six percent of respondents reported to have sought medical help during their stay in the Netherlands while having no health insurance (n = 57). Care was sought most frequently for injuries and dental problems. About 25% of these care seekers reported to have been denied care by a health care provider. Asian migrants were significantly less likely to seek care when compared to other ethnic groups, independent from age, chronic health problems and length of stay in the Netherlands. CONCLUSION: The study underlines the need for a better education of undocumented patients and providers concerning the opportunities for health care in the Netherlands. Moreover, there is a need to further clarify the reasons for the denial of care to undocumented patients, as well as the barriers to health care as perceived by undocumented migrants.

Suicide by helium inhalation in the Netherlands between 2012 and 2019.

INTRODUCTION: In 2012 and 2013 a movie and a book about a 'dignified end of life' were published in the Netherlands. These items described suicide using an 'exit bag' to establish asphyxiation using helium (the helium method). 'Right-to-die-organisations' inform the elderly about this method. The purpose of this study is to investigate whether the use of suicidal asphyxiation by means of the helium method substituted other, related, methods following its publication in the Netherlands. MATERIAL AND METHODS: We analysed suicides in the Netherlands over the period from 1 July 2012 to 30 June 2019. We compared the number of deaths caused by the helium method with other, related, cases. Secondly, we related these deaths to the total number of inhabitants and suicides recorded by Statistics Netherlands. RESULTS: The study showed a stable trend in the use of the helium method in the period 2012-2019 and this was the same for the other, related methods. Individuals using the helium method were significantly younger than those using other, related, methods. At the scene of death, information about suicide and suicide notes were found more often at 'helium method' cases than with the 'other, related, methods' cases. Family was significantly more often present during a helium method suicide than during suicide by other, related, methods. DISCUSSION: The number of suicides by the helium method and other, related, cases is stable in the Netherlands over the past years. Therefore, we conclude that there is no substitution effect within this category of suicides. Whilst 'right-to-die-organisations' strive to inform the old and sick of the helium method, it is noteworthy that the individuals using the helium method are significantly younger than the individuals who choose other, related, methods.

Undiscovered solitary deaths in the four largest cities in the Netherlands.

BACKGROUND: Research has shown a higher prevalence of individuals lying dead unnoticed in their homes (domestic-setting corpses) in Amsterdam, compared to adjacent less urbanized cities and villages. OBJECTIVE: To determine if there is a difference in incidence of domestic-setting corpses in the four major cities in the Netherlands and identifying demographic patterns accounting for possible differences. METHODS: Data of domestic-setting corpses with a post mortem interval of at least 14 days were extracted from forensic registrations of the four largest cities in the Netherlands. These data were analysed using Poisson-regression and compared to numbers of Statistics Netherlands to calculate the incidence rate of domestic-setting corpses. Only single households were included. RESULTS: The incidence of DSC14 is not significantly different between Amsterdam, The Hague and Rotterdam. The incidence rate of DSC in these cities is almost twice as high compared to Utrecht (corrected for age and sex 1,9; 95% CI:1,1-3,0). CONCLUSION: The incidence rate of DSC14 is comparable in the three largest cities of the Netherlands, and significantly higher compared to the smallest of the four (Utrecht). Possibly the lower number in Utrecht is related to less loneliness, a higher social participation and a difference in architecture.

Transitions in drug use in a new generation of problem drug users in Amsterdam: a 6-year follow-up study.

AIMS: This study describes the transitions in drug use in Amsterdam among young drug users (YDUs) who are inhaling or injecting cocaine or using illicitly obtained opiates. METHODS: From 2000 until 2003, 187 YDUs (< or = 30 years) were recruited of whom 126 were followed into 2007. RESULTS: During the 6 months prior to inclusion, 95% used cocaine, 60% used illicit opiates, and 9% injected more than once a week. During follow-up, the incidence of new-onset heroin use was 4.8/100 person-years. The incidence of injecting was much lower for never-injectors (2.1/100 person-years) than for ever-injectors who relapsed (13.2/100 person-years). Transition to abstinence or nonfrequent drug use is common (23/100 person-years), mostly followed by a relapse (73/100 person-years). Polydrug users were less likely to discontinue their frequent drug use than monodrug users. CONCLUSIONS: Treatment services should target the crack cocaine users to prevent further marginalization and, during abstinence, to prevent relapse. Although the prevalence and incidence of injecting are relatively low, it is still an option for opiate users, especially those with a history of injecting.

Domestic-setting corpses, an urban problem?

This study describes the domestic-setting corpses that remain unnoticed for two weeks or more. It compares the occurrence of this phenomenon in the city of Amsterdam with the surrounding municipalities of Amsterdam (SMA). Data of 437 cases were extracted from the forensic medical register of Amsterdam. Data of size and household situation of the population were extracted from Statistics Netherlands. A 3.7 (95%CI 2.8-4.9) times higher incidence rate, was observed in the city of Amsterdam (n = 379; 5.3/100,000 personyears) compared to the SMA (n = 58; 1.4/100,000 personyears). All but three cases lived alone. After limiting both cases and reference data to single households, the crude rate ratio was 2.1 (95%CI 1.6-2.7). Further adjustment for age and gender resulted in a Standardized Mortality Ratio of 0.36 (95%CI 0.28-0.47). This means the occurrence of domestic-setting corpses (14 + days) among people living alone is 2.7 times higher in the city of Amsterdam (95%CI 2.1-3.5). We conclude domestic-setting corpses are more likely to occur in an urban environment. This is partly explained by the higher proportion of single households in the city compared to the more rural areas. However, differences in social cohesion and architecture between urban and rural areas are expected to be important too.

Can pulmonary foam arise after postmortem submersion in water? An animal experimental pilot study.

It is difficult to differentiate drowning from postmortem submersion. Pulmonary foam can be found in bodies retrieved from water. It is unknown whether foam is a result of drowning or if it also forms after postmortem submersion. We divided deceased piglets into three groups: postmortem saltwater submersion (N = 20), postmortem freshwater submersion (N = 20) and dry-land controls (N = 20). All carcasses underwent endoscopic examination within 24 h of death and the presence of external and internal pulmonary foam was scored. No external foam was detected in the postmortem freshwater or the postmortem saltwater group. Internal foam was seen in 35% of the postmortem freshwater and 40% of the postmortem saltwater group. No external or internal foam was detected in the dry land control group. The literature shows external as well as internal foam in drowned humans. Internal foam is seen in postmortem submersion in the current piglet study and antemortem submersion in the literature in humans, and can therefore not be used to support/refute the diagnosis of drowning. No external foam was present in the postmortem submersed piglets, yet has been described in drowned humans. Hence the presence of external foam in bodies recovered from water may be indicative for drowning. The presence of external foam is a potentially valuable clinical sign in distinguishing drowning from postmortem submersion.

Decline in HIV incidence and injecting, but not in sexual risk behaviour, seen in drug users in Amsterdam: a 19-year prospective cohort study.

OBJECTIVE: To study temporal changes in HIV incidence, HIV transmission routes, and both injecting and sexual risk behaviour in the open Amsterdam Cohort Study (ACS) among drug users. Initiated in 1985, the ACS enables us to study changes in trends since HAART became widespread in 1996. METHODS: Person-time techniques were used to study the trend in HIV incidence among HIV-negative drug users. HIV transmission routes were determined using detailed standardised questionnaires. Trends in injecting and sexual risk behaviours were evaluated with a logistic regression model adjusted for correlations between visits of the same individual. RESULTS: The 1315 HIV-negative individuals, of whom 93 seroconverted for HIV, yielded 6970 HIV-negative person-years of follow-up. The HIV incidence was seven per 100 person-years in 1986 and varied between 0 and 0.5 per 100 person-years after 1999. The odds ratio was 15.6 (95% confidence interval, 2.6-94.6) for HIV transmission through unprotected heterosexual contact versus injecting after 1996 compared with the period before. Reports of both injecting and borrowing needles significantly declined over the period 1985-2004. Reports of sexual risk behaviour and sexually transmitted infections at follow-up visits decreased before 1996, but not after 1996. CONCLUSION: The HIV incidence among drug users in the ACS has declined since 1985. Accompanied by a reduction in injecting drug use and needle sharing, this decline occurred despite continued sexual risk behaviour. At present, new HIV seroconversions are related mainly to unprotected heterosexual contacts. Therefore, HIV prevention programmes for drug users should pay specific attention to the importance of safe sex practices.

Suicide by asphyxiation with or without helium inhalation in the region of Amsterdam (2005-2014).

INTRODUCTION: Annually about 28% of the 5800 death of unnatural cause in the Netherlands are a result of suicide. In 2012 and 2013 a movie and a book were published about a "dignified end of life" which also described the suicide using the exit bag to establish asphyxia using helium. The purpose of this study is to investigate if the suicide methods changed since the publicity in 2013 about suicidal asphyxiation by using helium gas. This study especially focuses on suicide using the 'exit bag' with or without helium gas. MATERIAL AND METHODS: In the period 2005 to 2014 all suicides in the region of Amsterdam-Amstelland and Zaanstreek-Waterland were analyzed and from these suicides cases using the exit bag were selected. RESULTS: The study shows a rising trend with the use of the helium (P > 0.01) and a decreasing trend for suicide by asphyxia using an exit bag (P < 0.05). The data does not show a sudden difference, but there seems to be a gradually change. DISCUSSION: The number of suicides using the helium method is rising in Amsterdam-Amstelland and Zaanstreek-Waterland, while suicides by asphyxiation without helium are decreasing. The specific publicity of books about suicides using helium may have influenced this transition.

The impact of extended closing times of alcohol outlets on alcohol-related injuries in the nightlife areas of Amsterdam: a controlled before-and-after evaluation.

BACKGROUND AND AIMS: The municipality of Amsterdam implemented a new alcohol policy allowing alcohol outlets in two of the five nightlife areas to extend their closing times from 1 April 2009 onwards. We investigated how levels and trends of alcohol-related injuries changed after implementation of this alcohol policy, by comparing areas with extended closing times to those without. DESIGN: A controlled before-and-after evaluation to compare changes in alcohol-related injuries between intervention and control areas. SETTING: Central district of Amsterdam, The Netherlands. PARTICIPANTS: Alcohol-related ambulance attendances for control and intervention areas between 1 April 2006 and 1 April 2009 (respectively, n = 544 and n = 499) and between 1 April 2009 and 1 April 2011 (respectively, n = 357 and n = 480). MEASUREMENTS: Alcohol-related injuries were defined as ambulance attendances for people who suffered from direct or indirect consequences of alcohol consumption. Injuries were counted per month in two intervention and three control nightlife areas. We used Poisson regression to assess changes in injuries. FINDINGS: After 1 April 2009, intervention areas showed a larger change in the level of alcohol-related injuries than control areas [incidence rate ratio 1.34, 95% confidence interval (CI) = 1.12, 1.61], but trends remained stable in all areas. This increase was only statistically significant for the following subgroups: 2.00-5.59 a.m., weekend days, men, individuals aged 25-34 years, and people transported to a hospital. However, the increase did not differ between subgroups with statistical significance. CONCLUSIONS: A 1-hour extension of alcohol outlet closing times in some of Amsterdam's nightlife areas was associated with 34% more alcohol-related injuries.

An increase in overdose mortality during the first 2 weeks after entering or re-entering methadone treatment in Amsterdam.

AIMS: It has been suggested that starting and temporarily discontinuing methadone treatment is related to an increased risk in overdose mortality. This study describes the incidence of overdose mortality in relation to time after (re)entering or leaving treatment. DESIGN: A dynamic cohort of 5200 Amsterdam methadone clients was observed during treatment and (a maximum of 1 year) after treatment. FINDINGS: Between 1986 and 1998, 29,729 person-years (py) and 68 overdose deaths were recorded, leading to an overdose mortality rate of 2.3/1000 py (2.2 during and 2.4 after treatment). A modest increase was observed during the first 2 weeks after (re)entering treatment; 6.0/1000 py (rate ratio: 2.9; 95% confidence interval 1.4; 5.8). Directly after leaving treatment no increase was observed. CONCLUSIONS: Inhaling heroin, common among Amsterdam heroin users, is thought to account for low OD mortality rates both during and after treatment. Accumulation of methadone, inadequate assessment of tolerance of known clients re-entering treatment and concurrent periods of stress or extreme heroin use when entering treatment are mentioned as possible explanations of the increased risk within the first 2 weeks. An Australian study reported a much higher increase. The modest increase in Amsterdam is explained by low background risk of overdose mortality, low starting dosage and the low threshold to treatment.

Chasing the dragon, related to the impaired lung function among heroin users.

AIM: To describe the pulmonary function and prevalence of dyspnoea among methadone patients and to study the relation with exposure to heroin by inhaling. STUDY POPULATION: A sample of 100 patients from methadone maintenance treatment (84% male, average age 42 years). MEASUREMENTS: Questionnaires were used to measure life-time exposure to heroin, cocaine, cannabis, tobacco, and symptoms of dyspnoea. Spirometry was performed and residual difference of measured FEV(1) from the age, sex, height and ethnicity predicted value (delta FEV(1)) was used as a main outcome parameter. FINDINGS: The median delta FEV(1) was -0.26 l (inter quartile range -0.70; +0.12). Twenty per cent experienced dyspnoea while 'walking at a normal pace with someone of their own age'. History of cigarette smoking was reported by 98%; heroin smoking by 88%. Multiple linear regression analysis showed a statistically significant association between heroin-smoking and delta FEV(1), logistic regression analysis showed an association between heroin-smoking and prevalence of dyspnoea. CONCLUSIONS: Chronic heroin smoking seems to be related to an impaired lung function and higher prevalence of dyspnoea. However, part of the observed lung function impairment will be caused by tobacco smoking. Further research is needed to quantify the effect of heroin smoking and disentangle the effect of smoking heroin and tobacco.

Detainees in Amsterdam, a target population of the Public Mental Health System?

The Forensic Medical Service of the Public Health Service offers health care to detainees in police cells in Amsterdam. This study describes the registered mental health, addiction and social problems and compares them to the self-reported problems among a sample of detainees. Registers of the Forensic Medical Service are related to information from registers of police detention episodes. A general assessment of substance use, mental health and social problems is obtained by interviewing a sample of 264 detainees. The Forensic Medical Service was contacted in 24% of the 17,321 detention episodes. In 14% of the episodes mental or substance related disorders were observed. Within the sample 59% scored positively on indicators of substance abuse or mental health problems, 35% had additional social problems (debts, unemployment, housing). This proportion increased with age. It is concluded that substance abuse and mental health problems combined with social problems are highly prevalent among detainees, especially among the older ones. This urges for a close cooperation between Public Mental Health Care and Forensic Medical Services.