Crystal Structures of the FAK Kinase in Complex with TAE226 and Related Bis-Anilino Pyrimidine Inhibitors Reveal a Helical DFG Conformation

Focal Adhesion Kinase (FAK) is a non-receptor tyrosine kinase required for cell migration, proliferation and survival. FAK overexpression has been documented in diverse human cancers and is associated with a poor clinical outcome. Recently, a novel bis-anilino pyrimidine inhibitor, TAE226, was reported to efficiently inhibit FAK signaling, arrest tumor growth and invasion and prolong the life of mice with glioma or ovarian tumor implants. Here we describe the crystal structures of the FAK kinase bound to TAE226 and three related bis-anilino pyrimidine compounds. TAE226 induces a conformation of the N-terminal portion of the kinase activation loop that is only observed in FAK, but is distinct from the conformation in both the active and inactive states of the kinase. This conformation appears to require a glycine immediately N-terminal to the “DFG motif”, which adopts a helical conformation stabilized by interactions with TAE226. The presence of a glycine residue in this position contributes to the specificity of TAE226 and related compounds for FAK. Our work highlights the fact that kinases can access conformational space that is not necessarily utilized for their native catalytic regulation, and that such conformations can explain and be exploited for inhibitor specificity

Definitions and factors associated with subthreshold depressive conditions:a systematic review

BACKGROUND: Subthreshold depressive disorders (minor and subthrehold depression) have been defined in a wide range of forms, varying on the number of symptoms and duration required. Disability associated with these conditions has also been reported. Our aim was to review the different definitions and to determine factors associated with these conditions in order to clarify the nosological implications of these disorders. METHODS: A Medline search was conducted of the published literature between January 2001 and September 2011. Bibliographies of the retrieved papers were also analysed. RESULTS: There is a wide heterogeneity in the definition and diagnostic criteria of minor and subthreshold depression. Minor depression was defined according to DSM-IV criteria. Regarding subthreshold depression, also called subclinical depression or subsyndromal symptomatic depression, between 2 and 5 depressive symptoms were required for the diagnosis, and a minimum duration of 2 weeks. Significant impairment associated with subthreshold depressive conditions, as well as comorbidity with other mental disorders, has been described. CONCLUSIONS: Depression as a disorder is better explained as a spectrum rather than as a collection of discrete categories. Minor and subthreshold depression are common conditions and patients falling below the diagnostic threshold experience significant difficulties in functioning and a negative impact on their quality of life. Current diagnostic systems need to reexamine the thresholds for depressive disorders and distinguish them from ordinary feelings of sadness

Pharmaceutical Cost Management in an Ambulatory Setting Using a Risk Adjustment Tool

© 2014 Vivas-Consuelo et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited.Background Pharmaceutical expenditure is undergoing very high growth, and accounts for 30% of overall healthcare expenditure in Spain. In this paper we present a prediction model for primary health care pharmaceutical expenditure based on Clinical Risk Groups (CRG), a system that classifies individuals into mutually exclusive categories and assigns each person to a severity level if s/he has a chronic health condition. This model may be used to draw up budgets and control health spending. Methods Descriptive study, cross-sectional. The study used a database of 4,700,000 population, with the following information: age, gender, assigned CRG group, chronic conditions and pharmaceutical expenditure. The predictive model for pharmaceutical expenditure was developed using CRG with 9 core groups and estimated by means of ordinary least squares (OLS). The weights obtained in the regression model were used to establish a case mix system to assign a prospective budget to health districts. Results The risk adjustment tool proved to have an acceptable level of prediction (R2 0.55) to explain pharmaceutical expenditure. Significant differences were observed between the predictive budget using the model developed and real spending in some health districts. For evaluation of pharmaceutical spending of pediatricians, other models have to be established. Conclusion The model is a valid tool to implement rational measures of cost containment in pharmaceutical expenditure, though it requires specific weights to adjust and forecast budgets.This study was financed by a grant from the Fondo de Investigaciones de la Seguridad Social Instituto de Salud Carlos III, the Spanish Ministry of Health (FIS PI12/0037). The authors would like to thank members (Juan Bru and Inma Saurf) of the Pharmacoeconomics Office of the Valencian Health Department. The opinions expressed in this paper are those of the authors and do not necessary reflect those of the afore-named. Any errors are the authors' responsibility. We would also like to thank John Wright for the English editing.Vivas Consuelo, DJJ.; Usó Talamantes, R.; Guadalajara Olmeda, MN.; Trillo Mata, JL.; Sancho Mestre, C.; Buigues Pastor, L. (2014). Pharmaceutical Cost Management in an Ambulatory Setting Using a Risk Adjustment Tool. BMC Health Services Research. 14:462-472. https://doi.org/10.1186/1472-6963-14-462S46247214Hux JE, Naylor CD: Drug prices and third party payment: do they influence medication selection?. Pharmacoecon. 1994, 5 (4): 343-350. 10.2165/00019053-199405040-00008.Sicras-Mainar A, Serrat-Tarres J, Navarro-Artieda R, Llopart-Lopez J: [Prospects of adjusted clinical groups (ACG’s) in capitated payment risk adjustment]. Rev Esp Salud Publica. 2006, 80 (1): 55-65. 10.1590/S1135-57272006000100006.Mossey JM, Roos LL: Using insurance claims to measure health-status - the illness scale. J Chronic Dis. 1987, 40: S41-S50.Newhouse JP, Manning WG, Keeler EB, Sloss EM: Adjusting capitation rates using objective health measures and prior utilization. Health Care Financ Rev. 1989, 10 (3): 41-54.Ash A, Porell F, Gruenberg L, Sawitz E, Beiser A: Adjusting Medicare capitation payments using prior hospitalization data. Health Care Financ Rev. 1989, 10 (4): 17-29.Ellis RP, Pope GC, Iezzoni L, Ayanian JZ, Bates DW, Burstin H, Ash AS: Diagnosis-based risk adjustment for Medicare capitation payments. Health Care Financ Rev. 1996, 17 (3): 101-128.Pope GC, Kautter J, Ellis RP, Ash AS, Ayanian JZ, Lezzoni LI, Ingber MJ, Levy JM, Robst J: Risk adjustment of Medicare capitation payments using the CMS-HCC model. Health Care Financ Rev. 2004, 25 (4): 119-141.Starfield B, Weiner J, Mumford L, Steinwachs D: Ambulatory care groups: a categorization of diagnoses for research and management. Health Serv Res. 1991, 26 (1): 53-74.Weiner JP, Starfield BH, Steinwachs DM, Mumford LM: Development and application of a population-oriented measure of ambulatory care case-mix. Med Care. 1991, 29 (5): 452-472. 10.1097/00005650-199105000-00006.Hughes JS, Averill RF, Eisenhandler J, Goldfield NI, Muldoon J, Neff JM, Gay JC: Clinical Risk Groups (CRGs): a classification system for risk-adjusted capitation-based payment and health care management. Med Care. 2004, 42 (1): 81-90. 10.1097/01.mlr.0000102367.93252.70.Berlinguet M, Preyra C, Dean S: Comparing the Value of Three Main Diagnostic-Based Risk-Adjustment Systems (DBRAS). 2005, Ottawa, Ontario: Edited by Foundation CHSRVon Korff M, Wagner EH, Saunders K: A chronic disease score from automated pharmacy data. J Clin Epidemiol. 1992, 45 (2): 197-203. 10.1016/0895-4356(92)90016-G.Malone DC, Billups SJ, Valuck RJ, Carter BL: Development of a chronic disease indicator score using a Veterans Affairs Medical Center medication database. IMPROVE Investigators. J Clin Epidemiol. 1999, 52 (6): 551-557. 10.1016/S0895-4356(99)00029-3.Clark DO, Von Korff M, Saunders K, Baluch WM, Simon GE: A chronic disease score with empirically derived weights. Med Care. 1995, 33 (8): 783-795. 10.1097/00005650-199508000-00004.Lamers LM: Pharmacy costs groups: a risk-adjuster for capitation payments based on the use of prescribed drugs. Med Care. 1999, 37 (8): 824-830. 10.1097/00005650-199908000-00012.Lamers LM: Health-based risk adjustment: is inpatient and outpatient diagnostic information sufficient?. Inquiry. 2001, 38 (4): 423-431.Lamers LM, van Vliet RC: The Pharmacy-based Cost Group model: validating and adjusting the classification of medications for chronic conditions to the Dutch situation. Health Policy. 2004, 68 (1): 113-121. 10.1016/j.healthpol.2003.09.001.Lamers LM, Vliet RC: Health-based risk adjustment Improving the pharmacy-based cost group model to reduce gaming possibilities. Eur J Health Econ. 2003, 4 (2): 107-114. 10.1007/s10198-002-0159-9.Johnson RE, Hornbrook MC, Nichols GA: Replicating the chronic disease score (CDS) from automated pharmacy data. J Clin Epidemiol. 1994, 47 (10): 1191-1199. 10.1016/0895-4356(94)90106-6.Zhao Y, Ellis RP, Ash AS, Calabrese D, Ayanian JZ, Slaughter JP, Weyuker L, Bowen B: Measuring population health risks using inpatient diagnoses and outpatient pharmacy data. Health Serv Res. 2001, 36 (6 Pt 2): 180-193.Stam PJ, van Vliet RC, van de Ven WP: Diagnostic, pharmacy-based, and self-reported health measures in risk equalization models. Med Care. 2010, 48 (5): 448-457. 10.1097/MLR.0b013e3181d559b4.Hanley GE, Morgan S, Reid RJ: Explaining prescription drug use and expenditures using the adjusted clinical groups case-mix system in the population of British Columbia, Canada. Can Med Care. 2010, 48 (5): 402-408. 10.1097/MLR.0b013e3181ca3d5d.Aguado A, Guino E, Mukherjee B, Sicras A, Serrat J, Acedo M, Ferro JJ, Moreno V: Variability in prescription drug expenditures explained by adjusted clinical groups (ACG) case-mix: a cross-sectional study of patient electronic records in primary care. BMC Health Serv Res. 2008, 8 (4): 11.Garcia-Goni M, Ibern P: Predictability of drug expenditures: An application using morbidity data. Health Econ. 2008, 17 (1): 119-126. 10.1002/hec.1238.Garcia-Goni M, Ibern P, Inoriza JM: Hybrid risk adjustment for pharmaceutical benefits. Eur J Health Econ. 2009, 10 (3): 299-308. 10.1007/s10198-008-0133-2.Vivas-Consuelo D, Uso-Talamantes R, Trillo-Mata JL, Caballer-Tarazona M, Barrachina-Martinez I, Buigues-Pastor L: Predictability of pharmaceutical spending in primary health services using Clinical Risk Groups. Health Policy. 2014, 116 (2–3): 188-195.Robst J, Levy JM, Ingber MJ: Diagnosis-based risk adjustment for medicare prescription drug plan payments. Health Care Financ Rev. 2007, 28 (4): 15-30.Zhao Y, Ash AS, Ellis RP, Ayanian JZ, Pope GC, Bowen B, Weyuker L: Predicting pharmacy costs and other medical costs using diagnoses and drug claims. Med Care. 2005, 43 (1): 34-43.Buchner F, Goepffarth D, Wasem J: The new risk adjustment formula in Germany: implementation and first experiences. Health Policy. 2013, 109 (3): 253-262. 10.1016/j.healthpol.2012.12.001.Inoriza JM, Coderch J, Carreras M, Vall-Llosera L, Garcia-Goni M, Lisbona JM, Ibern P: [Measurement of morbidity attended in an integrated health care organization]. Gac Sanit. 2009, 23 (1): 29-37. 10.1016/j.gaceta.2008.02.003.Orueta JF, Mateos Del Pino M, Barrio Beraza I, Nuno Solinis R, Cuadrado Zubizarreta M, Sola Sarabia C: [Stratification of the population in the Basque Country: results in the first year of implementation.]. Aten Primaria. 2012, 45 (1): 54-60.Sicras-Mainar A, Navarro-Artieda R: [Validating the Adjusted Clinical Groups [ACG] case-mix system in a Spanish population setting: a multicenter study]. Gac Sanit. 2009, 23 (3): 228-231. 10.1016/j.gaceta.2008.04.005.Omar RZ, O’Sullivan C, Petersen I, Islam A, Majeed A: A model based on age, sex, and morbidity to explain variation in UK general practice prescribing: cohort study. BMJ. 2008, 337: a238-10.1136/bmj.a238.Caballer-Tarazona M, Buigues-Pastor L, Saurí- Ferrer I, Uso-Talamantes R, Trillo-Mata JL: [A standardized amount indicator by equivalent patient to control outpatient pharmaceutical expenditure, Spain]. Rev Esp Salud Publica. 2011, 86: 371-380.De la Poza-Plaza E, Barrachina I, Trillo-Mata J, Uso-Talamantes R: Sistema de Prescripción y dispensación electrónica en la Agencia Valenciana de Salud. El Prof de la Inf. 2011, 20: 9.Vivas D, Guadalajara N, Barrachina I, Trillo JL, Uso R, De-la-Poza E: Explaining primary healthcare pharmacy expenditure using classification of medications for chronic conditions. Health Policy. 2011, 103 (1): 9-15. 10.1016/j.healthpol.2011.08.014.Buntin MB, Zaslavsky AM: Too much ado about two-part models and transformation? Comparing methods of modeling Medicare expenditures. J Health Econ. 2004, 23 (3): 525-542. 10.1016/j.jhealeco.2003.10.005.Duan N: Smearing estimate - a nonparametric retransformation method. J Am Stat Assoc. 1983, 78 (383): 605-610. 10.1080/01621459.1983.10478017.Calderon-Larranaga A, Abrams C, Poblador-Plou B, Weiner JP, Prados-Torres A: Applying diagnosis and pharmacy-based risk models to predict pharmacy use in Aragon, Spain: the impact of a local calibration. BMC Health Serv Res. 2010, 10: 22-10.1186/1472-6963-10-22

Clinical Subtypes of Depression Are Associated with Specific Metabolic Parameters and Circadian Endocrine Profiles in Women: The Power Study

Major depressive disorder (MDD) has been associated with adverse medical consequences, including cardiovascular disease and osteoporosis. Patients with MDD may be classified as having melancholic, atypical, or undifferentiated features. The goal of the present study was to assess whether these clinical subtypes of depression have different endocrine and metabolic features and consequently, varying medical outcomes.Premenopausal women, ages 21 to 45 years, with MDD (N = 89) and healthy controls (N = 44) were recruited for a prospective study of bone turnover. Women with MDD were classified as having melancholic (N = 51), atypical (N = 16), or undifferentiated (N = 22) features. Outcome measures included: metabolic parameters, body composition, bone mineral density (BMD), and 24 hourly sampling of plasma adrenocorticotropin (ACTH), cortisol, and leptin.Compared with control subjects, women with undifferentiated and atypical features of MDD exhibited greater BMI, waist/hip ratio, and whole body and abdominal fat mass. Women with undifferentiated MDD characteristics also had higher lipid and fasting glucose levels in addition to a greater prevalence of low BMD at the femoral neck compared to controls. Elevated ACTH levels were demonstrated in women with atypical features of depression, whereas higher mean 24-hour leptin levels were observed in the melancholic subgroup.Pre-menopausal women with various features of MDD exhibit metabolic, endocrine, and BMD features that may be associated with different health consequences.ClinicalTrials.gov NCT00006180

TLR9-Dependent and Independent Pathways Drive Activation of the Immune System by Propionibacterium Acnes

Propionibacterium acnes is usually a relatively harmless commensal. However, under certain, poorly understood conditions it is implicated in the etiology of specific inflammatory diseases. In mice, P. acnes exhibits strong immunomodulatory activity leading to splenomegaly, intrahepatic granuloma formation, hypersensitivity to TLR ligands and endogenous cytokines, and enhanced resistance to infection. All these activities reach a maximum one week after P. acnes priming and require IFN-γ and TLR9. We report here the existence of a markedly delayed (1–2 weeks), but phenotypically similar TLR9-independent immunomodulatory response to P. acnes. This alternative immunomodulation is also IFN-γ dependent and requires functional MyD88. From our experiments, a role for MyD88 in the IFN-γ-mediated P. acnes effects seems unlikely and the participation of the known MyD88-dependent receptors, including TLR5, Unc93B-dependent TLRs, IL-1R and IL-18R in the development of the alternative response has been excluded. However, the crucial role of MyD88 can partly be attributed to TLR2 and TLR4 involvement. Either of these two TLRs, activated by bacteria and/or endogenously generated ligands, can fulfill the required function. Our findings hint at an innate immune sensitizing mechanism, which is potentially operative in both infectious and sterile inflammatory disorders

Primary prevention of diabetes mellitus type 2 and cardiovascular diseases using a cognitive behavior program aimed at lifestyle changes in people at risk: Design of a randomized controlled trial

<p>Abstract</p> <p>Background</p> <p>The number of people with cardiovascular disease (CVD) and diabetes mellitus type 2 (T2DM) is growing rapidly. To a large extend, this increase is due to lifestyle-dependent risk factors, such as overweight, reduced physical activity, and an unhealthy diet. Changing these risk factors has the potential to postpone or prevent the development of T2DM and CVD. It is hypothesized that a cognitive behavioral program (CBP), focused in particular on motivation and self-management in persons who are at high risk for CVD and/or T2DM, will improve their lifestyle behavior and, as a result, will reduce their risk of developing T2DM and CVD.</p> <p>Methods</p> <p>12,000 inhabitants, 30-50 years of age living in several municipalities in the semi-rural region of West-Friesland will receive an invitation from their general practitioner (n = 13) to measure their own waist circumference with a tape measure. People with abdominal obesity (male waist ≥ 102 cm, female waist ≥ 88 cm) will be invited to participate in the second step of the screening which includes blood pressure, a blood sample and anthropometric measurements. T2DM and CVD risk scores will then be calculated according to the ARIC and the SCORE formulae, respectively. People with a score that indicates a high risk of developing T2DM and/or CVD will then be randomly assigned to the intervention group (n = 300) or the control group (n = 300).</p> <p>Participants in the intervention group will follow a CBP aimed at modifying their dietary behavior, physical activity, and smoking behavior. The counseling methods that will be used are <it>motivational interviewing </it>(MI) and <it>problem solving treatment </it>(PST), which focus in particular on intrinsic motivation for change and self-management of problems of the participants. The CBP will be provided by trained nurse practitioners in the participant's general practice, and will consists of a maximum of six individual sessions of 30 minutes, followed by 3-monthly booster sessions by phone. Participants in the control group will receive brochures containing health guidelines regarding physical activity and diet, and how to stop smoking. The primary outcome measures will be changes in T2DM and CVD risk scores. Secondary outcome measures will be changes in lifestyle behavior and cost-effectiveness and cost-utility ratios. All relevant direct and indirect costs will be measured, and there will be a follow-up of 24 months.</p> <p>Discussion</p> <p>Changing behaviors is difficult, requires time, considerable effort and motivation. Combining the two counseling methods MI and PST, followed by booster sessions may result in sustained behavioral change.</p> <p>Trial registration</p> <p>Current Controlled Trials ISRCTN59358434</p

Engineering T cells for cancer therapy

It is generally accepted that the immune system plays an important role in controlling tumour development. However, the interplay between tumour and immune system is complex, as demonstrated by the fact that tumours can successfully establish and develop despite the presence of T cells in tumour. An improved understanding of how tumours evade T-cell surveillance, coupled with technical developments allowing the culture and manipulation of T cells, has driven the exploration of therapeutic strategies based on the adoptive transfer of tumour-specific T cells. The isolation, expansion and re-infusion of large numbers of tumour-specific T cells generated from tumour biopsies has been shown to be feasible. Indeed, impressive clinical responses have been documented in melanoma patients treated with these T cells. These studies and others demonstrate the potential of T cells for the adoptive therapy of cancer. However, the significant technical issues relating to the production of natural tumour-specific T cells suggest that the application of this approach is likely to be limited at the moment. With the advent of retroviral gene transfer technology, it has become possible to efficiently endow T cells with antigen-specific receptors. Using this strategy, it is potentially possible to generate large numbers of tumour reactive T cells rapidly. This review summarises the current gene therapy approaches in relation to the development of adoptive T-cell-based cancer treatments, as these methods now head towards testing in the clinical trial setting

Acute effects of MDMA (3,4-methylenedioxymethamphetamine) on EEG oscillations: alone and in combination with ethanol or THC (delta-9-tetrahydrocannabinol)

Item does not contain fulltextRATIONALE: Typical users of 3,4-methylenedioxymethamphetamine (MDMA or "ecstasy") are polydrug users, combining MDMA with alcohol or cannabis [most active compound: delta-9-tetrahydrocannabinol (THC)]. OBJECTIVES: The aim of the present study was to investigate whether co-administration of alcohol or THC with MDMA differentially affects ongoing electroencephalogram (EEG) oscillations compared to the administration of each drug alone. METHODS: In two separate experiments, 16 volunteers received four different drug conditions: (1) MDMA (100 mg); (2) alcohol clamp (blood alcohol concentration = 0.6 per thousand) or THC (inhalation of 4, 6 and 6 mg, interval of 1.5 h); (3) MDMA in combination with alcohol or THC; and (4) placebo. Before and after drug administration, electroencephalography was recorded during an eyes closed resting state. RESULTS: Theta and alpha power increased after alcohol intake compared to placebo and reduced after MDMA intake. No interaction between alcohol and MDMA was found. Significant MDMA x THC effects for theta and lower-1-alpha power indicated that the power attenuation after the combined intake of MDMA and THC was less than the sum of each drug alone. For the lower-2-alpha band, the intake of MDMA or THC alone did not significantly affect power, but the intake of combined MDMA and THC significantly decreased lower-2-alpha power. CONCLUSIONS: The present findings indicate that the combined intake of MDMA and THC, but not of MDMA and alcohol, affects ongoing EEG oscillations differently than the sum of either one drug alone. Changes in ongoing EEG oscillations may be related to the impaired task performance that has often been reported after drug intake

Genetic Diversity among Ancient Nordic Populations

Using established criteria for work with fossil DNA we have analysed mitochondrial DNA from 92 individuals from 18 locations in Denmark ranging in time from the Mesolithic to the Medieval Age. Unequivocal assignment of mtDNA haplotypes was possible for 56 of the ancient individuals; however, the success rate varied substantially between sites; the highest rates were obtained with untouched, freshly excavated material, whereas heavy handling, archeological preservation and storage for many years influenced the ability to obtain authentic endogenic DNA. While the nucleotide diversity at two locations was similar to that among extant Danes, the diversity at four sites was considerably higher. This supports previous observations for ancient Britons. The overall occurrence of haplogroups did not deviate from extant Scandinavians, however, haplogroup I was significantly more frequent among the ancient Danes (average 13%) than among extant Danes and Scandinavians (∼2.5%) as well as among other ancient population samples reported. Haplogroup I could therefore have been an ancient Southern Scandinavian type “diluted” by later immigration events. Interestingly, the two Neolithic samples (4,200 YBP, Bell Beaker culture) that were typed were haplogroup U4 and U5a, respectively, and the single Bronze Age sample (3,300–3,500 YBP) was haplogroup U4. These two haplogroups have been associated with the Mesolithic populations of Central and Northern Europe. Therefore, at least for Southern Scandinavia, our findings do not support a possible replacement of a haplogroup U dominated hunter-gatherer population by a more haplogroup diverse Neolithic Culture

Cost-effectiveness of a vocational enablement protocol for employees with hearing impairment; design of a randomized controlled trial

Background: Hearing impairment at the workplace, and the resulting psychosocial problems are a major health problem with substantial costs for employees, companies, and society. Therefore, it is important to develop interventions to support hearing impaired employees. The objective of this article is to describe the design of a randomized controlled trial evaluating the (cost-) effectiveness of a Vocational Enablement Protocol (VEP) compared with usual care. Methods/Design. Participants will be selected with the 'Hearing and Distress Screener'. The study population will consist of 160 hearing impaired employees. The VEP intervention group will be compared with usual care. The VEP integrated care programme consists of a multidisciplinary assessment of auditory function, work demands, and personal characteristics. The goal of the intervention is to facilitate participation in work. The primary outcome measure of the study is 'need for recovery after work'. Secondary outcome measures are coping with hearing impairment, distress, self-efficacy, psychosocial workload, job control, general health status, sick leave, work productivity, and health care use. Outcome measures will be assessed by questionnaires at baseline, and 3, 6, 9, and 12 months after baseline. The economic evaluation will be performed from both a societal and a company perspective. A process evaluation will also be performed. Discussion. Interventions addressing occupational difficulties of hearing impaired employees are rare but highly needed. If the VEP integrated care programme proves to be (cost-) effective, the intervention can have an impact on the well-being of hearing impaired employees, and thereby, on the costs for the company as well for the society. Trial registration. Netherlands Trial Register (NTR): NTR2782. © 2012 Gussenhoven et al; BioMed Central Ltd