Annual Report Julius Center for Health Sciences and Primary Care

Transcription

1 Annual Report 2005 Julius Center for Health Sciences and Primary Care

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3 Annual Report 2005 Julius Center for Health Sciences and Primary Care

4 Colophon The Julius Center for Health Sciences and Primary Care is one of the twelve divisions of the University Medical Center Utrecht (UMC Utrecht). It carries out scientific research, provides education, and offers expertise and facilities in the clinical health sciences field. The Center aims for a leading and acquisitive position in the enlargement and dissemination of knowledge, especially in the field of health sciences. This is done by means of groundbreaking research into four disease-related themes and into research methodology, and by the provision of courses for (bio)medical students, researchers and clinicians. Disciplines represented in the Center are general practice, (clinical) epidemiology, nursing science, medical technology assessment, public health, and nutritional sciences. In this annual report the reader will find information on activities, output and finances in Contact information: M. Kluijtmans, PhD, Education and Research Strategy & Coordinator Master Programme Epidemiology Julius Center for Health Sciences and Primary Care University Medical Center Utrecht Visitors: Universiteitsweg 100, 3584 CG Utrecht, The Netherlands Correspondence: Str.6.131, P.O. Box 85500, 3508 GA Utrecht, The Netherlands URL: juliuscenter@azu.nl; M.Kluijtmans@umcutrecht.nl 2 Julius Center for Health Sciences and Primary Care

5 Contents Introduction 5 Organization 9 Brief history 9 Organizational structure Research 10 Research organization 10 Research themes 13 Research services, vascular imaging center, data management 22 IRAS 24 International collaboration 25 Education 29 Overview 29 Medical school 31 BSc Biomedical sciences 32 MSc Biomedical sciences, masterprogramme Epidemiology 34 MA Applied ethics 36 MSc Nursing science 37 General practice vocational training 40 Graduate schools (UGS Life Sciences, Nihes, ImageO, Eijkman and P&H 42 Advanced training in public health 45 Advanced training in general practice 46 Advanced training in clinical epidemiology 48 Annual Report

6 Patient care 49 Nutritional sciences and dietetics 49 Julius Center health care Leidsche Rijn 52 Business and operations 54 Personnel and finances 56 Personnel, figures 56 Personnel, listing 57 Financial report 65 Research projects Cardiovascular diseases 68 Infectious diseases 72 Cancer 74 Mental health 76 Research methodology and biostatistics 79 Miscellaneous 81 Research services 83 Vascular imaging center (VIC) 85 Data managament 86 Publications PhD theses 88 Books and book chapters 91 Professional publications 98 International publications Julius Center for Health Sciences and Primary Care

7 Introduction Since the Julius Center was established in 1996, it has built up a solid reputation in research and education. More recently the center broadened its ambition to obtain a similar reputation in patient care. The designation of epidemiology as a main research theme by the University Medical Center underlines the prominent role the center has played in applied research in Utrecht. In addition to the acquisition and conduct of its own research projects, either independently as an institute or in collaboration with other research groups, the Center plays an active role in providing methodologic advice and in the facilitation of clinical research across virtually all departments of the University Medical Center. In 2005 the center has further expanded its activities in the coordination and conduct of multinational and multicenter clinical trials supported by the ISO certified department of Research Services. Internationally, an alliance is being formed with like-minded and well-reputed academic institutes in Australia and the USA. The advantage of the three institutes operating together is their joint ability to offer complementary expertise and a documented management and recruitment capacity for trials which virtually spans the globe. Trials by the alliance can be conducted efficiently, using harmonized protocols and standard operating procedures in different countries and five continents. The Academic Alliance for Clinical Trials offers a valuable academic partnership to large international pharmaceutical companies and its ambition is to become a major player in the field in the coming years. On a more local scale, but of similar importance for the quality and extent of the trial activities of the Center, the board of the UMC Annual Report

8 Utrecht has agreed on a dedicated rol for the the Research Services department of the Julius Center in all clinical trials in which departments of the hospital engage. The Center s contribution in facilitating and promoting the quality of trials in the hospital is herewith formalized and the number of trials supported and monitored by the Research Services department is expected to increase significantly. As in previous years, the academic staff succeeded in maintaining scientific output on a high level both in terms of quality and quantity, even in times of reduced overall funding of research and increased competition. Major efforts have been made in maintaining competitive research funding on a high level. This definitely refers to the quality and perseverance of those staff members who managed to secure significant external funding again. As in 2004, the quality of published research output was not only reflected in citation scores, but also in the awarding of prestigious NWO research grants to members of the faculty of the Center: E. Hak received a Veni award and M. Geerlings a Vidi award. In the course of 2005 the recently acquired responsibility for health care centers in Leidsche Rijn, an expanding new residential area of Utrecht, required much attention by the management because of organizational and financial backlogs and threats. With combined efforts and firm support by the UMC Utrecht, as well as by other health care partners in the region, economic and managerial perspectives have much improved and these centers are now starting to show the much desired synergetic effects eventually culminating in a true and nationally unique academic workplace for excellence in care, research and education. For the staff of General Practice this now enables to combine medical practice with scientific work as part of the 6 Julius Center for Health Sciences and Primary Care

9 same academic appointments. The Julius Health Care Centers permanently house several trainees of the vocational training programme. In addition, several projects regarding innovation in health care have been initiated, such as the collaboration with other primary and secondary health care providers in care-chains for specific groups of patients. After intensive discussions, the board of the University Medical Center decided to follow the advice of an ad-hoc committee that was asked to analyze the current scientific situation and future perspectives of the department of Nursing Science. The advice proposes to concentrate on a more limited number of research topics with a greater emphasis on internationally competitive results. In 2005 Prof Mieke Grypdonck retired after having spent many years on promoting nursing science and help to establish its present position in Utrecht. The University Medical Center Utrecht had to set up a search committee for a new chair and allocated resources to strengthen the position of the group. The Center s educational activities in 2005 were marked by major developments. The GP vocational training started a renewed curriculum which focusses strongly on application of skills in practice, in addition to competence and theoretical knowledge. The master progam Nursing Science went through a major revision in which the previous four year part-time study program was transformed into a one year pre-master track and a two year part-time master phase. The research master program in epidemiology, a collaboration of four epidemiological research groups at Utrecht University, was extended with a postgraduate, condensed curriculum. Moreover, only one year after its start, this master program was awarded the exclusive Prestige Master label of Utrecht University. Major added benefits for the Julius Annual Report

10 Center of participating in the program are the resulting more intensive collaborations with other research groups at Utrecht University (UU), a better visibility within UU and, most of all, the creation of a pool of international and well-educated students from which new talents can be drawn for future PhD fellowships. The management and business organization of the Julius Center was restructured to be able to support the rapidly expanded division. The changing tasks and challenging environment led to a turbulent year, with rewards but inescapably also some difficulties and conflicts. After a period of intensive rebuilding, particularly in terms of personal relations and communication, the results of this process of renewal and contemplation is now becoming visible, both in terms of enhanced transparency and improved control in the Centers business affairs. All in all, 2005 was again a productive and successful year in which the Center, like a large tree, has shown a modest increase in size, and developed a ninth year ring. It has further extended its roots and strengthened its position in the University Medical Center Utrecht. Moreover, it has solidified its base by giving necessary attention to its management and business organization and investing in consolidation. The center has grown several new branches and leaves of research, care and educational activities. All of this is due to only one factor, its great people. None of this would have been possible without the commitment, hard work, inspiration and devotion of many. A word of thanks to all involved and contributing to the continued success of the Julius Center is highly appropriate and deeply meant. Prof. Diederick E. Grobbee, MD, PhD Chair 8 Julius Center for Health Sciences and Primary Care

11 Organization Brief history The Julius Center for patient-oriented research was established on 16 December 1996, building upon the previous department of epidemiology and public health, and the hospital unit of clinical epidemiology. Both scope and size have since then markedly increased, as is reflected by the Julius Centers subheadings, not in the least because other departments have been integrated in the current center. In 1999 the department of General Practice merged with the department of patient-oriented research to become the Julius Center for Patient-Oriented Research and General Practice. In 2002 the department of Nursing Science and the Nutritional Sciences group joined the Center to become the Julius Center for Health Sciences and Primary Care. In 2006 the Center will celebrate its tenth anniversary. Annual Report

12 Research Research organization The University Medical Center Utrecht has formulated seven main research themes.these form a matrix structure with four diseaserelated themes on the horizontal and three methodological themes on the vertical axis. The Julius Centers main contribution to the total body of research of the UMC Utrecht is through the epidemiological research theme. With rare exceptions all research of the Center can be classified as epidemiological. From this as a starting point, the Julius Center contributes to all four disease-related areas of research: heart and vascular diseases, infections and immunity, cancer, and mental health. Moreover, there is also a collaboration with the other two methodogical research themes, image sciences and genomics Within the Julius Center itself, research is similarly organized in a matrix structure. The vertical axis is formed by the scientific disciplines of the Center: clinical epidemiology, general practice, MTA/public health/medical ethics, nursing science, and nutritional sciences (research within all of these disciplines can be largely categorized as epidemiological which was the incentive for all these disciplines to be combined into one Center). The horizontal axis comprises the four UMC defined disease-based fields of interest; heart and vascular disease, infectious diseases, cancer, and mental health. Within these fields, there is a further focus on subfields, such as research on (etiology and complications of) diabetes mellitus. As from 2005 a fifth, methodological, research line has been formulated. Of course research into theoretical epidemiology and biostatistics is not truly new in the Center: the appointment of Prof. Carl Moons on a personal chair, in combination with his NWO VIDI research grant, and two 10 Julius Center for Health Sciences and Primary Care

13 methodologically orientated NWO VENI grants awarded to staff members Maroeska Rovers and Eelko Hak, have marked a significant increase in the volume of methodological research and justify the delineation of a dedicated research line within this field. The Center s policy is to concentrate its own research as much as possible on the matrix s intersections so that the disciplines within the Center maximally strengthen the scientific themes of the UMC Utrecht as a whole and cross-fertilize each other where possible. THEMES DISCIPLINES Cardiovascular Diseases Infection and Immunity Cancer Mental Health Methodology (Miscellaneous) General Practice (GP) Clinical Epidemiology (CE) Nursing Science (NS) Nutritional Sciences (Dietetics, DT) Public Health /MTA/Ethics (PH/MTA) The Julius Center is formally linked with the interfacultary Institute for Risk Assessment Sciences (IRAS), environmental and occupational epidemiology at UU by the joined appointment of Prof Bert Brunekreef and honorary appointment of Prof Dick Heederick. There is also a collaboration with other epidemiological research groups at Utrecht University, in particular with Pharmaco the Epidemiology and Veterinary Epidemiology groups. In addition to its own research, staff members act as consultants for research methods on a range of clinical investigations within and outside the UMC Utrecht. This is an important and growing activity Annual Report

14 for the Julius Center. With several clinical departments the intense interaction with epidemiology has resulted in joint appointments of staff, including with the departments of anaesthesiology, neurology, cardiology, cardio-thoracic surgery, internal medicine, psychiatry, radiology and pediatrics. 12 Julius Center for Health Sciences and Primary Care

15 Research themes Cardiovascular diseases A considerable part of the research carried out at the Julius Center focuses on the causes, diagnosis, prognosis and therapy of cardiovascular diseases. The approaches include the full range of epidemiological research methods, including multi-centered randomized controlled trials to study the effects of preventive and therapeutic interventions. One example is research on the influence of natural of synthetic sex hormones on the condition of the heart and blood vessels in postmenopausal women and elderly men. ADVANCE is an example of one of the larger international multi-centered cardiovascular trials the Julius Center is involved in. The Center coordinates a large number of other multi-center international cardiovascular prevention and treatment trials (also see: Research services and Vascular imaging center ). Increasingly, research includes genetic information and the interplay between genes and environment as, for example, in studies on genetic and non-genetic factors that determine the prognosis of patients with vascular diseases. The studies are conducted in close collaboration with partners within and outside the UMC Utrecht and abroad. A unique cohort study of patients at high risk of cardiovascular disease (CVD) was started in Utrecht in 1996, the Second Manifestations of ARTerial disease (SMART) Study. All patients referred to the UMC Utrecht who either have a high risk of CVD (hypertension, hyperlipidemia, diabetes) or clinically manifest vascular disease (ischaemic cerebral disease, asymptomatic stenosis of the internal carotid artery, myocardial infarction, angina pectoris, abdominal aortic aneurysm, intermittent claudication) are eligible for inclusion in the study. Patients undergo an extensive screening program to detect Annual Report

16 asymptomatic atherosclerotic lesions and to identify risk factors. Then, a multidisciplinary team formulates a treatment plan, consistent with evidence-based medicine, to reduce the patient s risk of future cardiovascular events and this treatment advice is sent to the patient s general practitioner and to the treating hospital specialist. In addition, patients are carefully monitored to identify future occurrences of cardiovascular disease. Currently, more than 6,000 patients have been enrolled in the study, and the scientific output includes more than 30 papers in peer-reviewed journals. Furthermore, the Center is involved in the setting up and scientific evaluation of both diagnostic and therapeutic heart failure outpatient departments in the broader Utrecht region. The purpose of this is to gain a better understanding of the nature and causes of heart failure and to improve early detection and adequate treatment and follow-up of this syndrome, which constitutes an increasing burden in our ageing society. Various cardiovascular studies are also being carried out on diabetes mellitus patients and on the metabolic syndrome. The Research Group on Diabetology conducts several trials in large` networks of general practices, notably in the adherence region of the Stichting Huisartsen Laboratorium Etten Leur and the Apeldoorn Region. In collaboration with Cambridge University (UK) and Aarhus University (Denmark) the ADDITION-trial has been set up, a five years follow-up RCT to study the effects on cardiovascular morbidity and mortality of intensive multi-factorial treatment in 3,000 screen detected diabetes patients. Other studies include the early roots of cardiovascular disease in the young, the etiology and prognostic role of coronary collateral formation, and the risk-benefit ratio of anticoagulation in patients at a high risk of stroke. In addition, the Julius Center is increasingly involved in the execution of large scale diagnostic studies, aimed at improving the early detection 14 Julius Center for Health Sciences and Primary Care

17 of cardiovascular diseases, both in the population at large and patients presenting to primary care of hospital. These include studies on the added value of, e.g., various diagnostic imaging techniques and early (bed-side) biomarkers in recognizing atherosclerotic disease (such as stroke, coronary artery disease, heart failure, peripheral arterial disease) as well as deep venous thrombosis. Infectious diseases Infectious diseases research at the Julius Center is primarily centered on the prevention, diagnosis and prognosis of respiratory tract infections. For example, research is being carried out to establish whether or not certain patient characteristics are predictive with regard to an abnormal and serious clinical progression of bronchial infections, and the consequences for treatment and patient advice. In addition, antibiotic use and indications for prescribing in general practice are being studied. In this area, research has also been expanding into the development of asthma and allergy, in relation to exposure to infectious agents and other environmental determinants, both in young children and in occupationally exposed subjects. Infections in patients with diabetes mellitus are also being studied in the Research group on Diabetology. Currently the project Development and evaluation of an educational program on the prevention of complicated infections in patients with diabetes is carried out. It focuses on respiratory and urinary tract infections. New research topics include the treatment of urinary tract infections and the relationship between onychomycosis and the diabetic foot. New research topics include the dynamics of influenza, both within and outside health care settings, with a special emphasis on the opportunities to prevent spreading through vaccination and preemptive therapy. Furthermore, the cost-effectiveness of infection Annual Report

18 control strategies in hospitals (such as search & destroy for MRSA) will be studied. Cancer Cancer research at the Julius Center focuses on the etiology, early diagnosis and prognosis of hormone dependant cancer, predominantly in women. With approximately 30,000 new cases a year amongst Dutch women, cancer is a serious health threat. However, the known causes can explain barely 30% of the cases encountered. An explanation for this rather low percentage may be sought in the fact that environmental and hormonal factors are predominantly studied without any consideration to genetic predisposition. Cancer etiological research within the Julius Center strongly focuses on the interaction between genes, hormones and the environment (or lifestyle habits). For the study of genetic determinants or gene-environmental interactions, the Julius Center has access to biological material originating from two large-scale on-going population-based cohorts, Prospect-EPIC and DOM. For studies of the optimal (early) diagnostic and (clinical) follow-up procedures in cancer patients, collaboration has been established with clinicians from other departments of the University Medical Center in Utrecht. Examples are the COBRA and MONET studies, both assessing optimal diagnostic procedures in women with non-palpable breast cancer. Studies to assess quality of life and evaluate nurse practitioners in the daily care of cancer patients also fall in the domain of the oncology research at the Julius Center. Mental health The section psychiatric epidemiology of the Julius Center studies psychiatric disease and related co-morbidity in primary care and the 16 Julius Center for Health Sciences and Primary Care

19 general population. Mental illness represents a sizeable proportion of the global burden of disease in the general population, but is only partly presented to health care professionals. Major psychiatric disease represents 5% of the prevalent morbidity in primary care, with an annual prevalence of 125 per 1000 patients. A substantial part of minor psychiatric morbidity is presented in relation to somatic disease or functional syndromes or expressed through excessive consultation frequency of unexplained functional syndromes. Mental illness is - though closely linked to somatic ill-health - traditionally studied in isolation. The section psychiatric epidemiology focuses on the study of somatic - psychiatric comorbidity, with the following themes: 1. The presentation of depression in primary care, and its association with somatic disease such as dementia, diabetes and vascular disease. 2. Functional disease and somatisation: presentation, determinants and treatment in primary care 3. Psychiatric morbidity in relation to socio-demographic context and consultation patterns 4. Nurse delegated interventions in mental health care The common background hypothesis is that somatic and psychiatric disorders share an overlapping etiology and that this overlap has social and psychological as well as physiological components. Our assessments typically aim to characterize individuals on several levels (psychological, physical and physiological). These themes are studied on the various levels at which disorders manifest themselves: Annual Report

20 a) the general population, by using existing and developing sampling frames such as LRGP (Leidsche Rijn Gezondheidsproject), NEMESIS (Netherlands Mental Health Survey and Incidence Study), AGIS health database and others. b) Primary health care, in primary care networks such as HNU (Huisartsen Netwerk Utrecht), PREDICT and Julius Gezondheidscentra. c) Populations of people with reported mental illness like those registered in our psychiatric case registry (RIPAG). d) Populations of people with reported somatic illness, such as samples of cardiovascular compromised patients (SMART), (pre)diabetic patients (UDES), and medication-using people (PHARMO). e) Populations of primary care emergency attenders like the Huisartsenpost Gelderse Vallei and the emergency department of the UMC Utrecht This approach of studying the phenomenon of somatic psychiatric comorbidity on various levels of the health care system is unique. It will yield information not only on the etiology of somatic-psychiatric comorbidity but also on its implications for the health care system. Most research projects are carried out in collaboration with partners within primary or secondary care health care: primary care physicians, secondary care centers for psychiatry and gastro-enterology, departments of nursing sciences, often in cooperation with other (international) academic centers. Research methodology and biostatistics Besides more applied studies on improving insights in the etiology, diagnosis, prognosis and therapy of specific disorders, the Julius Center 18 Julius Center for Health Sciences and Primary Care

21 also aims to further develop the theory and methodology of the discipline itself. The section Methodology conducts studies aiming to improve existing methods and to develop innovative methods for design and analysis of (clinical) epidemiological studies. The section focuses on the following themes: 1. Developing innovative designs for diagnostic and prognostic (prediction) research. 2. Developing innovative methods for quantifying the true value of (new) diagnostic and prognostic tests in a multivariable clinical context. 3. Developing innovative methods for the validation and updating of so-called clinical prediction rules. 4. Testing and improving sophisticated methods for dealing with missing values in epidemiologic research. 5. Investigating innovative methods for meta-analysis and individual patient data-analysis of therapeutic studies. 6. Development of models to combine data from randomised and observational studies including genetic information, for estimating (long term) prognosis according to specific patient characteristics in addition to treatment effects. Notably the improvement of methods for design and analysis of multivariable diagnostic and prognostic research is unique. Most research in this field focuses on single test evaluations rather than evaluations in a clinical context, accounting for other test results. But also the methodology for modeling data from randomised and nonrandomised studies combined, is in its infancy. This type of research is situated at the crossroad of clinical epidemiology and medical technology assessment. Annual Report

22 All above methodological themes are not only studied on a purely theoretical level, but are also illustrated by using empirical data from various medical disciplines, notably from the four disease-oriented sections of the Julius Center. For example, data are used from the above-mentioned LRGP (Leidsche Rijn Gezondheidsproject), the Predict study and the AMUSE study, and from other large ongoing studies in the UMC Utrecht. It may be obvious that the results of our methodological studies do not only serve the clinical domains studied, but may serve all medical domains in which e.g. diagnosis, prognosis and therapy are at issue. Most methodological projects are carried out in close collaboration with other clinical departments from the UMC Utrecht. However, also with other epidemiological and (bio)statistical departments from national an international academic centers, such as the Utrecht University, Academic Medical Center Amsterdam, Erasmus Medical Center Rotterdam, Dutch National Institute for Health and the Environment, VanderBilt University (USA), Harvard University (USA) and Oxford University (UK). Miscellaneous Several research projects do not directly relate to the core themes of research of the Julius Center. Some of these projects have their roots in former research environments of staff members, others originate from particular areas of expertise from staff members. For example, The Research Group on Diabetology conducts several projects that are especially relevant for diabetes care in the primary care setting, for example projects regarding the effectiveness of a behavioural intervention in screen detected diabetes patients (in collaboration with the research group Psychology and Health) or the effects of a 20 Julius Center for Health Sciences and Primary Care

23 computerised support system for diabetes care. Most of these projects are initiated from outside the Julius Center, and staff members are asked to collaborate or (co)supervise the research with an external party. The general policy is not to promote research outside the main themes. In the case of contributing expertise, the Julius center is obviously happy to consider advice and contribute, in particular when requested by other departments of the UMC Utrecht and affiliated institutions, and even when this occasionally addresses other areas. Annual Report

24 Research services, vascular imaging center, data management Studies supported by Research Services, VIC and/or data management, are carried out on the initiative of Julius Center or in collaboration with other academic centers (investigator-driven studies) or the pharmaceutical industry. This cluster of service activities is available for researchers at the Julius Center. Other researchers at the University Medical Center Utrecht can also take advantage of the expertise and facilities. Research Services, Vascular Imaging Center and Data management have been certified according to ISO 9001:2000 since January The Julius Center has a leading position in a project on the design of a Quality Assurance System for clinical drug trials performed in the UMCU. The plan has been approved by the Board of the UMCU and the Julius Center has responsibility for further implementation and execution of the Quality Assurance Activities. Research services The Julius Center has a research services unit and the infrastructure to support various scientific research projects, in particular clinical trials, in the efficient design and implementation, in which the Julius Center has considerable experience. The services include project management, monitoring (14 projects in 2005) and an outpatient research center (14 projects in 2005). The outpatient research center is equipped with the necessary facilities for carrying out clinical trials in accordance with ICH Good Clinical Practice guidelines. Monitoring activities are performed for both national and international studies (up to 15 European countries). 22 Julius Center for Health Sciences and Primary Care

25 Vascular imaging center The Vascular Imaging Center (VIC) is a core laboratory facility that supports all steps required in a vascular project, comprising development of protocols, advice on equipment, performing actual measurements, training and certification of technicians, continuous quality assurance and quality control programs during the study, quantitative QC/QA, reading of stored images, data management, statistical analyses and scientific reporting. Extensive expertise is available for (dynamic) measurements of the carotid artery and retinal vessels. In 2005 there were 8 ongoing projects in the VIC. Data management Data management provides a technical infrastructure for the collection, processing and analysis of epidemiological data. The department provides these services for the research conducted by the Julius Center, but also for other divisions of the UMC Utrecht as well as external parties. This year Data management participated in about 75 studies, 31 of which are carried out in cooperation with Research Services and the Vascular Imaging Center. The activities include data management for eight cohorts (pertaining to mental health care, oncology and general practice). In studies were started. In 2005 the department started the development of a web-based research system (Research Online Platform) in collaboration with Mediportaal. In 2006 the system will be used for GRACE, the first pan European primary care research network focussing on the challenge of treating respiratory tract infections in an era of emerging antibiotic resistance. GRACE is financed by the European Union. Annual Report

26 IRAS IRAS, the Institute for Risk Assessment Sciences (IRAS), is an interfaculty research institute within the faculties of Veterinary Medicine, Medicine and Biology of Utrecht University. The institute has a dual, complementary mission: it performs interdisciplinary research concentrating on aspects of risk assessment of the effects of chemical, physical and biological agents on man and the environment and also provides education and training in the disciplines of toxicology, environmental and occupational health and the epidemiology of graduate and postgraduate (Ph.D.) students. The research is performed in three divisions; Environmental and Occupational Health, Toxicology, Public Health and Food Safety. Research within the Environmental and Occupational Health and (Veterinary) Public Health and Food Safety Divisions is determinantoriented epidemiological research, which in most cases is conducted in close collaboration with groups from UMC Utrecht (Julius Center, Heart and Lung Institute, Wilhelmina Children s Hospital). The IRAS input to collaborative projects involves exposure assessment methodology and advanced exposure response modeling. Specific areas of research are cancer and exposure to ultrafine particulate matter and polycyclic aromatic compounds, asthma and allergen exposure, and modification by exposure to Microbial Associated Molecular Patterns (MAMPs). There is a particular interest in exposure to infectious agents and in veterinary public health issues including zoonoses and exposure to microbial agents through the food chain. 24 Julius Center for Health Sciences and Primary Care

27 International collaboration By nature of its scientific and educational activities the playing field of the Julius Centers is the world. Research is conducted in collaboration with research institutes and universities in many different countries. In addition to the inspiring and productive contacts between staff members and fellows, the Center aims to establish more extensive long-term structural partnerships with strategically selected high quality institutions. These contacts will play an important role in the ambition of the Julius Center to stay at the forefront of the international academic world. With the specific aim to expand its activities in major outcome trials, an international alliance was created in collaboration with the George Institute for International Health in Sydney, Australia, and the Berman Center for Outcomes and Clinical Research, University of Minnesota, Minneapolis, US. The Academic Alliance for Clinical Trials (www. academicalliance.com) is an academic contract research organization with a focus on interaction between pharmaceutical industry and academic investigators to promote high-quality innovative phase III and phase IV clinical trials. The Alliance builds upon an existing network of clinics and health care centers in five continents. Apart for designing and conducting research, the Alliance invests in improving the methodology an efficiency of research with ample attention to studies in the developing world. In international education there is a growing collaboration between the Julius Center and the Malaysian Ministry of Health, and the University of Malaya Medical Center (UMMC), Kuala Lumpur, Malaysia. Until now the collaboration was predominantly based on short intensive teaching courses on clinical epidemiology and evidence-based Annual Report

28 medicine, delivered by Julius faculty in collaboration with local staff in Kuala Lumpur. In 2006 we obtained a grant (commissie Internationalisering UMC Utrecht) to extend this collaboration to cover three domains: a) Collaborativeresearchin particular clinical trials and cohort studies, b) Development and creation of a regional research infrastructure, c) Expansion of educational programmes also focusing on the South Asian region. With regard to clinical trials South East Asia, and Malaysia in particular, offers an excellent competitive environment for innovative pharmaceutical companies and large scale studies, as well as a growing burden of chronic diseases that require attention. The interest of our partners in Malaysia fits in well with the research interests of the Julius Center and combining forces creates unique opportunities. The Ministry of Health, Medical technology assessment has very good connections with all major hospitals in the country. In 2006 the partners will jointly create a research infrastructure in Kuala Lumpur reflecting the philosophy of the Julius Center to establish a Julius Center-KL. In order to foster high quality of research, a robust research-support section is needed in which project managers, research nurses, data managers, computer experts, trial monitors, and administrative personnel, have their basis. In cooperation with local staff the Julius Center will continue and broaden the program of short courses on the methods of clinical research. These courses are targeted to medical doctors and clinical investigators in the South East Asian region. Eventually, these courses will be largely taken over by local staff. An important purpose of these courses is also the scouting and selection of bright young medical doctors for PhD fellowships. These PhD fellowships will be supervised by the Julius staff and imbedded in the 26 Julius Center for Health Sciences and Primary Care

29 research lines of both the UMCU and the UMMC. During the fellowship candidates will follow part of their education in the Netherlands, notably in the prestige master program. Depending on the subject, research will be carried out at the Julius Center or in their home country. In addition to clinical trials, the Julius Center also participates in the largest on-going observational study on nutrition and health in Europe, the EPIC Study. The European Prospective Investigation into Cancer and Nutrition started with the collection of extensive dietary questionnaires, anthropometric measurements and blood samples in 10 European countries between 1992 and The Julius Center sampled over 17,000 women. In addition to cancer, (healthy) longevity (EPIC-Elderly), cardiovascular diseases (EPIC-heart), and diabetes have been included as major endpoints. There is a strong cooperation with 23 research centers of oncology institutes, universities and public health institutes over Europe. In addition to the above-mentioned examples of recent more extensive initiatives, international collaboration exists with the following institutions: Berman Center for Outcomes and Clinical Research, University of Minnesota, Minneapolis, US Department of Clinical Epidemiology, University of Pretoria, South Africa. Clinical Trial Services Unit and Department of General Practice, University of Oxford, Oxford, UK Departements of Epidemiology and Nutrition, Harvard School of Public Health, Boston, USA. Department of Cancer Epidemiology, Imperial College, London, UK Annual Report

30 Department of Epidemiology, Karolinska Institute, Stockholm, Sweden. Department of Epidemiology, UCSF, San Francisco, USA. Department of Food Science and Nutrition, University of Minnesota, USA. Department of Health Evaluation Sciences, University of Virginia Medical School, Charlottesville, Virginia, USA. Department of Neurology, University of Western Ontario, Ontario, Canada. Department of Public Health, Wake Forest University, Winston Salem, USA. Depts. of Nutrition and Cancer, Hormones and Nutrition, International Agency for Research on Cancer, IARC, Lyon, France. Framingham Heart Study, NHLBI, Boston University Medical Center, Boston, USA. George Institute for International Health, Sydney, Australia. Medical Research Council London, UK Medical Research Council, Dunn, Cambridge, United Kingdom. University of Indonesia, Jakarta, Indonesia University of Malaya Medical Center (UMMC), Kuala Lumpur, Malaysia University of Tokai, Isehara, Japan Wallenberg Laboratory, Sahlgrenska Hospital, Gothenburg, Sweden. 28 Julius Center for Health Sciences and Primary Care

31 Education Overview Participation in numerous educational programs covering various aspects of health sciences or primary care is a core-business of the Julius Center, whose main activities are research and education. Combined research and educational tasks guarantee teaching on a high up-to-date level in all disciplines. The Center is, among other things, responsible for the specialist training of medical doctors as general practitioners in a three-year vocational training program. Furthermore the Center is home to the only Dutch graduate program for nursing science. The Center also actively participates in new educational developments such as the UMC Utrecht s ambitious undergraduate medicine program (CRU 99), which started in 1999 and is based on interdisciplinary problem-oriented learning, and SUMMA, a new 4- year medical grade program that started in The majority of educational programs are provided in co-operation with other divisions within or outside the University Medical Center Utrecht. Notably, a new training program for masters in epidemiology was started in 2004 in close collaboration with other faculties of Utrecht University. Education for the benefit of researchers at the Julius Center takes place by means of participation in recognized graduate schools such as the Netherlands Institute for Health Sciences (NIHES) (www. nihes.nl), Infection & Immunity ( Psychology and Health ( and ImagO ( Annual Report

32 Clinical Epidemiology Public Health /MTA/ Med Ethics General Practice Nursing Science Nutritional Sciences Undergraduate education Medical School (see also Graduate education ) Bachelor Biomedical Sciences x x x x x x Graduate education Medical School (CRU 99 and SUMMA) MA Applied Ethics MSc Nursing Science MSc Epidemiology x x x x x x x x x x Postgraduate education General Practice Vocational Training Graduate Schools (Nihes, ImagO, I&I, P&H) x x x x Post-academic education Advanced training in Public Health Advanced training in General Practice Advanced training in Epidemiology x x x 30 Julius Center for Health Sciences and Primary Care

33 Medical school Description The medical curriculum is a continuous six-year educational program without any distinction between the undergraduate and graduate phases. In 1999 the curriculum was completely revised. The problem-based learning method has been adopted (CRU 99) in this new curriculum. The sixth year of CRU 99 began in All disciplines at the Julius Center coordinate and/or participate in courses on the medical curriculum. In addition, the SUMMA - School for Utrecht Medical Masters - curriculum started in The aim of the program is that 40 bachelor students obtain their MD degree in four years. Course information CRU 99 (course names in Dutch) number of students year in curriculum discipline 1 coordination / participation Oriëntatie geneeskunde 312 1st year GP/PH coordination/part. Stofwisseling 312 1st year DT participation Klinisch lijn onderwijs 312 1st year GP coordination Patiënten volgprogramma 312 1st year GP/NS coordination/part. Patiënten volgprogramma 312 2nd year GP/NS coordination/part. Zintuigen, Hersenen en Beweging II 312 2nd year GP participation Stofwisseling II 312 2nd year GP participation Groei en ontwikkeling 312 2nd year DT participation Acute Geneeskunde 312 3rd year GP coordination/part. Architectuur klinisch wetenschappelijk onderzoek 288 3rd year CE/GP coordination/part. Infectie en Afweer 312 3rd year GP participation Keuzeblok gezondheidsrecht 75 3rd year PH coordination Keuzeblok zorgmanagement 75 3rd year PH coordination Keuzeblok medische ethiek 50 3rd year PH coordination/part. Keuzeblok voeding: curatief of preventief 44 3rd year DT coordination Introductiecursus CIBA PatientenZorg in Nederland 16 3rd year GP/PH coordination/part Leeronderzoek medische ethiek 15 4 th year PH participation Oogheelkunde 312 4th year GP participation Annual Report

34 CRU 99 (course names in Dutch) number of students year in curriculum discipline 1 coordination / participation Determinanten van ziekte 288 4th year GP participation Geneeskunde en maatschappij 288 5th year PH/GP coordination/part. Co-schap sociale geneeskunde 288 5th year PH coordination Keuzeonderwijs systematisch literatuuroverzicht 7x 4th/5th year CE coordination Co-schap huisartsgeneeskunde 288 5th year GP coordination Onderwijs professionaliteit startblok & terugkomdagen Algemene Semi-Arts Stage (ASAS) Huisartsgeneeskunde th year PH participation 20 6 th year GP coordination Startblok th year CE/PH coordination/part Terugkomdagen th year CE/PH coordination/part Wetenschapsstage Variable 6 th year All participation SUMMA 2 number of students year in curriculum Discipline 1 coordination / participation Praktijk van de zorg 40 1st year GP Coordination Klinisch Denken st year GP Participation Klinisch Denken st year GP Participation Wetenschappelijke Vorming nd year CE Coordination Co-schap huisartsgeneeskunde 40 3rd year GP Coordination 1 Disciplines: General Practice (GP), Clinical Epidemiology (CE), Nursing Science (NS), Nutritional Sciences, (Dietetics, DT), Public Health/ MTA/Medical Ethics (PH) 2 School for Utrecht Medical Masters Output 2005 Number of students See table above. 32 Julius Center for Health Sciences and Primary Care

35 Bachelor Biomedical sciences Description In the first year of the biomedical sciences bachelor program, staff members of the interfaculty Institute of Risk Assessment Sciences (IRAS) with joint posts at the Julius Center and the Faculty of Veterinary Medicine, are responsible for the coordination of a six-week course on epidemiology (Prof. D. Heederick, PhD, L. Portengen, PhD). In addition staff members of the Julius Center participate in these lectures (Prof. D.E. Grobbee, MD, PhD). In the second year of the program, staff members participate in course P3, an inductory course to the different masters programs student may choose to enter after completion of their bachelor studies. (C. Uiterwaal, MD, PhD). In the third year, staf members organise and teach a keuzecursus (optional course) Clinical Trials (I. van der Tweel (Julius Center and UU Center for biostatistics) and P.A.H. van Noord, MD, PhD, Julius Center). Course information BMS-bachelor (course names in Dutch) number of students year in curriculum discipline* coordination / participation Epidemiologie 189 1st year CE, EE coordination Project 3, Orientatie op de master programma s 150 2nd year CE participation Keuzecursus Clinical Trials 20 3rd year CE, Biostat coordination * Discipline: Clinical Epidemiology (CE), Environmental Epidemiology (EE), Biostat (Center for biostatistics, Utrecht University Output 2005 Number of students See table above. Annual Report

36 MSc Biomedical Sciences, masterprogramme Epidemiology Description Initiated by the combined epidemiological research groups at UMC Utrecht and Utrecht University (Julius Center, IRAS, veterinary epidemiology, and pharmaco-epidemiology) a research masters program in epidemiology is organised. The programme started in September 2004 with 15 students and the number of students has doubled in In 2005 a second variant of the programme started: in addition to the 2 year regular masterprogramme, a shorter 18 months postgraduate programme was developed, which is open to MDs, VDs, PhD students and other professionals at acdemical level. Coordination of the program is by the Julius Center. In December 2005 Utrecht University awarded the Epidemiology master program with the exclusive Prestige Master label. Specialisation possibilities within the epidemiology program are: Clinical Epidemiology Epidemiology of Infectious Diseases Veterinary Epidemiology Pharmaco-epidemiology Environmental and Occupational Epidemiology 34 Julius Center for Health Sciences and Primary Care

37 Course information 2005 (only courses with participation of JC staff in faculty) BMS- research master program epidemiology weeks number of students discipline* coordination / participation Advanced Diagnostic Research, 28 Feb-4 March wk 43 CE coordination Prognostic Research, March wk 29 CE coordination Clinical Trials and Drug Risk Assessment, April wk 29 CE coordination Introduction to Epidemiology, 5-16 Sep wk 45 CE participation Study Design, 19 Sep-7 Oct wk 55 CE coordination Clinical Epidemiology, 4 wk 56 CE coordination * Discipline: Clinical Epidemiology (CE) Output 2005 Number of students Start September 2005: 33 students: Origin of the subscriptions: UU BMS epidemiology, initial: 4 students UU BMS epidemiology, postgraduate 20 students UU BMS veterinary epidemiology and economics, postgraduate: 9 students Note: Courses are also attended by students from other masters programs and post-initial (Nihes) students, hence the larger number of attendance in several courses (see table). Annual Report

38 MA Applied Ethics Course information number of students ects (weeks) coordination/ participation Medical Ethics (10 weeks) Coordination/part. Output 2005 Number of students See table above. 36 Julius Center for Health Sciences and Primary Care

39 MSc Nursing Science Description In 2000, a Dutch Master of Science degree for the Health Sciences program was established at Utrecht University (UU). Nursing Science was the first major field of study to be offered within the Health Sciences program. Physiotherapy Science was added as a second major field of study in 2002 and Speech Therapy Science as the third field in However, a new curriculum for the Health Sciences program was necessary in order to comply with the European regulations for university education and to conform with the international Bachelor- Master structure in higher education. This resulted in the development of two programs: a one year part-time premaster program (30 ects) for graduates of a bachelor degree program in professional education with a deficiency in academic skills, and a two year part-time master program (60 ects) for graduates of a BSc-university degree program or a premaster program (see table below). Both the premaster and master Nursing Science UU programs started in September The Department of Nursing Science within the Julius Center for Health Sciences and Primary Care is responsible for the development and coordination of the Nursing Science field of study. Annual Report