Netherlands Armed Forces Research Articles

Complexities and Possibilities of Strengthening the Social Inclusion of Military Women in the Netherlands Armed Forces: Findings From an Action Research Project

The social inclusion of military women is negatively affected by dominant masculine norms. Often, military organizations try to promote inclusion through top-down policies. However, little is known about solutions military personnel themselves propose, and what is needed to implement those. Drawing on an action research project in the Netherlands Armed Forces, we identify four systemic collaborative requirements to implement initiatives aimed at improving inclusion: (a) awareness and recognition of women’s (negative) experiences, (b) a safe environment for dialogue and joint ownership, (c) organizational trust, support and mandate, and (d) the implementation of interventions in the organizational structure. We discuss two paradoxes we identified (a) addressing inclusion in unsafe workplaces requires safety and (b) creating awareness about women’s social inclusion without putting women in the spotlight. Our results show that a dialogic and collaborative approach is promising, especially to address the complexities that arise when trying to strengthen inclusion.

A Workplace Health Promotion Program for a Predominantly Military Population: Associations with General Health, Mental Well-Being and Sustainable Employability.

Due to the globally increasing life expectancies, many countries are raising their official retirement age to prevent labor shortages and sustain retirement systems. This trend emphasizes the need for sustainable employability. Unhealthy lifestyles pose a risk to sustainable employability as they contribute to chronic diseases and decreased productivity. Workplace Health Promotion (WHP) programs have gained attention as a strategy to enhance employee health and well-being. The Netherlands Armed Forces, a unique employer with demanding psychological and physical requirements, was used as a case study to investigate the associations of a WHP Program with workers health and sustainable employability. The program offered tailor-made guidance to participants (N = 341) through individual coaching trajectories. The program's impact was evaluated by measuring self-reported health, mental well-being, and sustainable employability over a 6-month period. Results indicated significant improvements across all these dimensions after participation in the program. This study provides valuable insights into the benefits of tailor-made WHP programs. While this was an observational study without a control group, this study supports the importance of incorporating individualized approaches in WHP initiatives to foster positive outcomes in health and sustainable employability.

Personal health monitoring in the armed forces – scouting the ethical dimension

BackgroundThe field of personal health monitoring (PHM) develops rapidly in different contexts, including the armed forces. Understanding the ethical dimension of this type of monitoring is key to a morally responsible development, implementation and usage of PHM within the armed forces. Research on the ethics of PHM has primarily been carried out in civilian settings, while the ethical dimension of PHM in the armed forces remains understudied. Yet, PHM of military personnel by design takes place in a different setting than PHM of civilians, because of their tasks and the context in which they operate. This case study therefore focusses on obtaining insights into the experiences and related values of different stakeholders regarding an existing form of PHM, the Covid-19 Radar app, in the Netherlands Armed Forces.MethodsWe carried out an exploratory qualitative study, using semi-structured interviews with twelve stakeholders in the Netherlands Armed Forces. We focussed on participation in the use of PHM, reflections on the practical use and use of data, moral dilemmas and the need for ethics support, all in regard to PHM. The data was analysed using an inductive thematic approach.ResultsThree interlinking categories reflecting ethical dimensions of PHM emerged: (1) values, (2) moral dilemmas, and (3) external norms. The main values identified were: security (in relation to data), trust and hierarchy. Multiple related values were found. Some, but no broadly shared, moral dilemmas were identified and no strong need for ethics support was expressed.ConclusionThis study shed light on key values, provide insights in the experienced and presumed moral dilemmas and bring to mind ethics support considerations when looking at PHM in the armed forces. Some values bring a certain vulnerability to military users when personal and organisational interests are not aligned. Furthermore, some identified values may hinder a careful consideration of PHM because they potentially conceal parts of ethical dimensions of PHM. Ethics support can assist in uncovering and addressing these concealed parts. The findings highlight a moral responsibility for the armed forces to devote attention to the ethical dimensions of PHM.

Frozen for combat: Quality of deep-frozen thrombocytes, produced and used by The Netherlands Armed Forces 2001-2021.

The Netherlands Armed Forces (NLAF) are using -80°C deep-frozen thrombocyte concentrate (DTC) since 2001. The aim of this study is to investigate the effect of storage duration and alterations in production/measurement techniques on DTC quality. It is expected that DTC quality is unaffected by storage duration and in compliance with the European guidelines for fresh and cryopreserved platelets. Pre-freeze and post-thaw product platelet content and recovery were collected to analyze the effects of dimethyl sulfoxide (DMSO) type, duration of frozen storage (DMSO-1 max 12 years and DMSO-2 frozen DTC max 4 years at -80°C) and type of plasma used to suspend DTC. Coagulation characteristics of thawed DTC, plasma and supernatant of DTC (2× 2500 G) were measured with Kaolin thromboelastography (TEG) and phospholipid (PPL) activity assay. Platelet content and recovery of DTC is ±10%-15% lower in short-stored products and remained stable when stored beyond 0.5 years. Thawed DTC (n=1724) were compliant to the European guidelines (98.1% post-thaw product recovery ≥50% from original product, 98.3% ≥200 × 109 platelets/unit). Compared to DMSO-1, products frozen with DMSO-2 showed ±8% reduced thaw-freeze recovery, a higher TEG clot strength (MA 58 [6] vs. 64 [8] mm) and same ±11 s PPL clotting time. The use of cold-stored thawed plasma instead of fresh thawed plasma did not influence product recovery or TEG-MA. Regardless of alterations, product quality was in compliance with European guidelines and unaffected by storage duration up to 12 years of -80°C frozen storage.

The haemostatic effect of deep-frozen platelets versus room temperature-stored platelets in the treatment of surgical bleeding: MAFOD—study protocol for a randomized controlled non-inferiority trial

BackgroundThe Netherlands Armed Forces have been successfully using deep-frozen (− 80 °C) thrombocyte concentrate (DTC) for the treatment of (massive) bleeding trauma patients in austere environments since 2001. However, high-quality evidence for the effectiveness and safety of DTCs is currently lacking. Therefore, the MAssive transfusion of Frozen bloOD (MAFOD) trial is designed to compare the haemostatic effect of DTCs versus room temperature-stored platelets (RSP) in the treatment of surgical bleeding.MethodsThe MAFOD trial is a single-blinded, randomized controlled non-inferiority trial and will be conducted in three level 1 trauma centres in The Netherlands. Patients 12 years or older, alive at hospital presentation, requiring a massive transfusion including platelets and with signed (deferred) consent will be included. The primary outcome is the percentage of patients that have achieved haemostasis within 6 h and show signs of life. Haemostasis is defined as the time in minutes from arrival to the time of the last blood component transfusion (plasma/platelets or red blood cells), followed by a 2-h transfusion-free period. This is the first randomized controlled study investigating DTCs in trauma and vascular surgical bleeding.DiscussionThe hypothesis is that the percentage of patients that will achieve haemostasis in the DTC group is at least equal to the RSP group (85%). With a power of 80%, a significance level of 5% and a non-inferiority limit of 15%, a total of 71 patients in each arm are required, thus resulting in a total of 158 patients, including a 10% refusal rate. The data collected during the study could help improve the use of platelets during resuscitation management. If proven non-inferior in civilian settings, frozen platelets may be used in the future to optimize logistics and improve platelet availability in rural or remote areas for the treatment of (massive) bleeding trauma patients in civilian settings.Trial registrationClinicalTrials.gov NCT05502809. Registered on 16 August 2022.

Towards a cultural perspective on the absorption of emerging technologies in military organizations

ABSTRACT Absorbing emerging technologies is crucial to the success of intelligence and security organizations. Scholars, however, tend to overlook the role of cultural traits in this process. Focusing on military organizations, this paper questions how military organizational culture shapes the absorption of emerging technologies. It draws upon literatures of military innovation, technology absorption and military sociology and empirically studies the absorption of counter improvised explosive devices technologies within the Netherlands Armed Forces. This paper argues that cultural influence on technology absorption becomes apparent in the innovation drivers, the distinction between war- and peacetime and the gradual shift of organizational identities.

Grit was not associated to dropout in Dutch Marine recruits

ABSTRACT Approximately half of all recruits drop out of Marine recruit training. Identifying associated and predisposing factors for dropout would be helpful to understand dropout patterns and induce preventive strategies. Grit has been suggested to be a predictor of who is likely to succeed and who is not. We aimed to investigate the association between baseline grit scores and dropout of Marine recruit training in the Netherlands Armed Forces. We performed an exploratory study using data of three platoons Marine recruit training of the Royal Netherlands Marine Corps. Individual grit levels were measured using the NL-Grit scale, including two subscales. The primary outcome of this study was successful completion or dropout of Marine recruit training. Data were available from 270 recruits, of whom 119 (44%) dropped out of training. The odds ratio for dropout were 1.01 (95% CI 0.84–1.21, p = .917) and 1.07 (95% CI 0.89–1.29, p = .481) per standard deviation increase of consistency of interests and perseverance of effort, respectively. Our study did not confirm the proposed association between baseline grit levels and dropout of Marine recruit training in Dutch Marine recruits using the NL-Grit scale.

Oral Health Disparities in the Royal Netherlands Armed Forces.

In the military, good oral health is essential for combat readiness. The Royal Netherlands Armed Forces (RNAF) Dental Service is responsible for delivering a high standard of dental care to soldiers to ensure that commanding officers can deploy dentally fit troops. Oral health inequalities are associated with lower socioeconomic status. Rank is reflective of social status within the military hierarchy. The aim of this study was to analyze differences in the oral health status of RNAF personnel in relation to ranks and other determinants. All soldiers of the RNAF who underwent a regular dental inspection between January 15, 2018 and February 2, 2018 were enrolled. The decayed, missing, filled permanent teeth (DMFT) index, Dutch Periodontal Screening Index, and Simplified Oral Hygiene Index (OHI-S) were used to assess their oral health. Dental fitness was categorized. Patients were questioned about their smoking behavior and perception of their oral health. Personnel were divided into the following three groups according to rank: officers, noncommissioned officers (NCOs), and enlisted ranks. Nine hundred and eighty-four soldiers of the RNAF were included in this study. Enlisted ranks had significantly higher DMFT index and OHI-S scores than officers and NCOs (both P < .001), which was associated with smoking and older age. Enlisted ranks were also significantly more often determined to have unacceptable dental fitness than officers and NCOs after the examination (P = .033). There was also a difference in dental fitness classification between officers and NCOs, but this was not statistically significant (P = .103). The lowest ranked military personnel are more frequently classified as dentally unfit for deployment than officers and NCOs due to oral health conditions. This is important when considering the allocation of dental resources to maximize the pool of deployable personnel.

Information Manoeuvre and the Netherlands Armed Forces: Legal Challenges Ahead

Information Manoeuvre and the Netherlands Armed Forces: Legal Challenges Ahead

Despite an improved aerobic endurance, still high attrition rates in initially low-fit recruits—results of a randomised controlled trial

BackgroundLow baseline fitness of recruits entering basic military training (BMT) is associated with an increased risk of musculoskeletal injuries (MSIs) and attrition from training. ObjectiveTo determine the effects of a pre-training conditioning program (PCP) on aerobic endurance, incidence of musculoskeletal injuries (MSIs), and attrition rates in BMT of a special infantry unit of the Netherlands Armed Forces. ParticipantsRecruits were considered eligible for this study when they were ‘low-fit’ at the start of BMT (time to complete a 2.7-km run ≥ 12′23″). Interventions‘Low-fit’ recruits were deferred to a seven to twelve week—depending on the time between two consecutive training platoons—PCP consisting of functional training to improve several fitness domains. The control (CON) group started regular BMT without delay. ResultsForty-nine recruits were included in this study; 26 in the PCP-group and 23 in the CON-group. Recruits who followed the PCP started BMT with better aerobic endurance than the CON-group who started BMT immediately (2.7 km run timings: PCP 11′32″, CON 13′16″). The risk of dropout was lower in the PCP-group (incidence density ratio (IDR) 0.63, 95%CI 0.32; 1.26), but dropout due to training-related MSIs was more frequent (IDR 1.23, 95%CI 0.32; 4.76 (per-protocol 0.94, 95%CI 0.24; 3.63), without statistically significant differences between the groups. ConclusionAlthough a PCP was effective to improve aerobic endurance in low-fit recruits to return to meet pre-enlistment fitness criteria, we could not demonstrate an effect on dropout from military training. Trial registrationDutch trial register Trial NL6791 (NTR6977) https://www.trialregister.nl/trial/6791.

One out of four recruits drops out from elite military training due to musculoskeletal injuries in the Netherlands Armed Forces

IntroductionMusculoskeletal injuries (MSIs) are among the main causes of dropout from military training. The main purpose of this study was to provide an overview of dropout rates and MSI incidence...

Epidemiology and Financial Burden of Musculoskeletal Injuries as the Leading Health Problem in the Military.

Musculoskeletal injuries (MSIs) have direct impact on occupational readiness and task performance in military populations. Until this date, no epidemiologic data have been published concerning MSI incidence in the Netherlands Armed Forces (NAF). The aim of this study was to assess the MSI incidence and related costs in the NAF. In this descriptive epidemiologic study, we collected injury surveillance data from the electronic patient records of multiple military units of the NAF. Using data of all new consultations with a military physician from January 1, 2014 to December 31, 2016, we calculated MSI incidence rates per 100 person-years, with a 95% confidence interval (CI). Physician care costs were determined based on the number of physician consults and the charge per appointment. We used two methods to determine productivity costs; the top-down microcosting method and the friction cost method. Our study sample included 22% (n=8,847) of the total NAF population of 2016 (n=40,178). In this sample, consultations of MSIs accounted for 23.2% (n=7,815) of all new consultations (n=33,666). MSI incidence rates per unit ranged from 12.5 to53.3 per 100 person-years. In the total sample, MSI incidence rates were highest in the back (6.73, 95% CI 6.39-7.10), knee (5.04, 95% CI 4.74-5.35), and foot (4.79, 95% CI 4.50-5.10). The estimated costs for physician visits for MSIs in our sample were €0.69 million. Limited duty days accounted for €1.10 million productivity costs using top-down microcosting method. Our study provided evidence that MSIs result in substantial financial burden. Injuries of the back, knee, and foot account for the majority of demands on curative care for MSIs.

An evaluation of measurement systems estimating gait speed during a loaded military march over graded terrain

This study aimed to evaluate the accuracy of three measurement systems estimating gait speed during a loaded military march over graded terrain. Systems developed by the Swiss and Netherlands Armed Forces and a commercial wrist-based device were evaluated in comparison to a Global Positioning System. The first part of the paper focuses on the development of the Dutch system, where speed is estimated from a chest worn accelerometer and body measurements. For this validation study 36 subjects were walking or running 13 laps of 200 m at different speeds. Results showed that walking and running speed can be estimated with a R2adj of 0.968 and 0.740, respectively. In the second part of this paper, data from 64 soldiers performing a 35 km march were used to evaluate the accuracy of three measurement systems in estimating speed. Data showed that estimating gait speed with a single accelerometer can be accurate for military activity, even without prior individual calibration measurements. However, predictions should be corrected for confounders such as body size and shoe type to be accurate. Both, downhill and uphill walking led to changes in gait characteristics and to an overestimation of speed by up to 10%. Correcting for slope or gradient using altimetry in future algorithms/experiments could improve the estimation of gait speed.

Transfusion: -80°C Frozen Blood Products Are Safe and Effective in Military Casualty Care.

IntroductionThe Netherlands Armed Forces use -80°C frozen red blood cells (RBCs), plasma and platelets combined with regular liquid stored RBCs, for the treatment of (military) casualties in Medical Treatment Facilities abroad. Our objective was to assess and compare the use of -80°C frozen blood products in combination with the different transfusion protocols and their effect on the outcome of trauma casualties.Materials and MethodsHemovigilance and combat casualties data from Afghanistan 2006–2010 for 272 (military) trauma casualties with or without massive transfusions (MT: ≥6 RBC/24hr, N = 82 and non-MT: 1–5 RBC/24hr, N = 190) were analyzed retrospectively. In November 2007, a massive transfusion protocol (MTP; 4:3:1 RBC:Plasma:Platelets) for ATLS® class III/IV hemorrhage was introduced in military theatre. Blood product use, injury severity and mortality were assessed pre- and post-introduction of the MTP. Data were compared to civilian and military trauma studies to assess effectiveness of the frozen blood products and MTP.ResultsNo ABO incompatible blood products were transfused and only 1 mild transfusion reaction was observed with 3,060 transfused products. In hospital mortality decreased post-MTP for MT patients from 44% to 14% (P = 0.005) and for non-MT patients from 12.7% to 5.9% (P = 0.139). Average 24-hour RBC, plasma and platelet ratios were comparable and accompanying 24-hour mortality rates were low compared to studies that used similar numbers of liquid stored (and on site donated) blood products.ConclusionThis report describes for the first time that the combination of -80°C frozen platelets, plasma and red cells is safe and at least as effective as standard blood products in the treatment of (military) trauma casualties. Frozen blood can save the lives of casualties of armed conflict without the need for in-theatre blood collection. These results may also contribute to solutions for logistic problems in civilian blood supply in remote areas.

Short-Term Results of a Rehabilitation Program for Service Members With Lower Leg Pain and the Evaluation of Patient Characteristics.

Lower leg pain (LLP), including medial tibial stress syndrome (MTSS) and chronic exertional compartment syndrome (CECS), remains a major problem for the military. Evaluation of patient characteristics and short-term results of the rehabilitation program for service members used in the Military Rehabilitation Centre Aardenburg. This retrospective study includes 161 service members of the Netherlands Armed Forces. Service members were grouped into the following diagnostic categories: MTSS (n = 47), conservative treatment of CECS (n = 34), and rehabilitation after operative intervention of the CECS (CECSo; n = 80). The results showed a significant improvement in all groups regarding the Patient-Specific Functional Scale (PSFS). Only the CECSo group showed significant improvement on the Numeric Pain Rating Score (NPRS). None of the patient characteristics like gender, age, military service, duration of symptoms, and treatment setting were identified to correlate with outcome results. Short-term results of the rehabilitation program for service members with LLP are successful as obtained with the PSFS. Evaluation by the NPRS seems insufficient and researchers should consider using other outcome measurements. The CECSo group seems to benefit the most from the rehabilitation program. No patient characteristics could be identified to correlate with outcome results.

Decision-Making and Parliamentary Control for International Military Cyber Operations by the Netherlands Armed Forces

This chapter focuses on the highly pertinent issues of political decision-making, the provision of information to parliament and parliamentary control related to the international ‘deployment’ of military cyber capabilities by the Netherlands armed forces. These military cyber operations will be based on the threefold purpose taken from the Constitution: defending the Kingdom, including collective defence; maintaining and promoting the international legal order; and protecting other (vital) interests of the Kingdom.

Deployment-related mental health support: comparative analysis of NATO and allied ISAF partners

BackgroundFor years there has been a tremendous gap in our understanding of the mental health effects of deployment and the efforts by military forces at trying to minimize or mitigate these. Many military forces have recently systematized the mental support that is provided to support operational deployments. However, the rationale for doing so and the consequential allocation of resources are felt to vary considerably across North Atlantic Treaty Organisation (NATO) International Security Assistance (ISAF) partners. This review aims to compare the organization and practice of mental support by five partnering countries in the recent deployment in Afghanistan in order to identify and compare the key methods and structures for delivering mental health support, describe bottlenecks and illustrate new developments.MethodInformation was collected through document analysis and semi-structured interviews with key military mental healthcare stakeholders. The review resulted from close collaboration between key military mental healthcare professionals within the Australian Defense Forces (ADF), Canadian Armed Forces (CAF), United Kingdom Armed Forces (UK), Netherlands Armed Forces (NLD), and the United States Army (US). Key stakeholders were interviewed about the mental health support provided during a serviceperson's military career. The main items discussed were training, prevention, early identification, intervention, and aftercare in the field of mental health.ResultsAll forces reported that much attention was paid to mental health during the individual's military career, including deployment. In doing so there was much overlap between the rationale and applied methods. The main method of providing support was through training and education. The educative focus was to strengthen the mental resilience of individual soldiers while providing a range of mental healthcare services. All forces had abandoned standard psychological debriefing after critical incidents. Instead, by default, mental healthcare professionals acted to support the leader and peer led “after action” reviews. All countries provided professional mental support close to the front line, aimed at early detection and early return to normal activities within the unit. All countries deployed a mental health support team that consisted of a range of mental health staff including psychiatrists, psychologists, social workers, mental health nurses, and chaplains. There was no overall consensus in the allocation of mental health disciplines in theatre. All countries (except the US) provided troops with a third location decompression (TLD) stop after deployment, which aimed to recognize what the deployed units had been through and to prepare them for transition home. The US conducted in-garrison ‘decompression’, or ‘reintegration training’ in the US, with a similiar focus to TLD. All had a reasonably comparable infrastructure in the field of mental healthcare. Shared bottlenecks across countries included perceived stigma and barriers to care around mental health problems as well as the need for improving the awareness and recognition of mental health problems among service members. among service personnel as well as the need for improving the awareness and recognition of symptoms as being indicative of a mental health problems among servicemembers.ConclusionThis analysis demonstrated that in all five partners state-of-the-art preventative mental healthcare was included in the last deployment in Afghanistan, including a positive approach towards strengthening the mental resilience, a focus on self-regulatory skills and self-empowerment, and several initiatives that were well-integrated in a military context. These initiatives were partly/completely implemented by the military/colleagues/supervisors and applicable during several phases of the deployment cycle. Important new developments in operational mental health support are recognition of the role of social leadership and enhancement of operational peer support. This requires awareness of mental problems that will contribute to reduction of the barriers to care in case of problems. Finally, comparing mental health support services across countries can contribute to optimal preparation for the challenges of military deployment.

Do soldiers seek more mental health care after deployment? Analysis of mental health consultations in the Netherlands Armed Forces following deployment to Afghanistan

BackgroundMilitary deployment to combat zones puts military personnel to a number of physical and mental challenges that may adversely affect mental health. Until now, few studies have been performed in Europe on mental health utilization after military deployment.ObjectiveWe compared the incidence of mental health consultations with the Military Mental Health Service (MMHS) of military deployed to Afghanistan to that of non-deployed military personnel.MethodWe assessed utilization of the MMHS by the full cohort of the Netherlands Armed Forces enlisted between 2008 and 2010 through linkage of mental health and human resource information systems.ResultsThe total population consisted of 50,508 military (18,233 deployed, 32,275 non-deployed), who accounted for 1,906 new consultations with the MMHS. The follow-up was limited to the first 2 years following deployment. We observed higher mental health care utilization in deployed vs. non-deployed military personnel; hazard ratio (HR), adjusted for sex, military branch and time in service, 1.84 [95% CI 1.61–2.11] in the first and 1.28 [1.09–1.49] in the second year after deployment. An increased risk of adjustment disorders (HR 2.59 [2.02–3.32] and 1.74 [1.30–2.32]) and of anxiety disorders (2.22 [1.52–3.25] and 2.28 [1.50–3.45]) including posttraumatic stress disorder (5.15 [2.55–10.40] and 5.28 [2.42–11.50]), but not of mood disorders (1.33 [0.90–1.97] and 1.11 [0.68–1.82]), was observed in deployed personnel in the first- and second-year post-deployment, respectively. Military personnel deployed in a unit with a higher risk of confrontation with potentially traumatic events had a higher HR (2.13 [1.84–2.47] and 1.40 [1.18–1.67]).ConclusionsThough absolute risk was low, in the first and second year following deployment to Afghanistan there was an 80 and 30% higher risk for mental health problems resulting in a consultation with the Dutch MMHS compared to military never deployed to Afghanistan. These observations underscore the need for an adequate mental health infrastructure for those returning from deployment.

Pitted keratolysis; physicians’ treatment and their perceptions in Dutch army personnel

Pitted keratolysis (PK) is a common plantar skin manifestation in army personnel, farmers and athletes. Due to pain while walking and marching, the condition can cause reduced operational deployability (in case of army personnel). We used a questionnaire to investigate currently used treatment options of PK and perceptions on perceived efficacy of these treatments among Royal Netherlands Armed Forces primary health care physicians. A cross-sectional anonymous postal questionnaire survey was conducted among all Royal Netherlands Armed Forces primary health care physicians. In addition to question about prescription behaviour on the treatment of PK by topical and oral therapies and given non-pharmacological treatment, several questions assessed perceived efficacy of these therapies. Of the 164 eligible primary health care physicians, 51 (31.1%) completed the questionnaire. Half of physicians had seen less than five patients with PK in the preceding year. Two-thirds of physicians reported problems with operational deployability in less than 10% of army personnel with PK. PK was treated mostly with topical and non-pharmacological treatments. Oral therapy was seldom prescribed. For hyperhidrosis, aluminium chloride hexahydrate was used in most cases. PK and related reduced operational deployability were less often reported than expected in this study. Dutch physicians prefer combined topical antibiotic therapy with non-pharmacological treatments and perceive the efficacy of topical antibiotic therapy superior to non-pharmacological treatments. Preventive measures, topical antibiotic therapy and adequate treatment of hyperhidrosis are the mainstay methods in the management of patients with PK.

Country Survey: An Economic Analysis Of Military Expenditures In The Netherlands, 1990–2009

This article examines the pattern of expenditures for national security of the Netherlands from 1990 until 2009. In 1990, military spending amounted to 2.7% of Gross Domestic Product (GDP). In 2009, almost two decades later, this ratio dropped by more than a full percent. During this period, the reduction of funds available for national security was in concurrence with the Dutch government’s spending policies. The Netherlands Armed Forces (NAF) changed dramatically in terms of capabilities, size, equipment and personnel in this two-decade time span. Our investigative results indicate that in spite of this transition, no significant changes have been implemented since 1990 in how the Dutch defence budget is allocated for the Navy, Army and Air Force. Furthermore, the mix of expenditures for salaries, operations and maintenance, as well as those for capital investment, stayed roughly the same for the duration of the period studied.