Differences in healthy life expectancy between older migrants and non-migrants in three European countries over time

OBJECTIVES

We analysed differences in healthy life expectancy at age 50 (HLE₅₀) between migrants and non-migrants in Belgium , the Netherlands, and England and Wales, and their trends over time between 2001 and 2011 in the latter two countries.

METHODS

Population, mortality and health data were derived from registers, census or surveys. HLE₅₀ and the share of remaining healthy life years were calculated for non-migrants, western and non-western migrants by sex. We applied decomposition techniques to answer whether differences in HLE₅₀ between origin groups and changes in HLE₅₀ over time were attributable to either differences in mortality or health.

RESULTS

In all three countries, older (non-western) migrants could expect to live less years in good health than older non-migrants. Differences in HLE₅₀ between migrants and non-migrants diminished over time in the Netherlands, but they increased in England and Wales. General health, rather than mortality, mainly explained (trends in) inequalities in healthy life expectancy between migrants and non-migrants.

CONCLUSIONS

Interventions aimed at reducing the health and mortality inequalities between older migrants and non-migrants should focus on prevention, and target especially non-western migrants.

The role of birth cohorts in long-term trends in liver cirrhosis mortality across eight European countries

BACKGROUND AND AIMS

Understanding why inequalities in alcohol-related mortality trends by sex and country exist is essential for developing health policies. Birth cohort effects, indicative of differences by generation in drinking, have rarely been studied. This study estimated the relative contributions of birth cohorts to liver cirrhosis mortality trends and compared sex- and country-specific cohort patterns across eight European countries.

DESIGN

Time-series analysis of population-level mortality data.

SETTING

Austria, Finland, Hungary, Italy, the Netherlands, Poland, Spain and Sweden; 1950-2011.

PARTICIPANTS

National populations aged 15-94 years.

MEASUREMENTS

We modelled country- and sex-specific liver cirrhosis mortality (from national vital registers) adjusting for age, period and birth cohort.

FINDINGS

Birth cohorts (adjusted for age and period) made statistically significant contributions to liver cirrhosis mortality in all countries and for both sexes (P < 0.001), and more so among women (average contribution to deviance reduction of 38.8%) than among men (17.4%). The observed cohort patterns were statistically different between all but two country pairs (P < 0.001). Sex differences existed overall (P < 0.001), but not in the majority of countries (P > 0.999). Visual inspection of birth cohort patterns reveals birth cohorts at higher risk of liver cirrhosis mortality.

CONCLUSIONS

The inclusion of the birth cohort dimension improves the understanding of alcohol-attributable mortality trends in Europe. Birth cohorts at higher risk of liver cirrhosis mortality were born during 1935-49 in Sweden and Finland, around 1950 in Austria and the Netherlands and 1960 or later in Hungary, Italy, Poland and Spain.

[Religious and cultural aspects of organ transplantation]

The number of transplantations is mainly limited by the shortage of organs, thereby leading to potentially lethal delays for patients registered on waiting lists. Among the causes of refusals of organ donation, religious reasons are often advocated. In order to make the point, we organized a debate between representatives of secularism ( " laïcité ") and of the most represented religions in Belgium, i.e. catholic, Islamic and Judaic. Even though the representation of death was variable, organ donation is authorized and even encouraged by the fundamental texts. Refusals of organ donation result more often from personal interpretations by local preachers. Therefore, the gathering of political and religious authorities in order to promote organ donation is desirable instead of sowing doubt for pseudo-religious reasons.

A new parametric model to assess delay and compression of mortality

BACKGROUND

A decrease in mortality across all ages causes a shift of the age pattern of mortality, or mortality delay, while differences in the rate of decrease across ages cause a change in the shape of the age-at-death distribution, mortality compression or expansion. Evidence exists for both compression and delay of mortality. Existing parametric models to describe the full age pattern of mortality are not able to capture mortality delay versus mortality compression. More recent models that assess delay versus compression mostly focused on the adult or old ages alone and did not distinguish mortality compression below and above the modal age at death, although they represent different mechanisms.

METHODS

This paper presents a new parametric model that describes the full age pattern of mortality and assesses compression - at different stages of life - and delay of mortality: the CoDe model. The model includes 10 parameters, of which five are constant over time. The five time-varying parameters reflect delay of mortality and compression of mortality in infancy, adolescence, young adulthood, late adulthood, and old age. The model describes infant and background mortality by two simple functions, uses a mixed logistic model with different slopes in adult, middle, and old age, and includes the modal age at death as a parameter to account for the delay in mortality.

RESULTS

Applying the CoDe model to age-specific probabilities of death for Japanese, French, American, and Danish men and women between 1950 and 2010 showed a very good fit of the full age pattern of mortality. Delay of mortality explained about two-thirds of the increase in life expectancy at birth, whereas compression of mortality due to mortality declines in young age explained about one-third. No strong compression of mortality in late adulthood age was observed. Mortality compression in old age has had a small negative impact on life expectancy.

CONCLUSIONS

The CoDe model proved a valid instrument for describing the full age pattern of mortality and for disentangling the effects of mortality delay and compression - at different stages of life - on the increase in life expectancy.

Differences in mortality between groups of older migrants and older non-migrants in Belgium, 2001-09

BACKGROUND

European societies are rapidly ageing and becoming multicultural. We studied differences in overall and cause-specific mortality between migrants and non-migrants in Belgium specifically focusing on the older population.

METHODS

We performed a mortality follow-up until 2009 of the population aged 50 and over living in Flanders and the Brussels-Capital Region by linking the 2001 census data with the population and mortality registers. Overall mortality differences were analysed via directly age-standardized mortality rates. Cause-specific mortality differences between non-migrants and various western and non-western migrant groups were analysed using Poisson regression models, controlling for age (model 1) and additionally controlling for socio-economic status and urban typology (model 2).

RESULTS

At older ages, most migrants had an overall mortality advantage relative to non-migrants, regardless of a lower socio-economic status. Specific migrant groups (e.g. Turkish migrants, French and eastern European male migrants and German female migrants) had an overall mortality disadvantage, which was, at least partially, attributable to a lower socio-economic status. Despite the general overall mortality advantage, migrants experienced higher mortality from infectious diseases, diabetes-related causes, respiratory diseases (western migrants), cardiovascular diseases (non-western female migrants) and lung cancer (western female migrants).

CONCLUSION

Mortality differences between older migrants and non-migrants depend on cause of death, age, sex, migrant origin and socio-economic status. These differences can be related to lifestyle, social networks and health care use. Policies aimed at reducing mortality inequalities between older migrants and non-migrants should address the specific health needs of the various migrant groups, as well as socio-economic disparities.

The effect of adherence to statin therapy on cardiovascular mortality: quantification of unmeasured bias using falsification end-points

BACKGROUND

To determine the clinical effectiveness of statins on cardiovascular mortality in practice, observational studies are needed. Control for confounding is essential in any observational study. Falsification end-points may be useful to determine if bias is present after adjustment has taken place.

METHODS

We followed starters on statin therapy in the Netherlands aged 46 to 100 years over the period 1996 to 2012, from initiation of statin therapy until cardiovascular mortality or censoring. Within this group (n = 49,688, up to 16 years of follow-up), we estimated the effect of adherence to statin therapy (0 = completely non-adherent, 1 = fully adherent) on ischemic heart diseases and cerebrovascular disease (ICD10-codes I20-I25 and I60-I69) as well as respiratory and endocrine disease mortality (ICD10-codes J00-J99 and E00-E90) as falsification end points, controlling for demographic factors, socio-economic factors, birth cohort, adherence to other cardiovascular medications, and diabetes using time-varying Cox regression models.

RESULTS

Falsification end-points indicated that a simpler model was less biased than a model with more controls. Adherence to statins appeared to be protective against cardiovascular mortality (HR: 0.70, 95 % CI 0.61 to 0.81).

CONCLUSIONS

Falsification end-points helped detect overadjustment bias or bias due to competing risks, and thereby proved to be a useful technique in such a complex setting.

Estimating time-varying drug adherence using electronic records: extending the proportion of days covered (PDC) method

PURPOSE

Accurate measurement of drug adherence is essential for valid risk-benefit assessments of pharmacologic interventions. To date, measures of drug adherence have almost exclusively been applied for a fixed-time interval and without considering changes over time. However, patients with irregular dosing behaviour commonly have a different prognosis than patients with stable dosing behaviour.

METHODS

We propose a method, based on the proportion of days covered (PDC) method, to measure time-varying drug adherence and drug dosage using electronic records. We compare a time-fixed PDC method with the time-varying PDC method through detailed examples and through summary statistics of 100 randomly selected patients on statin therapy.

RESULTS

We demonstrate that time-varying PDC method better distinguishes an irregularly dosing patient from a stably dosing patient and demonstrate how the time-fixed method can result in a biassed estimate of drug adherence. Furthermore, the time-varying PDC method may be better used to reduce certain types of confounding and misclassification of exposure.

CONCLUSIONS

The time-varying PDC method may improve longitudinal and time-to-event studies that associate adherence with a clinical outcome or (intervention) studies that seek to describe changes in adherence over time.

Impact of Pregnancy-Related Deaths on Female Life Expectancy in Zambia: Application of Life Table Techniques to Census Data

INTRODUCTION

Since 2000, the world has been coalesced around efforts to reduce maternal mortality. However, few studies have estimated the significance of eliminating maternal deaths on female life expectancy. We estimated, based on census data, the potential gains in female life expectancy assuming complete elimination of pregnancy-related mortality in Zambia.

METHODS

We used data on all-cause and pregnancy-related deaths of females aged 15-49 reported in the Zambia 2010 census, and evaluated, adjusted and smoothed them using existing and verified techniques. We used associated single decrement life tables, assuming complete elimination of pregnancy-related deaths to estimate the potential gains in female life expectancy at birth, at age 15, and over the ages 15-49. We compared these gains with the gains from eliminating deaths from accidents, injury, violence and suicide.

RESULTS

Complete elimination of pregnancy-related deaths would extend life expectancy at birth among Zambian women by 1.35 years and life expectancy at age 15 by 1.65 years. In rural areas, this would be 1.69 years and 2.19 years, respectively, and in urban areas, 0.78 years and 0.85 years. An additional 0.72 years would be spent in the reproductive age group 15-49; 1.00 years in rural areas and 0.35 years in urban areas. Eliminating deaths from accidents, injury, suicide and violence among women aged 15-49 would cumulatively contribute 0.55 years to female life expectancy at birth.

CONCLUSION

Eliminating pregnancy-related mortality would extend female life expectancy in Zambia substantially, with more gains among adolescents and females in rural areas. The application of life table techniques to census data proved very valuable, although rigorous evaluation and adjustment of reported deaths and age was necessary to attain plausible estimates. The collection of detailed high quality cause-specific mortality data in future censuses is indispensable.

High prevalence of unwanted pregnancies and induced abortions among HIV-infected women from Western India: need to emphasize dual method use?

This study examines the prevalence, reasons, and predictors of unwanted pregnancies and induced abortions among ever married HIV-infected women attending a care facility in Maharashtra, Western India, and discusses its programmatic and policy implications. Retrospectively collected data of pregnancies conceived after the diagnosis of HIV were analyzed using descriptive and logistic regression techniques. Among the 622 women interviewed, 113 women had 158 pregnancies with known outcomes after HIV diagnosis. Among these pregnancies, 80 (51%) were unwanted and 79 (50%) were voluntarily terminated. Fear of transmitting HIV to the child was a frequently mentioned reason for an unwanted pregnancy (71.8%) and induced abortion (59.5%). Women from urban areas [OR 2.43 (95% CI 1.23-4.79)] and with two or more live births before HIV diagnosis [OR 3.33 (95% CI 1.36-8.20)] were significantly more likely to report an unwanted pregnancy. Women with two or more live births before HIV diagnosis [OR 3.16 (95% CI 1.20-8.35)], who did not know that HIV transmission to the baby can be prevented [OR 3.29 (95% CI 1.48-7.34)] and with an unwanted pregnancy [OR 4.82 (95% CI 2.33-10.00)], were significantly more likely to terminate the pregnancy. Despite increased coverage of antiretroviral treatment, effective provision of reproductive healthcare services to HIV-infected women remains challenging. A high prevalence of unwanted pregnancies and induced abortions and a low level of knowledge about prevention of mother to child transmission (PMTCT) underscore the need for preconception counseling and provision of comprehensive family planning services to HIV-infected women. Enrolling all HIV-infected pregnant women, irrespective of their decision to continue with their pregnancy, in the PMTCT program and discussing with HIV-infected women and their partners at HIV diagnosis a full array of contraceptive methods and not just consistent use of condoms might be helpful in reducing unwanted pregnancies.

The Adoption of Smoking and Its Effect on the Mortality Gender Gap in Netherlands: A Historical Perspective

We examine in depth the effect of differences in the smoking adoption patterns of men and women on the mortality gender gap in Netherlands, employing a historical perspective. Using an indirect estimation technique based on observed lung cancer mortality from 1931 to 2012, we estimated lifetime smoking prevalence and smoking-attributable mortality. We decomposed the sex difference in life expectancy at birth into smoking-related and nonsmoking-related overall and cause-specific mortality. The smoking epidemic in Netherlands, which started among men born around 1850 and among women from birth cohort 1900 onwards, contributed substantially to the increasing sex difference in life expectancy at birth from 1931 (1.3 years) to 1982 (6.7 years), the subsequent decline to 3.7 years in 2012, and the high excess mortality among Dutch men born between 1895 and 1910. Smoking-related cancer mortality contributed most to the increase in the sex difference, whereas smoking-related cardiovascular disease mortality was mainly responsible for the decline from 1983 onwards. Examining nonsmoking-related (cause-specific) mortality shed new light on the mortality gender gap and revealed the important role of smoking-related cancers, the continuation of excess mortality among women aged 40-50, and a smaller role of biological factors in the sex difference than was previously estimated.

[Practical problems related to the management of febrile urinary tract infection in Vietnamese children]

BACKGROUND

To describe the practical problems related to urinary tract infection (UTI) management in febrile Vietnamese children.

METHODS

During a prospective 28-month inclusion period, 143 febrile children with significant bacteriuria were treated for UTI in the nephrology department of Nhi Dong 2 children's hospital in Ho Chi Minh City, Vietnam. Patients were treated after blood and urine samples had been taken for culture, according to a local antibiotic protocol, parenterally with ceftriaxone 75mg/kg/day. Oral treatment with cefixime 8mg/kg/day was started after 48h of apyrexia for 2 weeks. According to local protocol, antibiotic therapy was only changed if children did not respond clinically to treatment regardless of antibiogram results.

RESULTS

Among these 143 children, 51% were girls and 80% of them had their first UTI before the age of 2 years. The commonest causative agent was Escherichia coli (80% of cases) with a high resistance rate to ampicillin (91%) and cotrimoxazole (74%). Extended-spectrum β-lactamase (ESBL) production was observed in 52% of Enterobacteriaceae isolates. According to antibiotic susceptibility, the initial treatment with ceftriaxone was found to be inappropriate in 63% of cases.

CONCLUSIONS

E. coli was responsible for 80% of UTIs in Vietnamese children with a high rate of resistance to first-line antibiotics. ESBL production was found to be extremely high in this study. Based on these data, we propose a new empiric treatment schedule for Vietnamese children suspected of UTI.

Trajectories of Childbearing among HIV Infected Indian Women: A Sequence Analysis Approach

Background

HIV infection closely relates to and deeply affects the reproductive career of those infected. However, little is known about the reproductive career trajectories, specifically the interaction of the timing of HIV diagnosis with the timing and sequencing of reproductive events among HIV infected women. This is the first study to describe and typify this interaction.

Methods

Retrospective calendar data of ever married HIV infected women aged 15-45 attending a HIV clinic in Pune, Maharashtra, Western India (N=622) on reproductive events such as marriage, cohabitation with the partner, use of contraception, pregnancy, childbirth and HIV diagnosis were analyzed using sequence analysis and multinomial logistic regression.

Results

Optimal matching revealed three distinct trajectories: 1) HIV diagnosis concurrent with childbearing (40.7%), 2) HIV diagnosis after childbearing (32.1%), and 3) HIV diagnosis after husband’s death (27.2%). Multinomial logistic regression (trajectory 1 = baseline) showed that women who got married before the age of 21 years and who had no or primary level education had a significantly higher risk of knowing their HIV status either after childbearing or close to their husband’s death. The risk of HIV diagnosis after husband’s death was also higher among rural women and those who were diagnosed before 2005.

Conclusions

Three distinct patterns of interaction of timing of HIV diagnosis with timing and sequencing of events in the reproductive career were observed that have clear implications for (i) understanding of the individual life planning process in the context of HIV, (ii) formulation of assumptions for estimating HIV infected women in need of PMTCT services, and (iii) provision of care services.

Patient and graft outcome in current era of immunosuppression: a single centre pilot study

OBJECTIVES

The present single centre study aims at analyzing the impact on renal allograft outcome of the important changes which occurred in the transplant population and immunosuppressive therapy during the last two decades.

METHODS

From 2000 to 2013, 779 single kidney transplantations were performed on 635 patients who all received on an intent-to-treat basis steroids, a calcineurin inhibitor, mycophenolate mofetil and an induction therapy with either antithymocyte globulin or an antagonist directed to the interleukin (IL)-2 receptor. Uni- and multivariate analyses of patient and immunologic graft survival were conducted.

RESULTS

The sole factor predicting patient survival is recipient's age: 10-year survival rates are 94·7, 81·6 and 57·9% for the <45, 45-60 and >60 years age groups, respectively (P<0·001). Peak (>50% panel reactive antibodies) anti-human leucocyte antigens (HLA) sensitization, cold ischaemia time and HLA-B and -DR mismatches (MM) influence graft outcome: at 10 years, the difference in 10-year survival rates is 5·9% between grafts from sensitized and not sensitized patients (90·9 vs 96·8%, P = 0·002), 3·8% between grafts with <18 and ≧18 hours cold ischaemia (96·6 vs 92·8%, P = 0·003), 7·3% between grafts with no MM and either B or DR MM versus those with B and DR MM (96·8 vs 89·5%, P = 0·002).

CONCLUSION

In our single centre experience, graft survival was most strongly determined by HLA matching, offering excellent long term graft outcome to most patients.

The future of smoking-attributable mortality: the case of England & Wales, Denmark and the Netherlands

AIMS

We formally estimate future smoking-attributable mortality up to 2050 for the total national populations of England & Wales, Denmark and the Netherlands, providing an update and extension of the descriptive smoking-epidemic model.

METHODS

We used smoking prevalence and population-level lung cancer mortality data for England & Wales, Denmark and the Netherlands, covering the period 1950-2009. To estimate the future smoking-attributable mortality fraction (SAF) we: (i) project lung cancer mortality by extrapolating age-period-cohort trends, using the observed convergence of smoking prevalence and similarities in past lung cancer mortality between men and women as input; and (ii) add other causes of death attributable to smoking by applying a simplified version of the indirect Peto-Lopez method to the projected lung cancer mortality.

FINDINGS

The SAF for men in 2009 was 19% (44 872 deaths) in England & Wales, 22% (5861 deaths) in Denmark and 25% (16 385 deaths) in the Netherlands. In our projections, these fractions decline to 6, 12 and 14%, respectively, in 2050. The SAF for women peaked at 14% (38 883 deaths) in 2008 in England & Wales, and is expected to peak in 2028 in Denmark (22%) and in 2033 in the Netherlands (23%). By 2050, a decline to 9, 17 and 19%, respectively, is foreseen. Different indirect estimation methods of the SAF in 2050 yield a range of 1-8% (England & Wales), 8-13% (Denmark) and 11-16% (the Netherlands) for men, and 7-16, 12-26 and 13-31% for women.

CONCLUSIONS

From northern European data we project that smoking-attributable mortality will remain important for the future, especially for women. Whereas substantial differences between countries remain, the age-specific evolution of smoking-attributable mortality remains similar across countries and between sexes.

Role of smoking in regional variation in mortality in Poland

AIMS

We assess the effect of smoking on regional disparities in mortality in Poland and its contribution to the change in regional disparities during the last two decades.

DESIGN, SETTING AND PARTICIPANTS

We used population-level mortality data from the population registry for 379 Nomenclature of Territorial Units for Statistics (NUTS)-4 Polish regions for 1991-93 and 2008-10.

MEASUREMENTS

The importance of smoking was assessed by smoking-attributable mortality (SAM) derived using a simplified indirect Peto-Lopez method. Regional differences in age-standardized all-cause, smoking- and non-smoking-attributable mortality (NSAM) rates at ages 35 years and over were mapped, and spatial clustering (Moran's I) and coefficients of variation (CV) were estimated. The contribution of SAM to variation in all-cause mortality was assessed by variance decomposition and compared over time.

FINDINGS

In 2008-10, all-cause and SAM rates were characterized by a similar pattern of spatial clustering (Moran's I > 0.44, P < 0.0001). For NSAM, a more random pattern with less regional clustering showed (Moran's I = 0.34, P < 0.0001). The contribution of smoking to regional variation was substantial [54%, 95% confidence interval (CI) = 44.9, 62.5 among men; 24.9%, 95% CI = 20.9, 29.1 among women], and compared with 1991-93, 27.5 percentage points lower for men and 6.3 percentage points higher for women. Smoking contributed to the divergence between the regions in all-cause mortality between 1991-93 and 2008-10 for men [increase in CV of SAM by 2% (0, 4%)], but not for women [decrease in CV of SAM by 15% (22, 10%)].

CONCLUSIONS

Differences in past smoking behaviour may largely explain the regional differences in all-cause mortality existing in 2008-10 in Poland, and its trends since 1991-1993.

A Novel Time Series Approach to Bridge Coding Changes with a Consistent Solution Across Causes of Death

Revisions of the International Classification of Diseases (ICD) can lead to biases in cause-specific mortality levels and trends. We propose a novel time series approach to bridge ICD coding changes which provides a consistent solution across causes of death. Using a state space model with interventions, we performed time series analysis to cause-proportional mortality for ICD9 and ICD10 in the Netherlands (1979-2010), Canada (1979-2007) and Italy (1990-2007) on chapter level. A constraint was used to keep the sum of cause-specific interventions zero. Comparability ratios (CRs) were estimated and compared to existing bridge coding CRs for Italy and Canada. A significant ICD9 to ICD10 transition occurred among 13 cause of death groups in Italy, 7 in Canada and 3 in the Netherlands. Without the constraint, all-cause mortality after the classification change would be overestimated by 0.4 % (NL), 0.03 % (Canada) and 0.2 % (Italy). The time series CRs were in the same direction as the bridge coding CRs but deviated more from 1. A smooth corrected trend over the ICD-transition resulted from applying the time series approach. Comparing the time series CRs for Italy (2003), Canada (1999) and the Netherlands (1995) revealed interesting commonalities and differences. We demonstrated the importance of adding the constraint, the validity of our methodology and its advantages above earlier methods. Applying the method to more specific causes of death and integrating medical content to a larger extent is advocated.

Including the smoking epidemic in internationally coherent mortality projections

We present a new mortality projection methodology that distinguishes smoking- and non-smoking-related mortality and takes into account mortality trends of the opposite sex and in other countries. We evaluate to what extent future projections of life expectancy at birth (e 0) for the Netherlands up to 2040 are affected by the application of these components. All-cause mortality and non-smoking-related mortality for the years 1970-2006 are projected by the Lee-Carter and Li-Lee methodologies. Smoking-related mortality is projected according to assumptions on future smoking-attributable mortality. Projecting all-cause mortality in the Netherlands, using the Lee-Carter model, leads to high gains in e 0 (4.1 for males; 4.4 for females) and divergence between the sexes. Coherent projections, which include the mortality experience of the other 21 sex- and country-specific populations, result in much higher gains for males (6.4) and females (5.7), and convergence. The separate projection of smoking and non-smoking-related mortality produces a steady increase in e 0 for males (4.8) and a nonlinear trend for females, with lower gains in e 0 in the short run, resulting in temporary sex convergence. The latter effect is also found in coherent projections. Our methodology provides more robust projections, especially thanks to the distinction between smoking- and non-smoking-related mortality.

Using spatial analysis to predict health care use at the local level: a case study of type 2 diabetes medication use and its association with demographic change and socioeconomic status

Local health status and health care use may be negatively influenced by low local socio-economic profile, population decline and population ageing. To support the need for targeted local health care, we explored spatial patterns of type 2 diabetes mellitus (T2DM) drug use at local level and determined its association with local demographic, socio-economic and access to care variables. We assessed spatial variability in these associations. We estimated the five-year prevalence of T2DM drug use (2005-2009) in persons aged 45 years and older at four-digit postal code level using the University of Groningen pharmacy database IADB.nl. Statistics Netherlands supplied data on potential predictor variables. We assessed spatial clustering, correlations and estimated a multiple linear regression model and a geographically weighted regression (GWR) model. Prevalence of T2DM medicine use ranged from 2.0% to 25.4%. The regression model included the extent of population ageing, proportion of social welfare/benefits, proportion of low incomes and proportion of pensioners, all significant positive predictors of local T2DM drug use. The GWR model demonstrated considerable spatial variability in the association between T2DM drug use and above predictors and was more accurate. The findings demonstrate the added value of spatial analysis in predicting health care use at local level.

A systematic review of the application of spatial analysis in pharmacoepidemiologic research

PURPOSE

Although current reviews of the use of spatial analysis in general epidemiologic research illustrate an important and well-established role in exploring and predicting health, its application has not been reviewed in the subspecialty field of pharmacoepidemiology.

METHODS

We systematically reviewed the scientific literature to assess to what extent spatial analysis has been applied in pharmacoepidemiologic research and explored its potential added value.

RESULTS

A systematic search in PubMed and Embase/MEDLINE yielded 823 potentially relevant articles; 45 articles met our criteria for review. The studies were reviewed on study objective, applied spatial methods and units of analysis, and author-reported added value of the geographic approach used. Of the 45 included studies, 34 (76%) reported a geographic research objective. Comparative spatial methods were most often used (n = 25; 56%). Eleven studies used spatial statistics (32%); cluster analysis (n = 5) and aggregate data analysis (n = 4) being most common. Mapping was done in 15 studies (33%). The most common added value reported was to aid the planning of health policies and interventions (n = 24; 53%). A minority of pharmacoepidemiologic studies used a geographic approach and the applied methods were less advanced compared with the broader field of epidemiology.

CONCLUSIONS

Further advancements are needed to incorporate currently available spatial techniques to impact health care planning.

Assessing the effect of a guideline change on drug use prevalence by including the birth cohort dimension: the case of benzodiazepines

PURPOSE

The aim of this study was to investigate whether including the birth cohort dimension in time series analysis leads to a more accurate estimation of the (long-term) effect of a guideline change on the trend of benzodiazepine use.

METHODS

We calculated age-specific (20-84 years) and sex-specific prevalence of benzodiazepine use per 1000 population per quarter year (1998 to 2008) using a prescription database set in the Netherlands. We studied the prevalence over time by age group and within birth cohorts through interrupted time series analyses to estimate the effect of the guideline change in 2001.

RESULTS

From 1998 to 2008, the overall age-standardized prevalence of benzodiazepine use per 1000 population declined from ~54 for men and ~107 for women to ~45 for men and ~85 for women. The relative change increased significantly after 2001 for both sexes and for the majority of age groups. Within birth cohorts, the prevalence increased with age until the year 2001 and leveled thereafter. The age-period approach overall had worse model fit indicators than the within-cohort approach and predicted larger long-term effects than the within-cohort approach. The age-period projection estimated 36% decline in benzodiazepine use relative to 2008, whereas the birth-cohort projection estimated 8% decline.

CONCLUSION

Explicitly following birth cohort trajectories led to models with better fit; the conventional approach estimated a stronger long-term guideline effect. This has important implications for professional practice.

Effect of highly active antiretroviral treatment (HAART) during pregnancy on pregnancy outcomes: experiences from a PMTCT program in western India

Previous research regarding the effect of highly active antiretroviral treatment (HAART) on pregnancy outcomes shows conflicting results and is predominantly situated in developed countries. Recently, HAART is rapidly being scaled up in developing countries for prevention of mother-to-child transmission (PMTCT). This study compared adverse pregnancy outcomes among HIV infected women (N=516) who received either HAART (N=192)--mostly without protease inhibitor--or antepartum azidothymidine (AZT) with intrapartum nevirapine (N=324) from January 2008 to March 2012 through a PMTCT program in western India. We analyzed the effect of HAART on preterm births, low birth weight, and all adverse pregnancy outcomes combined using univariate and multivariate logistic regression models. Women on HAART had 48% adverse pregnancy outcomes, 25% preterm births, and 34% low birth weight children compared to respectively 32%, 13%, and 22% among women on AZT. Women receiving HAART were more likely to have adverse pregnancy outcomes and preterm births compared to women receiving AZT. Preconception HAART was significantly related to low birth weight children. This study demonstrated increased risk of adverse pregnancy outcomes with protease inhibitor excluded HAART. Prospective studies assessing the impact of HAART on MTCT as measured in terms of HIV-free survival among children are needed.

Inclusion of the birth cohort dimension improved description and explanation of trends in statin use

OBJECTIVE

Including the birth cohort dimension improves trend studies of mortality and health. We investigated the effect of including the birth cohort dimension in trend studies of prescription drug use by studying prevalence of statin use among adults.

STUDY DESIGN AND SETTING

Data from a drug prescription database in the Netherlands (IADB.nl) were used to obtain the number of users of statin per 1,000 population (prevalence) in the age range 18-85 years from 1994 to 2008. We applied descriptive graphs and standard age-period-cohort (APC) models.

RESULTS

From 1994 to 2008, the prevalence increased from ∼10 to ∼90 users per 1,000 population, with the peak in prevalence shifting from age 63 to 78 years. The APC model shows patterns that were masked in the age-period (AP) model. The prevalence rate ratio increased from the 1911 birth cohort to the 1930 birth cohort and then declined. Similar for both sexes, adding nonlinear period effects contributed ∼4.4% to reductions in deviance, whereas adding nonlinear birth cohort effects contributed ∼12.9%.

CONCLUSION

Adding the birth cohort dimension to AP analysis is valuable for academic and professional practice as trends can be more accurately described and explained and it can help improve projections of future trends.

Systematic review of public health research on prevention of mother-to-child transmission of HIV in India with focus on provision and utilization of cascade of PMTCT services

Background

In spite of effective strategies to eliminate mother-to-child-transmission of HIV, the implementation of such strategies remains a major challenge in developing countries. In India, programs for the prevention of mother-to-child transmission (PMTCT) have been scaled up widely since 2005. However, these programs reach only a small percentage of pregnant women, and their overall effectiveness is low. Evidence-based program planning and implementation could significantly improve their effectiveness. This study sought to systematically retrieve, thematically categorize and review published research on PMTCT of HIV in India, focusing on research related to the provision and/or utilization of the cascade of services provided in a PMTCT program, in order to direct further research to enhance program implementation and effectiveness.

Methods

A systematic search using MEDLINE, US National Library of Medicine Gateway system (PubMed) and ISI Web of Knowledge resulted in 1,944 abstracts, of which 167 met our inclusion criteria.

Results

A huge share of the empirical literature on PMTCT in India (N = 134) deals with epidemiological studies (N = 60). The 46 papers related to utilization/provision of the cascade of PMTCT services were mostly from the four high HIV prevalence states in southern India and from the public sector. Studies on experiences of implementing a PMTCT program (N = 20) show high rates of drop out of women in the cascade particularly prior to receiving ARV. Studies on individual components of the cascade (N = 26) show that HIV counseling and testing is acceptable and feasible. Literature on other components of the cascade - such as pregnant women’s access to ANC care, HIV infected women’s immunological assessment using CD4 testing, repeat HIV testing among pregnant women, early infant diagnosis and factors related to linking HIV infected women and children to postnatal care – is lacking.

Conclusions

While the scale of the Indian PMTCT program is large, comprehensive understanding of the context-driven factors affecting its efficiency is lacking. Systematic and more focused public health research output is needed on the issues related to reduction of drop outs of women in the cascade, role of PMTCT programs in improving maternal and child health indicators and role of private sector in delivering PMTCT services.

The decline in stroke mortality: exploration of future trends in 7 Western European countries

BACKGROUND AND PURPOSE

This article aims to make projections of future trends in stroke mortality in the Year 2030 based on recent trends in stroke mortality in 7 Western European countries.

METHODS

Mortality data were obtained from national cause of death registries. Annual rates of decline in stroke mortality of 1980 to 2005 were determined for men and women in the United Kingdom, France, the Netherlands, and 4 Nordic countries on the basis of regression analysis. Estimated rates of decline were extrapolated until 2030. Cause-elimination life tables were used to determine the effect of stroke in 2030 in terms of potential gain in life expectancy. The absolute numbers of stroke deaths in 2030 were estimated using national population projections of Eurostat.

RESULTS

In all countries, stroke mortality rates declined incessantly until 2005 among both men and women. If these trends were to continue, age-adjusted mortality rates would decline by approximately half between 2005 and 2030 with larger declines in France (approximately two thirds) and smaller declines in the Netherlands, Denmark, and Sweden (approximately one fourth). Similar rates of decline would be observed in terms of potential gain in life expectancy. Because of population aging, the absolute number of stroke deaths would decline slowly in the United Kingdom and France and stabilize or even increase in other countries.

CONCLUSIONS

In the near future, stroke may lose much of its effects on life expectancy but remain a frequent cause of death among elderly populations. The prevention of stroke-related disability instead of mortality may become increasingly more important.

The decline in ischaemic heart disease mortality in seven European countries: exploration of future trends

BACKGROUND

To assess the implication of a possible continuation of the decline in ischaemic heart disease (IHD) mortality in the future.

METHODS

Annual rates of decline in IHD mortality from 1980-2005 were determined for the national populations of the Netherlands, UK, France and four Nordic countries through regression analysis and used to extrapolate mortality rates until 2030. Through cause-elimination life tables we determined the impact of IHD on life expectancy at birth.

RESULTS

In all countries, IHD mortality rates among both sexes declined incessantly until 2005. Age-adjusted mortality rates would have declined by about 50% in 2030 compared to 2005 if past trends were to continue. The impact of IHD on life expectancy at birth would decline by about 25-50% in most populations. The absolute numbers of IHD deaths would decline slowly or even increase in some countries mainly because of population ageing.

CONCLUSIONS

If current IHD mortality trends continued, IHD would lose much of its importance as a cause of premature death in the near future. As the incidence and disabling impact of IHD might decline much less, prevention of IHD-related disability instead of mortality may become increasingly important in the future.

[Variations in the pace of mortality decline in elderly in 7 Northwestern European countries between 1950-1999: the impact of smoking]

OBJECTIVE

Examination of the variations in the pace of old-age (80+) mortality decline in 7 Northwestern European countries for the period 1950-1999, and the impact of smoking

DESIGN

Retrospective.

METHOD

The population mortality data of 7 Northwestern European countries were collated according to year of death for a 50 year period (1950-1999), single year of age (60+ and 80+) and sex. Both all-cause and non-smoking-related mortality were analysed. In addition, a comparison was made with the pace of mortality decline at younger age among the same cohorts. Regression and correlation analyses were used.

RESULTS

Marked variations in the pace of old-age mortality decline were found between countries, periods and sexes. While mortality declines were constantly strong in France and England and Wales, modest declines or even increases in mortality rate were observed in the 1950s in the Nordic countries, and since the 1980s in Denmark, The Netherlands, and (for men only) Norway. For non-smoking-related mortality, a high and consistent pace ofmortality decline was observed. The declines showed a clear cohort pattern, with the smallest declines or even increases for men born between 1890 and 1899, compared to an increased pace of mortality decline among women born between 1847 and 1937. Among men, but not women, the pace of old-age mortality decline correlated with the pace of mortality decline at ages 60-69 among the same cohorts.

CONCLUSIONS

Variations in the pace of old-age mortality decline are strongly influenced by smoking and probably also by other factors originating earlier in life. For future decades, substantial further declines in old-age mortality may be expected, even though rates of change in specific countries and periods would be difficult to predict.

The choice among past trends as a basis for the prediction of future trends in old-age mortality

We explored the extent to which projections of future old-age mortality trends differ when different projection bases are used. For seven European countries, four alternative sets of annual rates of mortality change were estimated with age-period log-linear regression models, and subsequently applied to age-specific all-cause mortality rates (80+) in 1999 to predict mortality levels up to 2050. On average, up to 2050, e80 is predicted to increase further by 2.33 years among men and 4.03 years among women. Choosing a historical period of 25 instead of 50 years results in higher predicted gains in e80 for men but lower gains for women. Choosing non-smoking-related mortality instead of all-cause mortality leads to higher gains for women and mixed results for men. In all alternatives there is a strong divergence of predicted mortality levels between the countries. Future projections should be preceded by a thorough study of past trends and their determinants.

[Pediatric nephrology from the fetal kidney to the kidney graft]

The department of pediatric uro-nephrology was created in 1977 in Brugmann hospital. Since then, various sectors have been developed including: hemodialysis and peritoneal dialysis, kidney transplantation, urological and genital surgery, antenatal screening and rapid management of uronephropathies, treatment of voiding dysfunction and neurogenic bladder, management of tubular and glomerular diseases. The progress in genetics, medical imaging, obstetrics, neonatology and surgery has allowed us to take care of our young patients within a multidisciplinary framework. The most original contributions of the department are related to the performance of combined liver-kidney transplantation in primary hyperoxaluria, to the determination of the natural history of several congenital anomalies of the kidney and urinary tract, to the assessment of the role of genetic mutations on tubular and glomerular diseases, to the usefulness of radioisotopic tracers in the measurement of renal function in infants, and to the study of experimental tolerance of allografts. The transition of young renal patients from pediatric to adult care is actually well organized due to our 30 years experience and the excellent collaboration with the adult nephrologists.

[Experience about more than 2000 renal transplantations at the university of Brussels]

Since 1965, more than 2000 renal transplantations (including more than 100 living-donor transplantations) have been performed at the University of Brussels. An end-stage renal disease patient candidate to renal transplantation will be therefore followed from his enrolment on the waiting list to the long-term post-transplant period. Improvement in the outcome of renal transplantation is achieved due to better knowledge in many fields of medicine, such as immunology, infectious disease, metabolic diseases (hyperlipemia, diabetes mellitus), pharmacology, use of immunosuppressive regimen, a more adequate cardiovascular prevention and treatment. If the best results were achieved with kidneys from living donors, the graft survival rate at the University of Brussels was nearly 80% for the last period (2000-2006). Unfortunately, renal transplantation cannot cure certain comorbid conditions and even may promote them: infectious diseases, neoplasia, metabolic disorders (e.a diabetes mellitus, hyperlipemia). Many efforts have to be done to develop less toxic and more immune selective therapeutic strategies. Living donation and extension of the pool of cadaveric donors will reduce the length of time spent on the waiting list and will significantly impact on mortality and morbidity after kidney transplantation.

Cohort-specific trends in stroke mortality in seven European countries were related to infant mortality rates

OBJECTIVES

To assess, in a population-based study, whether secular trends in cardiovascular disease mortality in seven European countries were correlated with past trends in infant mortality rate (IMR) in these countries.

STUDY DESIGN AND SETTING

Data on ischemic heart disease (IHD) and stroke mortality in 1950-1999 in the Netherlands, England & Wales, France, and four Nordic countries were analyzed. We used Poisson regression to describe trends in mortality according to birth cohort, for the cohorts born between 1860 and 1939. Pearson correlation coefficients were calculated to determine associations between IMR and IHD, or stroke mortality.

RESULTS

IHD mortality increased for successive cohorts up to 1900, and then started to decline. Stroke mortality levels were virtually stable among birth cohorts up to 1880, but declined rapidly among later cohorts. A strong positive association was found between cohort-specific IMR levels and stroke mortality rates. There were no strong cohort-wise associations between IMR and IHD mortality.

CONCLUSION

These results support other studies in suggesting that living conditions in early childhood may influence population levels of stroke mortality. Future studies should determine the contribution of specific early life factors to the mortality decline in IHD and especially stroke.

Trends in stomach cancer mortality in relation to living conditions in childhood. A study among cohorts born between 1860 and 1939 in seven European countries

AIM

To assess whether secular trends in stomach cancer mortality were correlated with trends in infant mortality rate (IMR) or gross domestic product (GDP).

METHODS

Data from seven European countries were analyzed. We used Poisson regression to describe mortality trends among birth cohorts of 1865-1939 and correlation coefficients to determine associations with IMR/GDP.

RESULTS

Large differences were observed between birth cohorts in mortality from stomach cancer. In each country, these cohort differences were closely related to IMR/GDP levels at birth time. However, stronger associations were observed with measures of living conditions during later life. In comparisons between countries, stomach cancer mortality rates were not consistently related to national levels of IMR/GDP.

CONCLUSION

General living conditions in childhood do not seem to have had a predominant effect on secular trends in stomach cancer mortality. The mortality decline is likely to be related to more 1specific factors, such as declining Helicobacter pylori prevalence.

Insulin-dependent diabetes mellitus as long term complication of haemolytic-uraemic syndrome

Haemolytic-uraemic syndrome (HUS) is a rare cause of insulin-dependent diabetes mellitus during the acute stage. We previously reported the case of a 3-year-old girl having presented with typical HUS with diarrhea, microangiopathic anaemia, thrombocytopenia and acute renal failure (17 days of anuria). Transient hyperglycaemia (highest level: 513 mg/dl) was observed, requiring continuous intravenous insulin infusion for 9 days. Subcutaneous insulin injections were stopped after 24 days. Oral glucose tolerance test performed 4 months after normalization of blood glucose was normal. HLA DQ genotype (DQA1-DQB1.AZH/DQA3-DQB3.1) was not at risk for type 1 diabetes and there were no auto-antibodies (ICA and IAA). The 3-years follow-up was marked by persistent arterial hypertension, proteinuria and slight renal insufficiency despite angiotensin-converting enzyme inhibitor treatment. Ten years after HUS occurred (the patient had been lost to follow-up for 7 years), she came back with complaints of headache but neither polyurodipsia nor weight loss. She was found to have arterial hypertension. Chronic renal impairment had moderately progressed with decreased glomerular filtration rate (63 ml/min/1.73 m2) and proteinuria (2 g/24 hours). Fasting blood glucose was 189 mg/dl and reached 315 mg/dl during an oral glucose tolerance test. HbA1c level was 8.2% (N<6.2%) and diabetes mellitus was diagnosed without any signs of autoimmunity (IAA, ICA, GADA and IA2B were negative). Good glycaemic control was obtained with 0.5 U/kg/day of insulin. In conclusion, transient beta-cell dysfunction complicating HUS acute stage may evolve to overt non-autoimmune diabetes mellitus (microangiopathic process?), even after a long free interval. This case emphasizes the need for a long-term follow-up of patients with HUS.

Association between gross domestic product throughout the life course and old-age mortality across birth cohorts: Parallel analyses of seven European countries, 1950–1999

Mortality levels of national populations have often been studied in relation to levels of gross domestic product (GDP) at time of death. Following the life course perspective, we assessed whether old-age mortality levels for subsequent cohorts are differentially associated with GDP levels prevailing at different ages of the cohorts. We used all-cause and cause-specific mortality data by sex, age at death (65-99), year at death (1950-1999), and year of birth (1865-1924) for Denmark, England and Wales, Finland, France, the Netherlands, Norway, and Sweden. Trends in national GDP per capita between 1865 and 1999 were reconstructed from historical national accounts data. Through Poisson regression analyses, we determined for each country both univariate and multivariate associations across five-year birth cohorts between mortality and GDP levels prevailing at time of death, and at earlier ages of the cohorts (i.e. 0-5, 6-19, 20-49, and 50-64). For the subsequent cohorts, levels of GDP at time of death were strongly inversely associated with all-cause mortality, especially among women, and among men in England and Wales, Finland, and France. In most countries, stronger associations were observed with GDP levels prevailing at earlier ages of the cohorts. After control for GDP at time of death, these associations remained. An independent association of GDP at earlier ages of the cohort was also observed for cause-specific mortality. The associations were negative for ischaemic heart diseases, cerebrovascular diseases, and stomach cancer. They were positive for prostate cancer, breast cancer, COPD (women), and lung cancer (women). GDP prevailing at ages 20-49 (men) and ages 50-64 (women) had the largest associations with old-age mortality. These findings suggest an independent, mostly negative effect of GDP prevailing at earlier ages of subsequent cohorts on old-age mortality. Socio-economic circumstances during adulthood and middle age seem more important in determining old-age mortality trends than those during infancy or childhood.

A prospective, randomized, multicenter trial of tacrolimus-based therapy with or without basiliximab in pediatric renal transplantation

In a 6-month, multicenter, randomized, controlled, open-label, parallel-group trial, we investigated the efficacy and safety of adding basiliximab to a standard tacrolimus-based regimen in pediatric renal transplant recipients. Patients < 18 years received tacrolimus/azathioprine/steroids (TAS, n = 93) or tacrolimus/azathioprine/steroids/basiliximab (TAS + B, n = 99). Target tacrolimus levels were 10-20 ng/mL between days 0-21 and 5-15 ng/mL thereafter. Steroid dosing was identical in both groups. Basiliximab was administered at 10 mg (patients < 40 kg) or 20 mg (patients > or = 40 kg) within 4 h of reperfusion; the same dose was repeated on day 4. Biopsy-proven acute rejection rates were 20.4% (TAS) and 19.2% (TAS + B); steroid-resistant acute rejection rates were 3.2% and 3.0%, respectively. Patient survival was 100%; graft survival rates were 95% in both arms. The nature and incidence of adverse events were similar in both arms except toxic nephropathy and abdominal pain, which were significantly higher in the TAS + B arm (14.1% vs. 4.3%; p = 0.03 and 11.1% vs. 2.2%; p = 0.02; respectively). Median serum creatinine concentrations at 6 months were 86 micromol/L in the TAS and 91 micromol/L in the TAS + B arm; glomerular filtration rate was 79.4 and 77.6 (mL/min/1.73 m2), respectively. Adding basiliximab to a tacrolimus-based regimen is safe in pediatric patients, but does not improve clinical efficacy.

Photosensibilisation au voriconazole : 7 cas

BACKGROUND

Voriconazole is a new second-generation fluconazole-derived triazole. With greater potency against susceptible species and a broader spectrum of activity than fluconazole, it is the treatment of choice for invasive pulmonary aspergillosis and other fungal infections (Fusarium, Scedosporium/Pseudalleschezria) is indicated in a visit Candida infections refractory to fluconazole. We describe 7 cases of photosensitivity during treatment with voriconazole in a setting of immunodepression.

CASE REPORTS

The patients comprised 5 women and 2 men with a mean age of 38 years (17-67 years). Five had undergone pulmonary transplantation for mucoviscidosis, one had undergone kidney transplantation for lupus nephroangiosclerosis and one was on long-term systemic steroid treatment for Sjögren's syndrome. All patients had very severe immunosuppression and were receiving voriconazole for pulmonary aspergillosis (6 cases) or Scedosporium infection (1 case). Photosensitization appeared within 5 weeks to 14 months after the start of treatment, and in all cases followed exposure to sun, occasionally at low levels. In all cases, cutaneous lesions rapidly disappeared on discontinuation of treatment.

DISCUSSION

There have been reports in the literature, although rare, of photosensitivity with voriconazole. Patients must be informed of the possibility of this adverse effect and sun protection must be recommended when voriconazole is prescribed, particularly during periods of intensive exposure.

Relation between trends in late middle age mortality and trends in old age mortality--is there evidence for mortality selection?

STUDY OBJECTIVE

To test whether mortality selection was a dominant factor in determining trends in old age mortality, by empirically studying the existence of a negative correlation between trends in late middle age mortality and trends in old age mortality among the same cohorts.

DESIGN AND METHODS

A cohort approach was applied to period data on total and cause specific mortality for Denmark, England and Wales, Finland, France, the Netherlands, Norway, and Sweden, in 1950-1999. The study described and correlated mortality trends for five year centralised cohorts from 1895 to 1910 at ages 55-69, with the trends for the same cohorts at ages 80-89. The research distinguished between circulatory diseases, cancers, and diseases specifically related to old age.

MAIN RESULTS

All cause mortality changes at ages 80-89 were strongly positively correlated with all cause mortality changes at ages 55-69, especially among men, and in all countries. Virtually the same correlations were seen between all cause mortality changes at ages 80-89 and changes in circulatory disease mortality at ages 55-69. Trends in mortality at ages 80-89 from infectious diseases, pneumonia, diabetes mellitus, symptoms, or external causes showed no clear negative correlations with all cause mortality trends at ages 55-69.

CONCLUSIONS

The consistently positive correlations seen in this study suggest that trends in old age mortality in north western Europe in the late 20th century were determined predominantly by the prolonged effects of exposures carried throughout life, and not by mortality selection.

Transcallosal inhibition across the menstrual cycle: A TMS study

OBJECTIVE

To determine if there are steroid-dependent changes in transcallosal transfer during the menstrual cycle in normal women.

METHODS

We tested 13 normally cycling women during the menstrual, follicular and midluteal phases. Blood levels of estradiol (E) and progesterone (P) were determined by radioimmunoassay. Ipsilateral tonic voluntary muscle activity suppression, called ipsilateral silent period (iSP), was evoked by applying transcranial magnetic stimulation (TMS) over the left motor cortex and by measuring the EMG of the ipsilateral first dorsal interosseus (FDI) muscle. Both iSP-duration and transcallosal conduction times were measured and related to cycle phase and steroid levels.

RESULTS

Duration of iSPs varied over the cycle with largest differences between follicular and midluteal phases. During the midluteal phase high levels of P were significantly related to short iSPs. This relation also applied to E levels and iSPs during the follicular phase.

CONCLUSIONS

Our study shows for the first time that the transcallosal transfer is modulated by E and P and changes over the menstrual cycle.

SIGNIFICANCE

It is suggested that gonadal steroid hormones affect the interhemispheric interaction and change the functional cerebral organization sex dependently via its neuromodulatory properties on GABAergic and glutamatergic neurons.

[The medico-surgical department of uro-nephrology, dialysis and renal transplantation in the Children's Hospital of Brussels]

The department of pediatric uro-nephrology was created in 1977 in Brugmann hospital. Since then, various sectors have been developed including: hemodialysis and peritoneal dialysis, kidney transplantation, urological and genital surgery, antenatal screening and rapid management of uronephropathies, treatment of voiding dysfunction and neurogenic bladder, management of tubular and glomerular diseases. The progress in genetics, medical imaging, obstetrics, neonatology and surgery has allowed us to take care of our young patients within a multidisciplinary framework. The most original contributions of the department are related to the performance of combined liver-kidney transplantation in primary hyperoxaluria, to the determination of the natural history of several congenital anomalies of the kidney and urinary tract, to the assessment of the role of genetical mutations on tubular and glomerular diseases, to the usefulness of radioisotopic tracers in the measurement of renal function in infants, and to the study of experimental tolerization of

[Immunosuppressive agents in pediatric renal transplantation]

Advances in immunosuppressive therapy over the past decade have led to dramatic improvements of patient and graft survival. The immunosuppression that is used is constantly evolving. The goal remains to find the best combination that will optimize long-term graft survival, while minimizing the adverse effects. It is likely that in the near future the results will even be improved further by the development of new medications with a better therapeutic index and the induction of transplant tolerance.