Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

Concepts of health in different contexts: a scoping review

The rationale of our study was that the World Health Organization's (WHO) definition of health from 1947 which includes "… complete physical, mental and social wellbeing…" does not fit the current societal viewpoints anymore. The WHO's definition of health implies that many people with chronic illnesses or disabilities would be considered unhealthy and complete wellbeing would be utopian and unfeasible for them. This is no longer uniformly accepted. Many alternative concepts of health have been discussed in the last decades such as 'positive health', which focusses on someone's capability rather than incapability,. However, the question remains whether a general health concept can guide all healthcare practices. More likely, health concepts need to be specified for professions or settings. The objective of our study was to create a structured overview of published concepts of health from different perspectives by conducting a scoping review using the PRISMA-ScR guideline. A literature search was conducted in Pubmed and Cinahl. Articles eligible for inclusion focussed on the discussion or the conceptualisation of health or health-related concepts in different contexts (such as the perspective of care workers' or patients') published since 2009 (the Dutch Health Council raised the discussion about moving towards a more dynamic perspective on health in that year). Seventy-five articles could be included for thematic analyses. The results showed that most articles described a concept of health consisting of multiple subthemes; no consensus was found on one overall concept of health. This implies that healthcare consumers act based on different health concepts when seeking care than care workers when providing care. Having different understandings of the concepts of health can lead to misunderstandings in practice. In conclusion, from every perspective, and even for every individual, health may mean something different. This finding stresses the importance that care workers' and healthcare consumers' meaning of 'health' has to be clear to all actors involved. Our review supports a more uniform tuning of healthcare between healthcare providers (the organisations), care workers (the professionals) and healthcare consumers (the patients), by creating more awareness of the differences among these actors, which can be a guide in their communication.

How service modularity can provide the flexibility to support person-centered care and shared decision-making

Background

Today’s healthcare provision is facing several challenges, that cause the level of complexity to increase at a greater rate than the managerial capacity to effectively deal with it. One of these challenges is the demand for person-centered care in an approach that is tuned towards shared decision-making. Flexibility is needed to adequately respond to individual needs.

Methods

We elaborate on the potential of service modularity as a foundation for person-centered care delivered in a shared decision-making context, and examine to what extent this can improve healthcare. We primarily focused on theory building. To support our effort and gain insight into how service modularity is currently discussed and applied in healthcare, we conducted a scoping review.

Results

Descriptions of actual implementations of modularity in healthcare are rare. Nevertheless, applying a modular perspective can be beneficial to healthcare service improvement since those service modularity principles that are still missing can often be fulfilled relatively easily to improve healthcare practice. Service modularity offers a way towards flexible configuration of services, facilitating the composition of tailored service packages. Moreover, it can help to provide insight into the possibilities of care for both healthcare professionals and patients.

Conclusions

We argue that applying a modular frame to healthcare services can contribute to individualized, holistic care provision and can benefit person-centered care. Furthermore, insight into the possibilities of care can help patients express their preferences, increasing their ability to actively participate in a shared decision-making process. Nevertheless, it remains essential that the healthcare professional actively collaborates with the patient in composing the care package, for which we propose a model. Altogether, we posit this can improve healthcare practice, especially for the people receiving care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07267-6.

[Revision of guideline on Q fever fatigue syndrome (QFS)]

In 2012 the multidisciplinary guideline Q fever fatigue syndrome was developed for the Netherlands. The availability of new research data and developments and experiences from daily clinical practice made it necessary to revise this guideline. The multidisciplinary working group that has revised the guideline is composed of representatives from all medical professions involved in the care of patients with QFS and representatives of the patients' association. The revised guideline incorporates a number of changes, including refinement of the QFS diagnostic criteria and updates regarding advice on support and reintegration.

Prevalence and Predictors of Uncontrolled Asthma in Children Referred for Asthma and Other Atopic Diseases

Background

Uncontrolled asthma in children is still highly prevalent despite the availability of effective asthma treatment. We investigated 1) the prevalence of uncontrolled asthma among children referred for asthma and referred for atopic diseases other than asthma (ie food allergy, allergic rhinitis or atopic dermatitis) to secondary care; and 2) the predictors associated with uncontrolled asthma.

Methods

All children (4 to 18 years) referred for asthma or atopic diseases other than asthma to 8 secondary care centers in The Netherlands were invited to an electronic portal (EP). The EP is a web-based application with several validated questionnaires including the ISAAC questionnaires and the Asthma Control Test (ACT). Children were eligible for inclusion in this study when their parents reported in the EP that their child had asthma diagnosed by a physician. The ACT was used to assess asthma control. Multiple predictors of asthma control (patient, asthma and atopic characteristics) were evaluated by univariable and multivariable logistic regression analyses.

Results

We included 408 children: 259 children (63%) with asthma referred for asthma and 149 children (37%) with asthma referred for atopic diseases other than asthma. Thirty-nine percent of all children had uncontrolled asthma: 47% of the children referred for asthma and 26% of the children referred for atopic diseases other than asthma. Predictors associated with uncontrolled asthma were a family history of asthma (odds ratio [OR] 2.08; 95% confidence interval [95% CI] 1.34 to 3.24), and recurrent upper and lower respiratory tract infections in the past year (OR 2.40; 95% CI 1.52 to 3.81 and OR 2.00; 95% CI 1.25 to 3.23, respectively).

Conclusion

Uncontrolled asthma is highly prevalent in children with asthma referred to secondary care, even if children are primarily referred for atopic diseases other than asthma. Thus, attention should be paid to asthma control in this population.

Abstract P5-13-12: Breast cancer in Colombia: A growing challenge for the health care system

INTRODUCTION

Colombia has a population of roughly 49 million people of predominantly Mestizo ethnicity. Cancer has become a growing public health problem in Colombia with nearly 71,000 newly diagnosed malignant tumors per year. It is expected that by 2035, 150,000 new cases of cancer will be diagnosed, making Colombia an intermediate country with regards to global cancer incidence according to IARC.

METHODS

Epidemiological data on breast cancer is scarce and varied due to multiple sources of information. These numbers are obtained thru population-based cancer registries that represent 4 distinct regions of the country. Other data originate from non-governmental institutions and healthcare providers within Colombia. The Colombian National Cancer Institute publishes a Cancer Mortality Atlas annually.

RESULTS

Local cancer registries have shown increases in breast cancer incidence in Colombia. In 2007, age-standardized incidence rate was 27.8 per 100,000 persons increasing to 49.7 cases per 100,000 persons in 2012. Approximately, 2200 women die every year in Colombia due to breast cancer with rates increasing historically, but now are stabilizing. Advanced breast cancers are most frequently found among women without health insurance, while early breast cancers are usually found among working women and those covered by private health insurance. Early breast cancer screening was made mandatory as public policy in the year 2000. However, only 30% of health care coverage was reported, translating to very low coverage by opportunistic screening programs with only 33% of women having had a mammography. In 2012, a National Cancer Control Plan was planned and implemented. It aims to increase early stage cancer diagnosis, increase biannual screening coverage, and guarantee timely access to diagnosis and treatment. A national health survey in 2015 showed only 48% of women had an annual mammographic screening. Multiple disparities have been found with regards to screening and early diagnosis such as economic strata, health insurance coverage, origin, and accessibility. Specifically, data shows that 23% needed to travel in order to obtain access to mammography. Often it is necessary for some patients to sue healthcare insurance systems to obtain specific health care, causing an increase in time to diagnosis and treatment. In 2016, on average a 90-day period was reported from time of onset of symptoms to suspected diagnosis of breast cancer, while the time to the initiation of treatment was 100 days for chemotherapy and close to 120 days for surgery.

DISCUSSION

These data serve to impact the landscape of breast cancer and improve patient outcomes in Colombia. While the National Cancer Plan has led to major changes, a big challenge remains related to the delays between suspicion of breast cancer and diagnosis and treatment. Quality of care provided by private and public insurance administrators is also of concern. General practitioners should receive more detailed training in breast cancer detection and management. The healthcare system should provide quality cancer care with urgent improvement in mammography, especially in more rural areas. Widely, more timely and appropriate follow-up is needed.

Citation Format: Duarte C, Salazar A, Strasser-Weippl K, de Vries E, Wiesner C, Krush L, Goss PE. Breast cancer in Colombia: A growing challenge for the health care system [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-13-12.

Truly selective primary IgM deficiency is probably very rare

Isolated decreased serum-immunoglobulin (Ig)M has been associated with severe and/or recurrent infections, atopy and autoimmunity. However, the reported high prevalence of clinical problems in IgM-deficient patients may reflect the skewed tertiary centre population studied so far. Also, many papers on IgM deficiency have included patients with more abnormalities than simply IgM-deficiency. We studied truly selective primary IgM deficiency according to the diagnostic criteria of the European Society for Immunodeficiencies (ESID) (true sIgMdef) by reviewing the literature (261 patients with primary decreased serum-IgM in 46 papers) and analysing retrospectively all patients with decreased serum-IgM in a large teaching hospital in 's-Hertogenbosch, the Netherlands [1 July 2005-23 March 2016; n = 8049 IgM < 0·4 g/l; n = 2064 solitary (IgG+IgA normal/IgM < age-matched reference)]. A total of 359 of 2064 (17%) cases from our cohort had primary isolated decreased serum-IgM, proven persistent in 45 of 359 (13%) cases; their medical charts were reviewed. Our main finding is that true sIgMdef is probably very rare. Only six of 261 (2%) literature cases and three of 45 (7%) cases from our cohort fulfilled the ESID criteria completely; 63 of 261 (24%) literature cases also had other immunological abnormalities and fulfilled the criteria for unclassified antibody deficiencies (unPAD) instead. The diagnosis was often uncertain (possible sIgMdef): data on IgG subclasses and/or vaccination responses were lacking in 192 of 261 (74%) literature cases and 42 of 45 (93%) cases from our cohort. Our results also illustrate the clinical challenge of determining the relevance of a serum sample with decreased IgM; a larger cohort of true sIgMdef patients is needed to explore fully its clinical consequences. The ESID online Registry would be a useful tool for this.

Screening protocols to monitor respiratory status in primary immunodeficiency disease: findings from a European survey and subclinical infection working group

Many patients with primary immunodeficiency (PID) who have antibody deficiency develop progressive lung disease due to underlying subclinical infection and inflammation. To understand how these patients are monitored we conducted a retrospective survey based on patient records of 13 PID centres across Europe, regarding the care of 1061 adult and 178 paediatric patients with PID on immunoglobulin (Ig) G replacement. The most common diagnosis was common variable immunodeficiency in adults (75%) and hypogammaglobulinaemia in children (39%). The frequency of clinic visits varied both within and between centres: every 1-12 months for adult patients and every 3-6 months for paediatric patients. Patients diagnosed with lung diseases were more likely to receive pharmaceutical therapies and received a wider range of therapies than patients without lung disease. Variation existed between centres in the frequency with which some clinical and laboratory monitoring tests are performed, including exercise tests, laboratory testing for IgG subclass levels and specific antibodies, and lung function tests such as spirometry. Some tests were carried out more frequently in adults than in children, probably due to difficulties conducting these tests in younger children. The percentage of patients seen regularly by a chest physician, or who had microbiology tests performed following chest and sinus exacerbations, also varied widely between centres. Our survey revealed a great deal of variation across Europe in how frequently patients with PID visit the clinic and how frequently some monitoring tests are carried out. These results highlight the urgent need for consensus guidelines on how to monitor lung complications in PID patients.

[Increasing incidence of thin melanomas in the Netherlands]

OBJECTIVE

In the Netherlands the incidence of melanomas in situ and thin invasive melanomas is rising more quickly than that of thicker melanomas. Our aim was to gain insight into this increase and to test the hypothesis that it is attributable to over-diagnosis.

METHOD

We analysed data taken from the Netherlands Cancer Registry on all primary melanomas diagnosed between 1994 and 2010. We assessed trends in European standardised rates (ESR) using joinpoint analysis, and expressed these trends as estimated annual percentage change (EAPC). Thin melanomas were subdivided into four subgroups.

RESULTS

Between 1994 and 2010, 34 156 persons were diagnosed with melanoma in situ or thin invasive melanoma. The incidence of melanoma in situ doubled during this period, with an acceleration in incidence in men from 2004, and in women from 2007. In men the ESR of thin melanoma doubled, whereby the thinnest category (< 0.25 mm) rose more quickly, but not significant compared to the other Breslow thicknesses ≤ 1 mm. In women, the ESR of thin melanomas nearly doubled, with the exception of the thinnest melanoma.

CONCLUSION

Between 1994 and 2010, the incidence of melanomas increased steadily. In part, this was a real rise as a result of increased exposure to ultraviolet rays. However, from 2006 the incidence of melanomas in situ and thin invasive melanomas in men has risen comparatively more quickly. This could point to over-diagnosis, but also to increased awareness, early detection, a diagnostic shift from benign to malignant lesions and changes in the Dutch health care system.

Survival of acral lentiginous melanoma in the National Cancer Institute of Colombia

OBJECTIVE

To determine survival of a cohort of patients with acral lentiginous melanoma (ALM), treated at the National Cancer Institute of Colombia, the largest referral hospital of the country.

METHODS

All patients diagnosed with an invasive ALM between 2003 and 2009 at the Colombian National Cancer Institute were included for analyses and followed for vital status and date of death. Using Kaplan-Meier methods, overall survival at 1, 3 and 5 years post diagnosis was determined, and Cox proportional hazards models were constructed for the variables showing a significant effect on survival in univariate analyses.

RESULTS

Overall survival of this cohort of 90 patients was 77% at 1 year, 59% at 3 years and 54% at 5 years after diagnosis. Females had a better prognosis in univariate analyses but this advantage disappeared in multivariate models. Clinical stage was a strong predictor of survival, in univariate and multivariate models, particularly among elderly patients.

CONCLUSIONS

Prognosis of ALM in Colombia is relatively poor, particularly for patients with higher clinical stage. The large proportions of ALM diagnosed in stage III and IV explain the relatively poor survival, and illustrate the importance of improving prognosis by lowering stage at diagnosis through better education and early detection programmes.

Regular sun exposure benefits health

Since it was discovered that UV radiation was the main environmental cause of skin cancer, primary prevention programs have been started. These programs advise to avoid exposure to sunlight. However, the question arises whether sun-shunning behaviour might have an effect on general health. During the last decades new favourable associations between sunlight and disease have been discovered. There is growing observational and experimental evidence that regular exposure to sunlight contributes to the prevention of colon-, breast-, prostate cancer, non-Hodgkin lymphoma, multiple sclerosis, hypertension and diabetes. Initially, these beneficial effects were ascribed to vitamin D. Recently it became evident that immunomodulation, the formation of nitric oxide, melatonin, serotonin, and the effect of (sun)light on circadian clocks, are involved as well. In Europe (above 50 degrees north latitude), the risk of skin cancer (particularly melanoma) is mainly caused by an intermittent pattern of exposure, while regular exposure confers a relatively low risk. The available data on the negative and positive effects of sun exposure are discussed. Considering these data we hypothesize that regular sun exposure benefits health.

The proportion of postmenopausal breast cancer cases in the Netherlands attributable to lifestyle-related risk factors

We aimed to estimate the proportion of Dutch postmenopausal breast cancer cases in 2010 that is attributable to lifestyle-related risk factors. We calculated population attributable fractions (PAFs) of potentially modifiable risk factors for postmenopausal breast cancer in Dutch women aged >50 in 2010. First, age-specific PAFs were calculated for each risk factor, based on their relative risks for postmenopausal breast cancer (from meta-analyses) and age-specific prevalence in the population (from national surveys) around the year 2000, assuming a latency period of 10 years. To obtain the overall PAF, age-specific PAFs were summed in a weighted manner, using the age-specific breast cancer incidence rates (2010) as weights. 95 % confidence intervals for PAF estimates were derived by Monte Carlo simulations. Of Dutch women >40 years, in 2000, 51 % were overweight/obese, 55 % physically inactive (<5 days/week 30 min activity), 75 % regularly consumed alcohol, 42 % ever smoked cigarettes and 79 % had a low-fibre intake (<3.4 g/1000 kJ/day). These factors combined had a PAF of 25.7 % (95 % CI 24.2–27.2), corresponding to 2,665 Dutch postmenopausal breast cancer cases in 2010. PAFs were 8.8 % (95 % CI 6.3–11.3) for overweight/obesity, 6.6 % (95 % CI 5.2–8.0) for alcohol consumption, 5.5 % (95 % CI 4.0–7.0) for physical inactivity, 4.6 % (95 % CI 3.3–6.0) for smoking and 3.2 % (95 % CI 1.6–4.8) for low-fibre intake. Our findings imply that modifiable risk factors are jointly responsible for approximately one out of four Dutch postmenopausal breast cancer cases. This suggests that incidence rates can be lowered substantially by living a more healthy lifestyle.

Two cases of rickets presenting with poor growth, hypotonia, and respiratory problems

Rickets is a rare disease in developed countries. In children, it is a disease which affects growing bone. Depending on the severity, it can present with a wide variety of symptoms. Because it is such a rare disease in developed countries, symptoms suggesting rickets are often not easily recognized. This can cause a delay in diagnosing and treating rickets. Often unnecessary and sometimes invasive investigations are performed. First leading clues to rickets on physical examination are poor growth, especially length, thickening of wrists, bow legs, and craniotabes. At further examination, special attention should be paid to osteopenia and cupping and fraying at the metaphyses on X-rays. Laboratory results suggestive for rickets are elevated alkaline phosphatase and disturbances in calcium and phosphate homeostasis. In this report, we present two cases presenting with poor growth, severe pain, and respiratory problems secondary to calcipenic rickets.

Levels of somatic hypermutations in B cell receptors increase during childhood

Somatic hypermutation (SHM) is an important step in antigen-driven B cell development creating B lymphocytes expressing high-affinity antibody receptors. It is known that the peripheral B lymphocyte compartments of healthy children and adults differ considerably. However, the development of SHM with age has not been studied in detail previously. Therefore, we used the immunoglobulin (Ig)κ-restriction enzyme hot-spot mutation assay (Igκ-REHMA) to gain an estimation of SHM levels in different age groups in order to relate this to the size of the memory B lymphocyte subpopulations. We show that the level of SHM increases rapidly during the first 2 years of life. This reflects the changes of the memory B cell subpopulations, but also changes in the SHM within memory B cell subsets, probably reflecting an increase of secondary memory B cell responses.

Association of change in physical activity and body weight with quality of life and mortality in colorectal cancer: a systematic review and meta-analysis

PURPOSE

A systematic review and a meta-analysis were performed to assess the associations between change over time in physical activity and weight and quality of life and mortality in colorectal cancer patients.

METHODS

The PubMed, Embase, and Cochrane Central Register of Controlled Trials databases were searched for English language articles published between January 1, 1990 and October 7, 2013. These articles reported results for changes in physical activity and body weight, assessed at pre- to post-diagnosis or at post-diagnosis only. A random effects model was used to analyze pooled quality of life and mortality estimates.

RESULTS

Seven eligible studies were identified and analyzed. Increased physical activity was associated with higher overall quality of life scores (N = 3 studies; standardized mean difference (SMD) = 0.74, 95 % confidence interval (CI) = 0.66-0.82), reduced disease-specific mortality risk (hazard ratio (HRpooled) = 0.70, 95 % CI = 0.55-0.85), and reduced overall mortality (HRpooled = 0.75, CI = 0.62-0.87) (N = 2 studies). Weight gain was not associated with disease-specific (HRpooled = 1.02, CI = 0.84-1.20) or overall (HRpooled = 1.03, CI = 0.86-1.19) mortality (N = 3 studies).

CONCLUSIONS

Increased physical activity was associated with improved quality of life, a reduced risk of colorectal cancer, and overall mortality rate. Given the paucity of the literature published on this topic, this finding should be interpreted with caution.

The PedPAD study: boys predominate in the hypogammaglobulinaemia registry of the ESID online database

Hypogammaglobulinaemias are the most common primary immunodeficiency diseases. This group of diseases is very heterogeneous, and little is known about these diseases in children. In the Pediatric Predominantly Antibody Deficiencies (PedPAD) study, we analysed data from the European Society for Immunodeficiencies (ESID) online database to gain more insight into the characteristics of children with hypogammaglobulinaemia; 46 centres in 18 different countries agreed to participate. Data from 2076 of the 3191 children who were registered at the time of data extraction with a diagnosis of hypogammaglobulinaemia (this excludes agammaglobulinaemia and defects in class-switch recombination) were available for analysis. The data set showed several limitations. Because of country-related differences in diagnostic criteria used for the classification of different types of primary hypogammaglobulinaemia, further analysis of the data was performed in the combined data set. The most striking observation is the strong majority of male patients in the group of children with primary hypogammaglobulinaemia (n = 1292, 63%). This male predominance was observed in each of the 18 countries involved. The boys were younger at diagnosis (mean age males 5·3 years; mean age females 5·8 years). Moreover, one or more complications were more frequently reported in boys (12%) compared to girls (5%). The male predominance suggests that patients with an undetected or unknown X-linked genetic cause are included in this group of children registered as primary hypogammaglobulinaemia.

Burden of disease due to cutaneous melanoma has increased in the Netherlands since 1991

BACKGROUND

The burden of disease, describing loss of health and death due to a disease, has not been fully studied for melanoma in the general population over time.

OBJECTIVES

To determine the burden of disease due to melanoma in the Netherlands.

METHODS

Age- and sex-specific incidence data from all patients with melanoma in the Netherlands between 1991 and 2010 were obtained from the Netherlands Cancer Registry. Melanoma-specific mortality and life expectancy data were obtained from Statistics Netherlands. Melanoma duration was calculated using the DISMOD software from the World Health Organization. The years of life lived with disability (YLD) and years of life lost (YLL) due to melanoma were calculated using Dutch disability weights, incidence and mortality of melanoma, and the life expectancy from the general population. The number of disability-adjusted life-years (DALYs) was estimated by adding YLD and YLL.

RESULTS

The world-standardized incidence rates of melanoma have more than doubled for both men (7·1 per 100 000 inhabitants in 1991 to 17·0 in 2010) and women (9·4 per 100 000 inhabitants in 1991 to 19·8 in 2010). Likewise, the burden of melanoma to society has increased rapidly. The YLD for men increased from 4795 (1991-4) to 12 441 (2007-10), and for women from 7513 (1991-4) to 16 544 (2007-10). In 2007-10 the total YLL due to melanoma was 30 651 for men and 26 244 for women compared with 17 238 and 16 900, respectively, in 1991-4. The DALYs increased by 96% for men, from 22 033 (1991-4) to 43 092 (2007-10), and by 75% for women, from 24 413 (1991-4) to 42 788 (2007-10).

CONCLUSIONS

Melanoma is becoming a great burden to Dutch society.

Significant impact of recurrent respiratory tract infections in children with Down syndrome

OBJECTIVE

Parents and health professionals believe that recurrent respiratory tract infections (RRTI) have a large impact on children with Down syndrome (DS). We studied the relation between parent-reported RRTI and development, behaviour and health-related quality of life (HRQoL) in 8-year-old children with DS.

METHOD

During a 3-year period, 325 children with DS were recruited for inclusion in this observational study. Parents were asked to fill in the Child Behavior Checklist and TNO-AZL Children's Quality of Life Parent Form. A psychological assistant administrated the McCarthy Scales of Children's Abilities. The children were divided into a group with presence of RRTI (RRTI (+) ) and a group without RRTI (RRTI (-) ), on the basis of parental report. Linear regression analyses were performed to assess the effect of RRTI, while correcting for the influence of confounders.

RESULTS

Compared with RRTI (-) children (n = 176), RRTI (+) children (n = 149, 46%) showed decreased mental and motor development (mean developmental age 3.67 vs. 4.08 years), more behavioural problems and lower scores on most HRQoL scales (P < 0.05). Moreover, school enrolment is less favourable in RRTI (+) children.

CONCLUSION

In 8-year-olds with DS, the children with parent-reported RRTI show more delayed development, more behavioural problems and lower HRQoL compared with the children without RRTI. Although this association does not prove a causal relationship, further studies should focus on this, because RRTI are potentially preventable.

Adaptation of novel H7N9 influenza A virus to human receptors

The emergence of the novel H7N9 influenza A virus (IAV) has caused global concerns about the ability of this virus to spread between humans. Analysis of the receptor-binding properties of this virus using a recombinant protein approach in combination with fetuin-binding, glycan array and human tissue-binding assays demonstrates increased binding of H7 to both α2-6 and α2-8 sialosides as well as reduced binding to α2-3-linked SIAs compared to a closely related avian H7N9 virus from 2008. These differences could be attributed to substitutions Q226L and G186V. Analysis of the enzymatic activity of the neuraminidase N9 protein indicated a reduced sialidase activity, consistent with the reduced binding of H7 to α2-3 sialosides. However, the novel H7N9 virus still preferred binding to α2-3- over α2-6-linked SIAs and was not able to efficiently bind to epithelial cells of human trachea in contrast to seasonal IAV, consistent with its limited human-to-human transmission.

Trends in incidence and predictions of cutaneous melanoma across Europe up to 2015

BACKGROUND

Melanoma is a significant health problem in Caucasian populations. The most recently available data from cancer registries often have a delay of several months up to a few years and they are generally not easily accessible.

OBJECTIVES

To assess recent age- and sex-specific trends in melanoma incidence and make predictions for 2010 and 2015.

METHODS

A retrospective registry-based analysis was performed with data from 29 European cancer registries. Most of them had data available from 1990 up to 2006/7. World-standardized incidence rates (WSR) and the estimated annual percentage change (EAPC) were computed. Predictions were based on linear projection models.

RESULTS

Overall the incidence of melanoma is rapidly rising and will continue to do so. The incidence among women in Europe was generally higher than in men. The highest incidence rates were seen for Northern and north-western countries like the UK, Ireland and the Netherlands. The lowest incidence rates were observed in Portugal and Spain. The incidence overall remained stable in Norway, where, amongst young (25-49 years) Norwegian males rates significantly decreased (EAPC -2.8, 95% CI -3.6; -2.0). Despite a low melanoma incidence among persons above the age of 70, this age group experienced the greatest increase in risk during the study period.

CONCLUSIONS

Incidence rates of melanoma are expected to continue rising. These trends are worrying in terms of disease burden, particularly in eastern European countries.

β-Blocker use and all-cause mortality of melanoma patients: results from a population-based Dutch cohort study

BACKGROUND

Results from preclinical and observational studies suggest that β-adrenoreceptor inhibition might influence disease progression of melanoma.

PATIENTS AND METHODS

Patients ⩾18years with cutaneous melanoma (Breslow thickness >1mm) registered in the Eindhoven Cancer Registry between January 1, 1998 and December 31, 2010, who were also registered with PHARMO record linkage system (RLS), were eligible. Randomly selected patients using β-blockers from PHARMO record linkage system (RLS) matched on age and gender served as a control cohort. Adjusted time-dependent and time-fixed Cox proportional hazard models were employed to estimate the hazard ratio of all-cause mortality. Five-year relative survival rates for all-cause mortality were calculated to estimate disease specific survival.

RESULTS

203 of 709 eligible patients used β-blockers after melanoma diagnosis. The use of β-blockers was not associated with the risk of dying (adjusted hazard ratio (HR) 0.82, 95% confidence interval (CI) 0.55-1.24). Neither duration of exposure nor β-blocker dosage showed significant influence on survival. Five-year relative survival for β-blocker users was lower than in non-users amongst melanoma patients (80.9% and 83.7%, respectively) but higher among the β-blocker control group compared to the general population (101.4%).

CONCLUSION

Our results do not show a statistically significant impact of β-blocker exposure on overall survival of melanoma patients, regardless of the timing, duration or dosage of β-blocker use.

Routine screening for Coxiella burnetii infection during pregnancy: a clustered randomised controlled trial during an outbreak, the Netherlands, 2010

Between 2007 and 2010, the Netherlands experienced one of the largest outbreaks of Q fever. Since asymptomatic Coxiella burnetii infection has been associated with maternal and obstetric complications, evidence about the effectiveness of routine screening during pregnancy in outbreak areas is needed. We performed a clustered randomised controlled trial during the Dutch outbreak, in which 55 midwife centres were randomised to recruit pregnant women for an intervention or control strategy. In both groups a serum sample was taken between 20 and 32 weeks of gestation. In the intervention group (n=536), the samples were analysed immediately by indirect immunofluorescence assay for the presence of IgM and IgG (phase I/II) and treatment was given during pregnancy in case of an acute or chronic infection. In the control group (n=693), sera were frozen for analysis after delivery. In both groups 15% were seropositive. In the intervention group 2.2% of the women were seropositive and had an obstetric complication, compared with 1.4% in the control group (Odds ratio: 1.54 (95% confidence interval 0.60-3.96)). During a large Q fever outbreak, routine C. burnetii screening starting at 20 weeks of gestation was not associated with a relevant reduction in obstetric complications and should therefore not be recommended.

Inferior survival for young patients with contralateral compared to unilateral breast cancer: a nationwide population-based study in the Netherlands

To compare overall survival between women with unilateral breast cancer (UBC) and contralateral breast cancer (CBC). Women with UBC (N = 182,562; 95 %) and CBC (N = 8,912; 5 %) recorded in the Netherlands Cancer Registry between 1989 and 2008 were included and followed until 2010. We incorporated CBC as a time-dependent covariate to compute the overall mortality rate ratio between women with CBC and UBC. Prognostic factors for overall death were examined according to age at first breast cancer. Women with CBC exhibited a 30 % increase in overall mortality (Hazard Ratio (HR), 95 % Confidence Interval: 1.3, 1.3-1.4) compared with UBC, decreasing with rising age at diagnosis of first breast cancer (<50 years: 2.3, 2.2-2.5 vs. ≥70 years: 1.1, 1.0-1.1). Women older than 50 years at CBC diagnosis and diagnosed 2-5 years after their first breast cancer exhibited a 20 % higher death risk (1.2, 1.0-1.3) compared to those diagnosed within the first 2 years. In women younger than 50 years, the HR was significantly lower if the CBC was diagnosed >5 years after the first breast cancer (0.7, 0.5-0.9). The prognosis for women with CBC significantly improved over time (2004-2008: 0.6, 0.5-0.7 vs. 1989-1993). Women with CBC had a lower survival compared to women with UBC, especially those younger than 50 years at first breast cancer diagnosis. A tailored follow-up strategy beyond current recommendations is needed for these patients who, because of their age and absence of known familial risk, are currently not invited for population-based screening.

Basal cell carcinomas without histological confirmation and their treatment: an audit in four European regions

BACKGROUND

Limited data are available on how often basal cell carcinomas (BCCs) are clinically diagnosed without histological confirmation and how they are treated.

OBJECTIVES

Within the framework of the EPIDERM project, an audit was conducted in four European countries to study the occurrence of clinically diagnosed BCCs without histological confirmation and to investigate how these are treated.

METHODS

In the Netherlands, Scotland, Finland and Malta studies were performed within different timeframes. Patients with one or more BCC(s) were selected and the number of clinically diagnosed BCCs without histological confirmation and their treatment was investigated by (manually) reviewing the (electronic) patient records and checking the (hospital) pathology databases to find evidence of histological confirmation.

RESULTS

In the Netherlands, 1089 patients with a first histologically confirmed BCC developed 1974 BCCs of which 1833 (92·9%) were histologically confirmed and 141 (7·1%) were not. A 4-month retrospective study conducted in Scotland selected 294 patients with 344 BCCs; 306 (89·0%) were histologically confirmed and 38 (11·0%) were not. A 3-month prospective study performed at the same centre in Scotland identified 44 patients who developed 58 BCCs; 44 (75·9%) of these were histologically confirmed and 14 (24·1%) were not. In Finland, there were 701 patients who developed 977 BCCs, of which 807 (82·6%) were histologically and 170 (17·4%) nonhistologically confirmed. In Malta, there were 420 patients with 477 BCCs. Only three (0·7%) of them were clinically diagnosed without histological confirmation. In the Netherlands and Finland, clinically diagnosed BCCs without histological confirmation were most often treated with cryotherapy, whereas in Scotland 5% imiquimod cream was the preferred treatment modality.

CONCLUSIONS

Although the frequency of clinically diagnosed BCCs without histological confirmation differed between the four European regions (range 0·7-24·1%), this confirms that the burden of BCC in Europe is underestimated when based on data from pathology and/or cancer registries.

Potential impact of interventions resulting in reduced exposure to ultraviolet (UV) radiation (UVA and UVB) on skin cancer incidence in four European countries, 2010-2050

BACKGROUND

Behavioural interventions to reduce exposure to ultraviolet radiation (UVR) can reduce risk of skin cancer.

OBJECTIVES

To integrate the data and to evaluate the impact of interventions to limit exposure to UVR on skin cancer incidence in four selected countries.

METHODS

Using PREVENT, a dynamic simulation model, we modelled the potential for skin cancer prevention in four European countries under various scenarios to avoid damage by UVR.

RESULTS

In general, the most effective interventions were those aimed at protecting people during outdoor work and outdoor hobbies against the harmful effects of UVR, and combinations of several interventions. These could in theory lead to reductions of up to 45% in skin cancer cases projected for the year 2050.

CONCLUSIONS

The scope for prevention depends on the prevalence of the risk factors in the different countries, as well as the associated risk factors and time lags modelled.

Melanoma incidence and mortality in Europe: new estimates, persistent disparities

BACKGROUND

Melanoma incidence and mortality in Europe are high but there are significant gaps in the epidemiological information available across the continent.

OBJECTIVES

With the aim of enhancing the planning of educational programmes for reducing the melanoma burden in Europe, we analysed the most recent incidence and mortality data for Europe with a new focus on the regional disparities of melanoma reporting.

METHODS

GLOBOCAN 2008, the standard set of worldwide estimates of cancer incidence and mortality produced by the International Agency for Research on Cancer for 2008, was used to provide the estimated age-standardized rates (world standard population) of melanoma incidence and mortality in European countries and regions.

RESULTS

The estimated age-standardized incidence of melanoma (measured per 100 000 person-years) varies widely from 19·2 in Switzerland to 2·2 in Greece. The incidence rate of 4·3 of Central and Eastern Europe (CEE) is less than half of that of Western Europe. Melanoma mortality rates of 1·5 are similar in CEE and Western Europe, although rates vary with a high of 3·2 in Norway and a low of 0·9 in Greece. Over 20 000 deaths from melanoma were estimated in Europe in 2008, with CEE having the largest share (35·5%) among the four geographical European regions. Population-based data are lacking for significant parts of CEE, which must rely on estimates.

CONCLUSIONS

The most recent estimates of melanoma incidence and mortality in Europe reveal sharp differences between European countries, possibly related to missed opportunities for early diagnosis and incomplete reporting of melanoma in Eastern Europe.

Paediatric reference values for the peripheral T cell compartment

Immunophenotyping of blood lymphocyte subpopulations is an important tool in the diagnosis of immunological and haematological diseases. Paediatric age-matched reference values have been determined for the major lymphocyte populations, but reliable reference values for the more recently described T lymphocyte subpopulations, like different types of memory T lymphocytes, recent thymic emigrants, regulatory T cells and CXCR5(+) helper T lymphocytes, are not sufficiently available yet. We determined reference values for the absolute and relative sizes of T lymphocyte subpopulations in healthy children using the lysed whole blood method, which is most often used in diagnostic procedures. When the absolute numbers of some or all T lymphocyte subpopulations fall outside these reference ranges, this may indicate disease. The reference values show the course of T lymphocyte development in healthy children. Absolute T lymphocyte numbers increase 1.4-fold during the first months of life, and after 9-15 months, they decrease threefold to adult values; this is mainly caused by the expansion of recent thymic emigrants and naive cells. Helper and cytotoxic T lymphocytes show the same pattern. Regulatory T cells increase in the first 5 months of life and then gradually decrease to adult values, although the absolute numbers remain small. The relative number of CXCR5(+) cells within the CD4(+) CD45RO(+) T lymphocytes increases during the first 6 months of life and then remains more or less stable around 20%.