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Buyer's clubs were first recognised during the HIV/AIDS pandemic in the 1980s and focussed on knowledge curation and distribution of treatments. In the past decade, there has been a resurgence of buyer's clubs, mostly focussed on hepatitis C treatment and PrEP. This paper aims to increase understanding of buyer's clubs and stimulate discussion on their role in achieving equitable access to medicines. Our proposed definition of a buyer's club is 'a community-led organisation or group which seeks to improve an individual's access to medication through knowledge sharing and/or distribution as its primary goal'. The logistical and relational infrastructures of buyer's clubs have been mapped out. Networks and communities are integral to buyer's clubs by facilitating practical aspects of buyer's clubs and creating a sense of community that serves as a foundation of trust. For a user to receive necessary medical support, doctors play a crucial role, yet, obtaining this support is difficult. Whilst buyer's clubs are estimated to have enabled thousands of people to access medicines, and they run the risk of perpetuating health inequities and injustices. They may have the potential to serve as a health activism tool to stimulate sustainable changes; however, this needs to be explored further.

Rationale & Objective: Although patients with chronic kidney disease (CKD) are at risk for work disability and loss of employment, not all experience work disruption. We aimed to describe the barriers to and facilitators of sustained employment experienced by Dutch patients with CKD.Study Design: Qualitative study using semi-structured interviews.Setting & Participants: 27 patients with CKD glomerular filtration rate categories 3b-5 (G3b-G5) from 4 nephrology outpatient clinics in The Netherlands.Analytical Approach: Content analyses with constant comparison of interview data based on the International Classification of Functioning, Disability and Health framework.Results: Participants were 6 patients with CKD G3b-G4, 8 patients receiving maintenance dialysis, and 13 patients with functioning kidney transplants. We identified health-related barriers (symptoms, physical toll of dialysis/transplantation, limited work capacity) and facilitators (few physical symptoms, successful posttransplantation recovery, absence of comorbidities, good physical condition), personal barriers (psychological impact, limited work experience) and facilitators (positive disposition, job satisfaction, work attitude, person-job fit), and environmental barriers and facilitators. Environmental barriers were related to nephrology care (waiting time, use of a hemodialysis catheter) and work context (reorganization, temporary contract, working hours, physical demands); environmental facilitators were related to nephrology care (personalized dialysis, preemptive transplant), work context (large employer, social climate, job requiring mental rather than physical labor, flexible working hours, adjustment of work tasks, reduced hours, remote working, support at work, peritoneal dialysis exchange facility), and support at home. Occupational health services and social security could be barriers or facilitators.Limitations: The study sample of Dutch patients may limit the transferability of these findings to other countries.Conclusions: The wide range of barriers and facilitators in all International Classification of Functioning, Disability and Health components suggests great diversity among patients and their circumstances. These findings underline the importance of personalized nephrology and occupational health care as well as the importance of individually tailored workplace accommodations to promote sustained employment for patients with CKD.

Background: Low-grade inflammation (LGI) and endothelial dysfunction (ED) might play a key role in the development of depression. We investigated the associations and mediation of LGI and ED with four-year incidence and course of depressive symptoms (remitted, recurrent or persistent). Design, setting, participants, measurements: In this prospective cohort study (mean age 59.6 +/- 8.2 years, 48.9% women, 26.6% diabetes by design), Cox and multinomial regression analyses, adjusted for age, sex, educational level and diabetes status were used to investigate the associations of LGI and ED with onset and course of depressive symptoms as assessed by the PHQ-9 questionnaire. Results: During 10,847 person-years of follow-up, 264 participants developed incident depression. Higher levels of LGI (OR [95%CI] per SD 1.32[1.16-1.49], p < 0.001) and ED (1.26[1.11-1.43], p < 0.001) were associated with incident depressive symptoms. In mediation analysis, 60% of the total effect of ED with incident depressive symptoms could be attributed to LGI. 76 out of 2637 participants had a persistent course of depressive symptoms. Higher levels of LGI (1.75[1.40-2.19], p < 0.001) and ED (1.33[1.04-1.71], p = 0.021) were associated with a persistent course of depressive symptoms. Higher ED was more strongly associated with persistent depressive symptoms (1.33[1.04-1.71], p = 0.021), while LGI was associated with remission of depression symptoms. Conclusions: LGI and ED were both associated with incident depressive symptoms, where the latter association was substantially mediated by LGI. ED was further associated with a persistent course of depressive symptoms, while LGI was not. These results suggest a temporal, vascular contribution of both LGI and ED to the etiology and chronicity of depressive symptoms.

Background and ObjectivesObservational research has shown that a substantial proportion of all dementia cases worldwide are attributable to modifiable risk factors. Dementia risk scores might be useful to identify high-risk individuals and monitor treatment adherence. The objective of this study was to investigate whether a dementia risk score, the Lifestyle for Brain Health (LIBRA) index, is associated with MRI markers and cognitive functioning/impairment in the general population.MethodsCross-sectional data were used from the observational population-based cohort of The Maastricht Study. The weighted compound score of LIBRA (including 12 dementia risk and protective factors, e.g., hypertension, physical inactivity) was calculated, with higher scores indicating higher dementia risk. Standardized volumes of white matter, gray matter, and CSF (as proxy for general brain atrophy), white matter hyperintensities, and presence of cerebral small vessel disease were derived from 3T MRI. Cognitive functioning was tested in 3 domains: memory, information processing speed, and executive function and attention. Values ≤1.5 SDs below the average were defined as cognitive impairment. Multiple regression analyses and structural equation modeling were used, adjusted for age, sex, education, intracranial volume, and type 2 diabetes.ResultsParticipants (n = 4,164; mean age 59 years; 49.7% men) with higher LIBRA scores (mean 1.19, range −2.7 to 9.2), denoting higher dementia risk, had higher volumes of white matter hyperintensities (β = 0.051,p= 0.002) and lower scores on information processing speed (β = −0.067,p= 0.001) and executive function and attention (β = −0.065,p= 0.004). Only in men, associations between LIBRA score and volumes of gray matter (β = −0.093,p< 0.001) and CSF (β = 0.104,p< 0.001) and memory (β = −0.054,p= 0.026) were found. White matter hyperintensities and CSF volume partly mediated the association between LIBRA score and cognition.DiscussionHigher health- and lifestyle-based dementia risk is associated with markers of general brain atrophy, cerebrovascular pathology, and worse cognition, suggesting that LIBRA meaningfully summarizes individual lifestyle-related brain health. Improving LIBRA factors on an individual level might improve population brain health. Sex differences in lifestyle-related pathology and cognition need to be further explored.Classification of EvidenceThis study provides Class II evidence that higher LIBRA scores are significantly associated with lower scores in some cognitive domains and a higher risk of cognitive impairment.

BackgroundIndividuals with depression often experience widespread and persistent cognitive deficits, which might be due to brain atrophy and cerebral small vessel disease (CSVD). We therefore studied the associations between depression, markers of brain atrophy and CSVD, and cognitive functioning.MethodsWe used cross-sectional data from the population-based Maastricht study (n = 4734; mean age 59.1 ± 8.6 years, 50.2% women), which focuses on type 2 diabetes. A current episode of major depressive disorder (MDD, n = 151) was assessed by the Mini-International Neuropsychiatric Interview. Volumes of cerebral spinal fluid, white matter, gray matter and white matter hyperintensities, presence of lacunar infarcts and cerebral microbleeds, and total CSVD burden were assessed by 3 T magnetic resonance imaging. Multiple linear and logistic regression analyses tested the associations between MDD, brain markers and cognitive functioning in memory, information processing speed, and executive functioning & attention, and presence of cognitive impairment. Structural equation modeling was used to test mediation.ResultsIn fully adjusted models, MDD was associated with lower scores in information processing speed [mean difference = −0.18(−0.28;−0.08)], executive functioning & attention [mean difference = −0.13(−0.25;−0.02)], and with higher odds of cognitive impairment [odds ratio (OR) = 1.60(1.06;2.40)]. MDD was associated with CSVD in participants without type 2 diabetes [OR = 1.65(1.06;2.56)], but CSVD or other markers of brain atrophy or CSVD did not mediate the association with cognitive functioning.ConclusionsMDD is associated with more impaired information processing speed and executive functioning & attention, and overall cognitive impairment. Furthermore, MDD was associated with CSVD in participants without type 2 diabetes, but this association did not explain an impaired cognitive profile.

BackgroundThis study examined the associations between accelerometer-derived sedentary time (ST), lower intensity physical activity (LPA), higher intensity physical activity (HPA) and the incidence of depressive symptoms over 4 years of follow-up.MethodsWe included 2082 participants from The Maastricht Study (mean ± s.d. age 60.1 ± 8.0 years; 51.2% men) without depressive symptoms at baseline. ST, LPA and HPA were measured with the ActivPAL3 activity monitor. Depressive symptoms were measured annually over 4 years of follow-up with the 9-item Patient Health Questionnaire (PHQ-9). Cox regression analysis was performed to examine the associations between ST, LPA, HPA and incident depressive symptoms (PHQ-9 ⩾ 10). Analyses were adjusted for total waking time per day, age, sex, education level, type 2 diabetes mellitus, body mass index, total energy intake, smoking status and alcohol use.ResultsDuring 7812.81 person-years of follow-up, 203 (9.8%) participants developed incident depressive symptoms. No significant associations [Hazard Ratio (95% confidence interval)] were found between sex-specific tertiles of ST (lowest v. highest tertile) [1.13 (0.76–1.66], or HPA (highest v. lowest tertile) [1.14 (0.78–1.69)] and incident depressive symptoms. LPA (highest v. lowest tertile) was statistically significantly associated with incident depressive symptoms in women [1.98 (1.19–3.29)], but not in men (p-interaction ConclusionsWe did not observe an association between ST or HPA and incident depressive symptoms. Lower levels of daily LPA were associated with an increased risk of incident depressive symptoms in women. Future research is needed to investigate accelerometer-derived measured physical activity and ST with incident depressive symptoms, preferably stratified by sex.

BACKGROUND Investigation was undertaken to determine the genetic relatedness of Neisseria gonorrhoeae (NG) isolates of young (

Background There is ongoing debate about the possible protective effect of the bivalent human papillomavirus (2vHPV) vaccine, targeting oncogenic types HPV-16/18, against anogenital warts (AGWs), commonly attributed to HPV-6/11. We performed a retrospective registry-based open cohort study to assess the effect of 2vHPV vaccination on AGWs. Methods We linked general practice (ie, primary care) data from women born between 1993 and 2002, who had been eligible for HPV vaccination in the Netherlands, to the Dutch national immunization registry on an individual level. Women were followed until their first AGW diagnosis or end of follow-up. Adjusted incidence rate ratios (aIRRs) were estimated using Poisson regression with vaccination status as a time-dependent exposure. Results We linked data of 96 468 women with a total of 328 019 years observation time and 613 AGW diagnoses (incidence: 1.87/1000 person-years). At the end of follow-up, 61% were 2vHPV vaccinated (≥ 1 dose) of whom 91% were fully vaccinated. The AGW incidence was lower among those with ≥ 1 dose vs 0 doses (aIRR, 0.75 [95% confidence interval {CI}, .64–.88]). The effect of vaccination was stronger after full vaccination (aIRR, 0.72 [95% CI, .61–.86]) and for women who were offered vaccination at 12–13 years of age (aIRR, 0.69 [95% CI, .51–.93]) vs those at 13–16 years of age (aIRR, 0.77 [95% CI, .64–.93]). Conclusions This is the largest population-based study so far to examine the effect of 2vHPV vaccination on AGWs, with reliable individual information on AGW diagnoses and vaccination status. The results indicate that 2vHPV vaccination partially protects against AGWs, especially when administered in early adolescence., In this large population-based cohort study linking primary care and immunization registry data, anogenital wart incidence was significantly reduced among human papillomavirus (HPV) type 16/18–vaccinated vs unvaccinated women, suggesting a partial protective effect of bivalent HPV vaccination against anogenital warts.

AIM: We examined how gut feelings of child health care physicians' (CHCPs) contribute to the development of a suspicion of child abuse, how they act upon this suspicion and what barriers they experience in their management. To gain insight into the youth health care chain, we compared the diagnostic reasoning and management regarding this issue by CHCPs and family physicians (FPs).METHODS: Three focus groups, 20 CHCPs, thematic content analysis.RESULTS: A gut feeling acted as an early alert to look for the triggering cue(s), by observing more closely and asking relevant questions. CHCPs struggled to distinguish whether the situation involved child abuse or a lack of parenting skills, and how to communicate their concerns with parents. They tried to motivate parents to improve the situation, avoiding the term child abuse and considered involving the Child Abuse Counselling and Reporting Centre (CACRC) a measure of last resort only.CONCLUSION: As with FPs, gut feelings support CHCPs in becoming attentive to child abuse and to situations which can lead to child abuse. The next step, discussing their suspicion with the parents, is a difficult one, and the CACRC might actually help to make this step easier.

Background Because of an expected increase in the number of family caregivers, there is a growing public and scientific interest in family caregiving and more specifically in the combination of family care with paid employment. It is important to gain insight in the family caregivers' strain and determining factors in the job and family domain. Aim The aim of the study was to examine the associations of job and family demands and job and family resources with indicators of caregivers' psychological strain, that is caregiver burden, work-related emotional exhaustion and general ill mental health. In our research, we focused on individuals who combine paid employment with family caregiving. Methods A cross-sectional design was used. The study sample was derived in 2011 from a Dutch financial organisation and a healthcare organisation. A digital fully structured questionnaire was used. The sample consisted of 187 employees who identified themselves as family caregivers. Descriptive statistics and hierarchical linear regression analysis were performed. Results Job demands (i.e. workload, work-family conflict) and family demands (i.e. family care hours and family-work conflict) were significantly positively associated with all three domain-specific indicators of strain. The resources of work-family and family-work enrichment and autonomy did not contribute to less experienced strain. More supervisor and colleague support was associated with lower ill mental health. Conclusion Our study showed that job demands (workload, work-family conflict) and family demands (family care hours, family-work conflict) were clearly associated with caregiver strain, while associations for job and family resources were not evident. It remains necessary to pay attention to the demanding aspects of dual roles of family caregivers but also to investigate the resources they have available at work as well as in their home situation and explore their potential reducing effect on family caregivers' strain.

Women are not routinely tested for oropharyngeal Neisseria gonorrhoeae. At present, selective testing based on sexual behaviour or risk groups is advocated by international guidelines. Many oropharyngeal infections are asymptomatic and thus remain undetected, establishing a reservoir for ongoing transmission. Data on effectiveness of routine testing are scarce, thus we aimed to assess the optimal testing strategy for oropharyngeal N gonorrhoeae in women.In this retrospective cohort study, we used surveillance data obtained from all sexually transmitted infection (STI) clinics in the Netherlands between Jan 1, 2008, and Dec 31, 2017. We collected consultation-level data, and individual-level patient data from 2016 onwards, on sociodemographic characteristics, sexual behaviour in the past 6 months, self-reported symptoms, and STI diagnoses. We compared the prevalence of oropharyngeal N gonorrhoeae between women who attended clinics that offered routine universal testing (defined as85% of women tested per clinic-year) and women who attended clinics that offered selective testing (defined as 5-85% of women tested per clinic-year) or incidental testing (5% of women tested per clinic-year). We calculated the number of infections missed by selective testing by extrapolating prevalence for the routine universal testing group to that of weighted and unweighted samples of all selectively tested women. We used multivariable generalised estimating equations to identify independent risk factors for oropharyngeal N gonorrhoeae to identify the optimal selective testing strategy.554 266 consultations with at least one N gonorrhoeae test were recorded, of which 545 750 consultations (including repeat visits) were included in the analyses. Of 545 750 consultations, routine universal testing was used in 57 359 (10·5%), selective testing in 444 283 (81·4%), and incidental testing in 44 108 (8·1%). The prevalence of oropharyngeal N gonorrhoeae was 1·4% (95% CI 1·3-1·5; 703 of 50 962 consultations) in the routine testing group compared with 1·4% (1·3-1·5; 1858 of 132 276) in the selective testing group (p=0·68) and 2·8% (1·9-3·9; 30 of 1088) in the incidental testing group (p0·0001). The prevalence of oropharyngeal-only infections was 47·7% (335 of 703 women) in the routine testing group, 53·3% (991 of 1858) in the selective testing group, and 60·0% (18 of 30) in the incidental testing group. Selective testing would have missed an estimated 4363 (70%; 95% CI 69-71) of all 6221 oropharyngeal N gonorrhoeae infections. Independent risk factors for oropharyngeal N gonorrhoeae were being notified for any STI (adjusted odds ratio 2·1, 95% CI 1·5-3·0), reporting sex work (4·0, 2·3-6·7), and having concurrent genital (51·5, 34·1-77·7) or anorectal (2·6, 1·4-4·8) N gonorrhoeae. Selective testing of women notified for any STI, or who reported sex work, would have led to 5418 (27·8%) of 19 455 women being tested and would have identified 119 (55·6%) of 214 oropharyngeal N gonorrhoeae infections.Selective testing potentially misses more than two-thirds of oropharyngeal N gonorrhoeae infections in women, of whom half have oropharyngeal infections without concurrent genital or anorectal infections. Using independent risk factors for oropharyngeal infection to guide testing is a minimal testing strategy. Routine universal testing is the optimum scenario to detect the majority of infections. However, future studies are needed to assess the cost-effectiveness of routine testing and its effect on antimicrobial resistance.Public Health Service South Limburg.

Purpose The MiLES intervention is a web-based intervention targeted at employers with the objective of enhancing successful return to work (RTW) of cancer survivors. The aim of this study is to gain insight into the employers’ use and perceived usefulness of the MiLES intervention. Methods Employer representatives (e.g. Human Resource managers and supervisors) were given access to the MiLES intervention, which contains, among others, interactive videos, conversation checklists and tailored tips. After six weeks, an online questionnaire gathered data on employers’ use and the perceived usefulness of the intervention. In-depth qualitative data on these topics were gathered during semi-structured interviews, which were analyzed using a content analysis. Results Thirty-one eligible employers were included. Twenty-two of them filled out the questionnaire and twenty were interviewed. Typically, employers used the intervention 2–3 times, for 26 min per visit. The usefulness of the intervention scored 7.6 out of 10 points, and all employers would recommend it to colleagues. Employers’ use decreased when support needs were low and when the intervention did not correspond with their specific situation (e.g. complex reintegration trajectories). Employers perceived the intervention to be supporting and practically oriented. They appreciated the fact that the intervention was web-based and combined visual and textual content. The possibility of consulting specialized services for complex situations would further enhance its usefulness. Conclusion The MiLES intervention provides employers with a useful tool in their daily practice. Its effectiveness for enhancing employers’ managerial skills and cancer survivors’ successful RTW is subject for further research.

ObjectivesGeneral practitioners (GPs) and sexual health centres (SHCs) are the main providers of HIV testing and diagnose two-thirds of HIV infections in the Netherlands. We compared regional HIV testing and positivity by GPs versus SHCs to gain insight into strategies to improve HIV testing, to enable timely detection of HIV infections.MethodsLaboratory data (2011–2018) on HIV testing by GPs and SHCs in five Dutch regions with varying levels of urbanisation were evaluated. Regional HIV testing rates per 10 000 residents ≥15 years (mean over period and annual) were compared between providers using negative binomial generalised additive models and additionally stratified by sex and age (15–29 years, 30–44 years, 45–59 years, ≥60 years). χ2 tests were used to compare positivity percentage between the two groups of providers.ResultsIn the study period, 505 167 HIV tests (GP 36%, SHC 64%) were performed. The highest HIV testing rates were observed in highly urbanised regions, with large regional variations. The HIV testing rates ranged from 28 to 178 per 10 000 residents by GPs and from 30 to 378 per 10 000 by SHCs. Testing rates by GPs were lower than by SHCs in three regions and comparable in two. In all regions, men were tested less by GPs than by SHCs; for women, this varied by region. Among those aged 15–29 years old, GPs’ testing rates were lower than SHCs’, while this was reversed in older age categories in four out of five regions. The overall mean HIV positivity was 0.4%. In contrast to other regions, positivity in Amsterdam was significantly higher among individuals tested by GPs than by SHCs.ConclusionsThis retrospective observational study shows that besides SHCs, who perform opt-out testing for key groups, GPs play a prominent role in HIV testing, especially in non-key populations, such as women and older individuals. Large regional variation exists, requiring region-specific interventions to improve GPs’ HIV testing practices.

Aims CVD is the main cause of morbidity and mortality in individuals with diabetes. It is currently unclear whether daily glucose variability contributes to CVD. Therefore, we investigated whether glucose variability is associated with arterial measures that are considered important in CVD pathogenesis. Methods We included participants of The Maastricht Study, an observational population-based cohort, who underwent at least 48 h of continuous glucose monitoring (CGM) (n = 853; age: 59.9 ± 8.6 years; 49% women, 23% type 2 diabetes). We studied the cross-sectional associations of two glucose variability indices (CGM-assessed SD [SDCGM] and CGM-assessed CV [CVCGM]) and time in range (TIRCGM) with carotid–femoral pulse wave velocity (cf-PWV), carotid distensibility coefficient, carotid intima–media thickness, ankle–brachial index and circumferential wall stress via multiple linear regression. Results Higher SDCGM was associated with higher cf-PWV after adjusting for demographics, cardiovascular risk factors and lifestyle factors (regression coefficient [B] per 1 mmol/l SDCGM [and corresponding 95% CI]: 0.413 m/s [0.147, 0.679], p = 0.002). In the model additionally adjusted for CGM-assessed mean sensor glucose (MSGCGM), SDCGM and MSGCGM contributed similarly to cf-PWV (respective standardised regression coefficients [st.βs] and 95% CIs of 0.065 [−0.018, 0.167], p = 0.160; and 0.059 [−0.043, 0.164], p = 0.272). In the fully adjusted models, both higher CVCGM (B [95% CI] per 10% CVCGM: 0.303 m/s [0.046, 0.559], p = 0.021) and lower TIRCGM (B [95% CI] per 10% TIRCGM: −0.145 m/s [−0.252, −0.038] p = 0.008) were statistically significantly associated with higher cf-PWV. Such consistent associations were not observed for the other arterial measures. Conclusions Our findings show that greater daily glucose variability and lower TIRCGM are associated with greater aortic stiffness (cf-PWV) but not with other arterial measures. If corroborated in prospective studies, these results support the development of therapeutic agents that target both daily glucose variability and TIRCGM to prevent CVD. Graphical abstract

Objectives: To determine the effect of a single dose of gentamicin on the incidence and persistence of acute kidney injury (AKI) in patients with sepsis in the emergency department (ED).Methods: We retrospectively studied patients with sepsis in the ED in three hospitals. Local antibiotic guidelines recommended a single dose of gentamicin as part of empirical therapy in selected patients in one hospital, whereas the other two hospitals did not. Multivariate analysis was used to evaluate the effect of gentamicin and other potential risk factors on the incidence and persistence of AKI after admission. AKI was defined according to the KDIGO (Kidney Disease Improving Global Outcomes) criteria.Results: Of 1573 patients, 571 (32.9%) received a single dose of gentamicin. At admission, 181 (31.7%) of 571 of the gentamicin-treated and 228 (22.8%) of 1002 of the noneg-ntamicin-treated patients had AKI (p < 0.001). After admission, AKI occurred in 64 (12.0%) of 571 patients who received gentamicin and in 82 (8.9%) of 1002 people in the control group (p 0.06). Multivariate analysis showed that shock (odds ratio (OR), 2.72; 95% CI, 1.31-5.67), diabetes mellitus (OR, 1.49; 95% CI, 1.001-2.23) and higher baseline (i.e. before admission) serum creatinine levels (OR, 1.007; 95% CI, 1.005-1.009) were associated with the development of AKI after admission, but not receipt of gentamicin (OR, 1.29; 95% CI, 0.89-1.86). Persistent AKI was rare in both the group that received gentamicin (16/260, 6.2%) and the group that did not (15/454, 3.3%, p 0.09).Conclusions: With regard to renal function, a single dose of gentamicin in patients with sepsis in the ED is safe. The development of AKI after admission was associated with shock, diabetes mellitus and higher baseline creatinine level. (C) 2020 The Author(s). Published by Elsevier Ltd on behalf of European Society of Clinical Microbiology and Infectious Diseases.

Background The Chlamydia trachomatis bacterial load could have impact on transmission and sequelae. This is the first study providing comparison of C. trachomatis load at 3 anatomic sites estimated by cycle quantification (Cq) values. Methods Data from 7900 C. trachomatis-positive samples were included (2012–2018). Cq value was used as an inversely proportional measure for C. trachomatis load. Multivariable linear regression analyses assessed differences in mean Cq values. Results Vaginal swabs had the lowest Cq values (31.0) followed by urine (32.5), anorectal swabs (34.0), and oropharyngeal swabs (36.8) (P < .001). Men and women had similar oropharyngeal (36.4 vs 37.3; P = .13) and anorectal (34.2 vs 33.9; P = .19) Cq values. Men (32.2) and women (30.7) aged Conclusions Men and women have a similar C. trachomatis load at extragenital locations arguing for similar transmission potential and clinical relevance. Older patients and HIV-coinfected patients had lower C. trachomatis load, suggesting exposure to previous C. trachomatis infections potentially leading to partial immunity reducing load.

Background Guinea undertook health workforce reform in 2016 following the Ebola outbreak to overcome decades-long shortages and maldistribution of healthcare workers (HCWs). Specifically, over 5000 HCWs were recruited and deployed to rural health districts and with a signed 5-year commitment for rural medical practice. Governance structures were also established to improve the supervision of these HCWs. This study assessed the effects of this programme on local health systems and its influence on HCWs turnover in rural Guinea. Methods An exploratory study design using a mixed-method approach was conducted in five rural health districts. Data were collected through semi-structured questionnaires, in-depth interview guides, and documentary reviews. Results Of the 611 HCWs officially deployed to the selected districts, 600 (98%) took up duties. Female HCWs (64%), assistant nurses (39%), nurses (26%), and medical doctors (20%) represented the majority. Findings showed that 69% of HCWs were posted in health centres and the remaining in district hospitals and the health office (directorate); the majority of which were medical doctors, nurses, and midwives. The deployment has reportedly enhanced quality and timely data reporting. However, challenges were faced by local health authorities in the posting of HCWs including the unfamiliarity of some with primary healthcare delivery, collaboration conflicts between HCWs, and high feminization of the recruitment. One year after their deployment, 31% of the HCWs were absent from their posts. This included 59% nurses, 29% medical doctors, and 11% midwives. The main reasons for absenteeism were unknown (51%), continuing training (12%), illness (10%), and maternity leave (9%). Findings showed a confusion of roles and responsibilities between national and local actors in the management of HCWs, which was accentuated by a lack of policy documents. Conclusion The post-Ebola healthcare workers policy appears to have been successfully positive in the redistribution of HCWs, quality improvement of staffing levels in peripheral healthcare facilities, and enhancement of district health office capacities. However, greater attention should be given to the development of policy guidance documents with the full participation of all actors and a clear distinction of their roles and responsibilities for improved implementation and efficacy of this programme.

Division of domestic work by gender has been discussed as part of the explanation why women present a higher sickness absence rate than men. This study aimed to examine the association between gender equality in domestic work and sickness absence. Data from 2,609 co-habiting women and men (aged 19-64) collected in a general population in Sweden were used. Associations between different measures of gender equality in domestic work and numbers of sick-leave days were analyzed with logistic regression analysis adjusted for age, children, and paid work. Results show that women reported lower levels of gender equality than men did. Satisfaction with division of domestic work was in the final model associated with lower odds ratio (OR) for sickness absence in men irrespective of number of days. Work-family conflicts were associated with higher ORs for sickness absence in men, 1-7 sick-leave days (OR 1.51 (CI 1.04-2.18)), and in women, 8-30 days (OR 1.51 (1.00-2.33)). More knowledge on the meaning of gender equality in domestic work in relation to sickness absence for women and men are important for future prevention activities.

Background: Sexually transmitted infections (STIs) can be transmitted from mother to neonate. We determined the frequency of mother-to-child transmission (MTCT) of Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis to the newborn nasopharynx. Methods: This study was nested in a cohort study of etiologic testing versus syndromic management for STIs among pregnant women living with human immunodeficiency virus in South Africa. Mothers were tested for STIs using the GeneXpert platform within 60 days after delivery. Nasopharyngeal swabs were obtained from newborns of mothers with a positive STI test; these were then tested by Xpert® on the same day based on the maternal STI diagnosis. Results. We tested nasopharyngeal swabs from 85 STI-exposed newborns; 74 (87%) were tested within 2 weeks after birth (median five; range 2–12 days). MTCT frequency of any STI was 30/74 (41%); 43% (23/53) for C. trachomatis, 29% (2/7) for N. gonorrhoeae, and 24% (6/25) for T. vaginalis. Also, 4/11 (36%) swabs obtained between 14 and 60 days after delivery tested positive for STI. Conclusions: There was a high frequency of MTCT of STIs to the nasopharynx of newborns in our setting. The impact of nasopharyngeal colonization and the benefits of STI testing on newborn health remain to be determined.

This paper critically engages with dynamics of the Chinese food safety governance infrastructure following the melamine crisis. It presents a qualitative analysis of sixteen in-depth stakeholder interviews in Hunan, Hubei and Henan. We reveal tensions between a segmented model of governance and a centralised model, between a centralised top-down model and stakeholder participation, and between a public model and a private, decentral market where corporate reputation must result in transparency and trust. Stakeholders also see gaps between ideals of inclusive, transparent and participatory governance, and effective problem-solving. Governance of food safety in China, even when targeting inclusion and public accountability, remains heavily dependent on the central state as a pivotal actor.

A variety of serological tests have been developed to detect the presence of antibodies against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We evaluated the performance of 18 commercially available SARS-CoV-2 antibody assays. Early (6–8 days after the start of symptoms) and late sera (>14 days) from ICU patients (n=10 andn=16, respectively) and healthcare workers (n=5 andn=9, respectively) were included. Additionally, 22 sera were included to detect potential cross-reactivity. Test characteristics were determined for the 18 assays. In >14 days samples, the Vircell IgG and Wantai Ig ELISAs had superior sensitivity compared to the other ELISAs (96%). Furthermore, the Roche Ig, the Epitope Diagnostics IgM, Wantai IgM, Euroimmun IgG, and IgA all showed a specificity of 100%. The POCTs of Boson Biotech and ACRO Biotech showed the highest sensitivities: 100% and 96% (83.5–99.8), respectively. The POCT of Orient Gene Biotech, VOMED Diagnostics, and Coris-Bioconcept showed highest specificities (100%). For the IgM and IgA assays, the Euroimmun IgA test showed the highest sensitivity in early samples: 46.7% (23.5–70.9) to 53.3% (29.1–76.5). In general, all tests performed better in patients with severe symptoms (ICU patients). We conclude that the Wantai Ig and Vircell IgG ELISAs may be suitable for diagnostic purposes. The IgM/IgA tests performed poorer than their IgG/Ig counterparts but may have a role in diagnoses of SARS-CoV-2 in a population in which the background seroprevalence of IgG high, and IgM and/or IgA may distinguish between acute or past infection.

ObjectivesMacrolide resistance in Mycoplasma genitalium is emerging globally. There is paucity of data from sub-Saharan Africa where syndromic management is used to treat sexually transmitted infections (STIs). We conducted a molecular epidemiological study to determine the prevalence of azithromycin resistance and epidemic diversity of M. genitalium infections in South Africa.MethodsWe analysed 90 M. genitalium-positive specimens that had been collected consecutively from men and women (50% symptomatic) from geographically diverse communities across the northern part of South Africa between 2015 and 2019. Melting curve analysis followed by targeted sequencing of the 23S rRNA gene was performed to detect azithromycin resistance. Molecular typing was done through single nucleotide polymorphism (SNP) analysis of the MG191 gene and short tandem repeats (STR) assessment of the MG309 gene. An overview of all published M. genitalium sequence types was generated and novel sequence types identified in this study were allocated numbers accordingly.ResultsAzithromycin resistance was detected in 1/90 M. genitalium-positive specimens (1.1%; 95% CI 0% to 3.3%) as conferred by A2071G mutation; this strain also harboured a C234T mutation in the parC gene with wild type gyrA gene. SNP typing and STR assessment was successful in 38/90 specimens (42%) and showed a genetically diverse epidemic, without geographic clustering, with eight novel sequence types identified.ConclusionThis is the first study that determines resistance in M. genitalium infection since introduction of azithromycin in the syndromic management regimen for STIs in South Africa in 2015. Despite a well-established epidemic, azithromycin-resistant M. genitalium infection is still uncommon in the public healthcare sector. However, it has the potential to undermine the effectiveness of syndromic management. Introduction of molecular diagnostics and continuous surveillance are warranted for early detection emergence of resistance.

Background Human papillomavirus (HPV) vaccination programs achieve substantial population-level impact, with effects extending beyond protection of vaccinated individuals. We assessed trends in HPV prevalence up to 8 years postvaccination among men and women in the Netherlands, where bivalent HPV vaccination, targeting HPV types 16/18, has been offered to (pre)adolescent girls since 2009 with moderate vaccination coverage. Methods We used data from the PASSYON study, a survey initiated in 2009 (prevaccination) and repeated biennially among 16- to 24-year-old visitors of sexual health centers. We studied genital HPV positivity from 2009 to 2017 among women, heterosexual men, and unvaccinated women using Poisson generalized estimating equation models, adjusted for individual- and population-level confounders. Trends were studied for 25 HPV types detected by the SPF10-LiPA25 platform. Results A total of 6354 women (64.7% self-reported unvaccinated) and 2414 heterosexual men were included. Percentual declines in vaccine types HPV-16/18 were observed for all women (12.6% per year [95% confidence interval {CI}, 10.6–14.5]), heterosexual men (13.0% per year [95% CI, 8.3–17.5]), and unvaccinated women (5.4% per year [95% CI, 2.9–7.8]). We observed significant declines in HPV-31 (all women and heterosexual men), HPV-45 (all women), and in all high-risk HPV types pooled (all women and heterosexual men). Significant increases were observed for HPV-56 (all women) and HPV-52 (unvaccinated women). Conclusions Our results provide evidence for first-order herd effects among heterosexual men against HPV-16/18 and cross-protective types. Additionally, we show second-order herd effects against vaccine types among unvaccinated women. These results are promising regarding population-level and clinical impact of girls-only bivalent HPV vaccination in a country with moderate vaccine uptake., This study presents trends in human papillomavirus (HPV) positivity since girls-only HPV vaccine introduction in the Netherlands, with moderate vaccine uptake. We show declining prevalences of vaccine types HPV-16/18 in heterosexual men and unvaccinated women, and of cross-protective types in heterosexual men.

Background. Reports have emerged globally of antimicrobial resistance (AMR) in Neisseria gonorrhoeae and Mycoplasma genitalium infections. In South Africa (SA), there are substantial differences between private and public healthcare with regard to antimicrobial drug prescribing practice, which could affect AMR patterns of private and public healthcare patients. Objectives. To perform a pilot study to determine the frequency of AMR of N. gonorrhoeae and M. genitalium in patients accessing SA’s private healthcare sector. Methods. In this cross-sectional study, N. gonorrhoeae -positive cultures and M. genitalium DNA samples were collected from a private healthcare reference laboratory from August 2018 to August 2019. In N. gonorrhoeae -positive cultures, antimicrobial susceptibility testing was performed, followed by N. gonorrhoeae multiantigen sequence typing (NG-MAST) to determine genetic relatedness of the isolates. To determine macrolide and fluoroquinolone resistance rates, M. genitalium- positive samples were analysed by sequencing the 23S rRNA, gyrA and parC genes. Results. Twenty-one N. gonorrhoeae- and 27 M. genitalium -positive specimens were included in this analysis. High rates of resistance were detected among gonococcal isolates, with 90% resistance to tetracycline, 86% to penicillin and 62% to ciprofloxacin, but no resistance to azithromycin, cefixime and ceftriaxone. NG-MAST revealed genetically diverse isolates with 83% novel NG-MAST sequence types. Macrolide and fluoroquinolone resistance-associated mutations were detected in 18.5% ( n =5/27) and 7.4% ( n =2/27) of M. genitalium strains, respectively. Conclusions. We observed high frequencies of ciprofloxacin, penicillin and tetracycline resistance in N. gonorrhoeae and macrolide resistance-associated mutations in M. genitalium in private healthcare sector patients in SA. This finding highlights the need to use diagnostics for sexually transmitted infections and to include the private healthcare sector in antimicrobial surveillance and stewardship programmes.

AIMS: Previous uncontrolled studies suggested a possible benefit of intravenous immunoglobulin (IVIg) in parvovirus B19 (B19V)-related dilated cardiomyopathy (DCM). This randomized, double-blind, placebo-controlled, single-centre trial investigated the benefits of IVIg beyond conventional therapy in idiopathic chronic DCM patients with B19V persistence. METHODS AND RESULTS: Fifty patients (39 men; mean age 54 ± 11 years) with idiopathic chronic (>6 months) DCM on optimal medical therapy, left ventricular ejection fraction (LVEF) 200 copies/µg DNA were blindly randomized to either IVIg (n = 26, 2 g/kg over 4 days) or placebo (n = 24). The primary outcome was change in LVEF at 6 months after randomization. Secondary outcomes were change in functional capacity assessed by 6-min walk test (6MWT), quality of life [Minnesota Living with Heart Failure Questionnaire (MLHFQ)], left ventricular end-diastolic volume (LVEDV), and EMB B19V load at 6 months after randomization. LVEF significantly improved in both IVIg and placebo groups (absolute mean increase 5 ± 9%, P = 0.011 and 6 ± 10%, P = 0.008, respectively), without a significant difference between groups (P = 0.609). Additionally, change in 6MWT [median (interquartile range) IVIg 36 (13;82) vs. placebo 32 (5;80) m; P = 0.573], MLHFQ [IVIg 0 (-7;5) vs. placebo -2 (-6;6), P = 0.904] and LVEDV (IVIg -16 ± 49 mL/m2 vs. placebo -29 ± 40 mL/m2 ; P = 0.334) did not significantly differ between groups. Moreover, despite increased circulating B19V antibodies upon IVIg administration, reduction in cardiac B19V did not significantly differ between groups. CONCLUSION: Intravenous immunoglobulin therapy does not significantly improve cardiac systolic function or functional capacity beyond standard medical therapy in patients with idiopathic chronic DCM and cardiac B19V persistence. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov ID NCT00892112. ispartof: EUROPEAN JOURNAL OF HEART FAILURE vol:23 issue:2 pages:302-309 ispartof: location:England status: published

Background Moderate to vigorous physical activity (MVPA) can help to prevent depression, but identification of the most important psycho-biological pathways involved is unclear. The improvement of cardio-respiratory fitness (CRF) in response to MVPA can vary markedly, we therefore examined the association between CRF and the incidence of depressive symptoms. Methods We used data from The Maastricht Study, a large population-based prospective-cohort study. CRF was estimated at baseline from a graded submaximal exercise protocol and MVPA was measured with accelerometry. Depressive symptoms were assessed using the validated Dutch version of the 9-item Patient Health Questionnaire, both at baseline and during annual follow-up over five years. Cox proportional hazards models were used. Results A total of 1,730 individuals without depressive symptoms at baseline were included in the analysis. During the 5-year follow-up, n = 166 (9.6%) of individuals developed depressive symptoms. Compared to individuals with a low CRF, those with a moderate-to-high CRF had a significantly lower risk of developing depressive symptoms, independent of MVPA (medium CRF: HR = 0.49 (95%CI = 0.33–0.72); high CRF: HR = 0.48 (95% CI = 0.30–0.75). These associations were adjusted for age, sex, level of education, diabetes status, smoking status, alcohol use, energy intake, waist circumferences and antidepressant medications. Limitations PHQ-9 is a validated screening instrument, but it is not a diagnostic tool of depression. Conclusions Higher CRF was strongly associated with a lower risk of incident depressive symptoms over 5-year follow-up, independent of the level of MVPA at baseline, suggesting that interventions aimed at improving CRF could reduce the risk of depression.

Background Hepatitis B virus (HBV) immunity is recommended to optimize outcomes after solid organ transplantation (SOT). This study assessed the prevalence and predictors of HBV immunity at the time patients were placed on transplant waiting list over a period from 1997 to 2019 in a low HBV endemic region. Methods Data were obtained from the University Hospitals Leuven transplant database. Minors and patients with past/current HBV infection were excluded. From 1986, Belgian patients are covered by the universal infant vaccination; therefore, birth cohort was stratified in those born >= 1986 vs The study population consisted of 3297 SOT candidates. HBV immunity rate was superior in renal transplant candidates (55.3%), and this number was 21.5%, 15.4% and 16.8% for liver, cardiac and pulmonary transplant candidates, respectively,P < .001. Among liver transplant candidates, HBV immunity rate was 14.8% in decompensated cirrhotic patients and 27.9% in those without advanced cirrhosis (P < .001). The overall immunity rate increased from 19.3% in period 1997-2008 to 32.8% in 2009-2019,P < .001. In multivariable analyses, younger age (odds ratio (OR) 95% confidence interval (CI): 0.97-0.98,P < .001) and birth cohort >= 1986 (OR 95% CI: 1.18-2.66,P = .006) were associated with increased HBV immunity. Conclusion An increase in HBV immunity was observed over a 20-year period related to the introduction of universal infant HBV vaccination. Nevertheless, this study highlights the low overall HBV immunity at the time of listing for organ transplantation and points out the need of an increased awareness and vaccination strategy at an early disease stage. This research is part of the Limburg Clinical Research Center (LCRC) UHasselt-ZOL-Jessa, supported by the foundation Limburg Sterk Merk, province of Limburg, Flemish government, Hasselt University, Jessa Hospital and Ziekenhuis Oost-Limburg. The authors specially thank Bruno Desschans and Albert Herelixka for the management of the transplant database. Koc, OM (corresponding author), Hasselt Univ, Fac Med & Life Sci, Martelarenlaan 42, B-3500 Hasselt, Belgium. ozgur.koc@uhasselt.be

Pharyngeal Chlamydia trachomatis (CT) was diagnosed in 1.2% and pharyngeal-only CT in 0.5% of routinely universally tested men who have sex with men (MSM). In these 3-anatomic-site tested MSM, pharyngeal-only CT comprised 4.8% of all CT. The low positivity of pharyngeal-only CT indicates low public health impact of pharyngeal CT.

Information is clearly vital to public health, but the acquisition and use of public health data elicit serious privacy concerns. One strategy for navigating this dilemma is to build 'trust' in institutions responsible for health information, thereby reducing privacy concerns and increasing willingness to contribute personal data. This strategy, as currently presented in public health literature, has serious shortcomings. But it can be augmented by appealing to the philosophical analysis of the concept of trust. Philosophers distinguish trust and trustworthiness from cognate attitudes, such as confident reliance. Central to this is value congruence: trust is grounded in the perception of shared values. So, the way to build trust in institutions responsible for health data is for those institutions to develop and display values shared by the public. We defend this approach from objections, such as that trust is an interpersonal attitude inappropriate to the way people relate to organisations. The paper then moves on to the practical application of our strategy. Trust and trustworthiness can reduce privacy concerns and increase willingness to share health data, notably, in the context of internal and external threats to data privacy. We end by appealing for the sort of empirical work our proposal requires.

Environmental exposures are increasingly investigated as possible drivers of health behaviours and disease outcomes. So-called exposome studies that aim to identify and better understand the effects of exposures on behaviours and disease risk across the life course require high-quality environmental exposure data. The Netherlands has a great variety of environmental data available, including high spatial and often temporal resolution information on urban infrastructure, physico-chemical exposures, presence and availability of community services, and others. Until recently, these environmental data were scattered and measured at varying spatial scales, impeding linkage to individual-level (cohort) data as they were not operationalised as personal exposures, that is, the exposure to a certain environmental characteristic specific for a person. Within the Geoscience and hEalth Cohort COnsortium (GECCO) and with support of the Global Geo Health Data Center (GGHDC), a platform has been set up in The Netherlands where environmental variables are centralised, operationalised as personal exposures, and used to enrich 23 cohort studies and provided to researchers upon request. We here present and detail a series of personal exposure data sets that are available within GECCO to date, covering personal exposures of all residents of The Netherlands (currently about 17 M) over the full land surface of the country, and discuss challenges and opportunities for its use now and in the near future.

A previous chlamydia infection did not result in fewer pregnant women, but among women with a pregnancy intention, time to pregnancy was longer compared with women without a previous infection. Supplemental digital content is available in the text., Background A Chlamydia trachomatis infection (chlamydia) can result in tubal factor infertility in women. To assess if this association results in fewer pregnant women, we aimed to assess pregnancy incidences and time to pregnancy among women with a previous chlamydia infection compared with women without one and who were participating in the Netherlands Chlamydia Cohort Study (NECCST). Methods The NECCST is a cohort of women of reproductive age tested for chlamydia in a chlamydia screening trial between 2008 and 2011 and reinvited for NECCST in 2015 to 2016. Chlamydia status (positive/negative) was defined using chlamydia screening trial–nucleic acid amplification test results, chlamydia immunoglobulin G presence in serum, or self-reported chlamydia infections. Data on pregnancies were collected via questionnaires in 2015–2016 and 2017–2018. Overall pregnancies (i.e., planned and unplanned) and time to pregnancy (among women with a pregnancy intention) were compared between chlamydia-positive and chlamydia-negative women using Cox regressions. Results Of 5704 women enrolled, 1717 (30.1%; 95% confidence interval [CI], 28.9–31.3) women was chlamydia positive. Overall pregnancy proportions were similar in chlamydia-positive and chlamydia-negative women (49.0% [95% CI, 46.5–51.4] versus 50.5% [95% CI, 48.9–52.0]). Pregnancies per 1000 person-years were 53.2 (95% CI, 51.5–55.0) for chlamydia negatives and 83.0 (95% CI, 78.5–87.9) for chlamydia positives. Among women with a pregnancy intention, 12% of chlamydia-positive women had a time to pregnancy of >12 months compared with 8% of chlamydia negatives (P < 0.01). Conclusions Overall pregnancy rates were not lower in chlamydia-positive women compared with chlamydia-negative women, but among women with a pregnancy intention, time to pregnancy was longer and pregnancy rates were lower in chlamydia-positive women. Trial registration number: Dutch Trial Register NTR-5597.

ObjectivesSpontaneous clearance of Chlamydia trachomatis (CT) infections can occur between diagnosis and treatment. We followed CT patients to assess clearance using a conventional definition (no total CT-DNA, assessed by routine quantitative PCR methods) and a definition accounting for viability, assessed by viability PCR testing.MethodsThree outpatient STI clinics included CT-diagnosed women (The Netherlands, 2016–2017, FemCure study); participants had vaginal CT (vCT) and rectal CT (rCT) (group A: n=155), vCT and were rectally untested (group B: n=351), single vCT (group C: n=25) or single rCT (group D: n=29). Follow-up (median interval 9 days) vaginal and rectal samples underwent quantitative PCR testing (detecting total CT-DNA). When PCR positive, samples underwent V-PCR testing to detect ‘viable CT’ (CT-DNA from intact CT organisms; V-PCR positive). ‘Clearance’ was the proportion PCR-negative patients and ‘clearance of viable CT’ was the proportion of patients testing PCR negative or PCR positive but V-PCR negative. We used multivariable logistic regression analyses to assess diagnosis group (A–D), age, days since initial CT test (diagnosis) and study site (STI clinic) in relation to clearance and clearance of viable CT.ResultsClearance and clearance of viable CT at both anatomic sites were for (A) 0.6% and 3.9%; (B) 5.4% and 9.4%; (C) 32.0% and 52.0% and (D) 27.6% and 41.4%, respectively. In multivariate analyses, women with single infections (groups C and D) had higher likelihood of clearance than women concurrently infected with vCT and rCT (pOf rectally untested women (group B), 76.9% had total CT-DNA and 46.7% had viable CT (V-PCR positive) at the rectal site.ConclusionsOf untreated female vCT patients who had CT also at the rectal site, or who were rectally untested, only a small proportion cleared CT (in fact many had viable CT) at their follow-up visit (median 9 days). Among single site infected women clearance was much higher.Trial registration numberNCT02694497.

Objectives Chemsex-using illicit drugs during sex-is prevalent among men who have sex with men (MSM) and associated with sexual and mental health harms. Sexually transmitted disease (STD) clinics are a frequently visited and trusted health care facility for MSM. This study assessed the frequency and extent to which chemsex is addressed by Dutch STD nurses. Methods Of the 24 Dutch public STD clinics, an online questionnaire was distributed in 20 STD clinics (83%) in 2019; the questionnaire was sent to 191 STD nurses, of whom 108 (57%) completed the questionnaire. The main outcome was addressing chemsex during regular MSM consultations, measured on a 5-point Likert scale (never-always). Items measuring knowledge, attitude, self-efficacy, and the social norm were also measured on a 5-point Likert scale (totally disagree-totally agree). Results Of the 108 participating STD nurses, 77 (71%) addressed chemsex regularly or always during MSM consultations. In general, STD nurses indicated to have sufficient knowledge about chemsex (mean [SD], 3.6 [0.5]) and a positive attitude toward addressing chemsex (mean [SD], 4.3 [0.5]). A need for training on chemsex was reported by 82 (76%) STD nurses, especially in signaling problematic chemsex (56/82; 68%). Three STD clinics (15%) had a protocol on addressing chemsex, and 3 STD clinics (15%) had referral pathways to addiction care. Conclusion Sexually transmitted disease nurses from Dutch STD clinics regularly addressed chemsex during MSM consultations. Our results show relevance of educating STD nurses on signaling problematic chemsex and arranging referral pathways to addiction care to optimize chemsex related health care.

Aims/hypothesis We aimed to examine associations of cardiometabolic risk factors, and (pre)diabetes, with (sensorimotor) peripheral nerve function. Methods In 2401 adults (aged 40–75 years) we previously determined fasting glucose, HbA1c, triacylglycerol, HDL- and LDL-cholesterol, inflammation, waist circumference, blood pressure, smoking, glucose metabolism status (by OGTT) and medication use. Using nerve conduction tests, we measured compound muscle action potential, sensory nerve action potential amplitudes and nerve conduction velocities (NCVs) of the peroneal, tibial and sural nerves. In addition, we measured vibration perception threshold (VPT) of the hallux and assessed neuropathic pain using the DN4 interview. We assessed cross-sectional associations of risk factors with nerve function (using linear regression) and neuropathic pain (using logistic regression). Associations were adjusted for potential confounders and for each other risk factor. Associations from linear regression were presented as standardised regression coefficients (β) and 95% CIs in order to compare the magnitudes of observed associations between all risk factors and outcomes. Results Hyperglycaemia (fasting glucose or HbA1c) was associated with worse sensorimotor nerve function for all six outcome measures, with associations of strongest magnitude for motor peroneal and tibial NCV, βfasting glucose = −0.17 SD (−0.21, −0.13) and βfasting glucose = −0.18 SD (−0.23, −0.14), respectively. Hyperglycaemia was also associated with higher VPT and neuropathic pain. Larger waist circumference was associated with worse sural nerve function and higher VPT. Triacylglycerol, HDL- and LDL-cholesterol, and blood pressure were not associated with worse nerve function; however, antihypertensive medication usage (suggestive of history of exposure to hypertension) was associated with worse peroneal compound muscle action potential amplitude and NCV. Smoking was associated with worse nerve function, higher VPT and higher risk for neuropathic pain. Inflammation was associated with worse nerve function and higher VPT, but only in those with type 2 diabetes. Type 2 diabetes and, to a lesser extent, prediabetes (impaired fasting glucose and/or impaired glucose tolerance) were associated with worse nerve function, higher VPT and neuropathic pain (p for trend Conclusions/interpretation Hyperglycaemia (including the non-diabetic range) was most consistently associated with early-stage nerve damage. Nonetheless, larger waist circumference, inflammation, history of hypertension and smoking may also independently contribute to worse nerve function.

Aims/hypothesis Depression is twice as common in individuals with type 2 diabetes as in the general population. However, it remains unclear whether hyperglycaemia and insulin resistance are directly involved in the aetiology of depression. Therefore, we investigated the association of markers of hyperglycaemia and insulin resistance, measured as continuous variables, with incident depressive symptoms over 4 years of follow-up. Methods We used data from the longitudinal population-based Maastricht Study (n = 2848; mean age 59.9 ± 8.1 years, 48.8% women, 265 incident depression cases, 10,932 person-years of follow-up). We assessed hyperglycaemia by fasting and 2 h post-load OGTT glucose levels, HbA1c and skin autofluorescence (reflecting AGEs) at baseline. We used the Matsuda insulin sensitivity index and HOMA-IR to calculate insulin resistance at baseline. Depressive symptoms (nine-item Patient Health Questionnaire score ≥10) were assessed at baseline and annually over 4 years. We used Cox regression analyses, and adjusted for demographic, cardiovascular and lifestyle risk factors. Results Fasting plasma glucose, 2 h post-load glucose and HbA1c levels were associated with an increased risk for incident depressive symptoms after full adjustment (HR 1.20 [95% CI 1.08, 1.33]; HR 1.25 [1.08, 1.44]; and HR 1.22 [1.09, 1.37] per SD, respectively), while skin autofluorescence, insulin sensitivity index and HOMA-IR were not (HR 0.99 [0.86, 1.13]; HR 1.02 [0.85, 1.25]; and HR 0.93 [0.81, 1.08], per SD, respectively). Conclusions/interpretation The observed temporal association between hyperglycaemia and incident depressive symptoms in this study supports the presence of a mechanistic link between hyperglycaemia and the development of depressive symptoms.

The etiology of late-life depression (LLD) is still poorly understood. Microvascular dysfunction (MVD) has been suggested to play a role in the etiology of LLD, but direct evidence of this association is scarce. The aim of this study was to investigate whether direct and indirect markers of early microvascular dysfunction are associated with prevalent and incident LLD in the population-based Maastricht Study cohort. We measured microvascular dysfunction at baseline by use of flicker light-induced retinal vessel dilation response (Dynamic Vessel Analyzer), heat-induced skin hyperemic response (laser- Doppler flowmetry), and plasma markers of endothelial dysfunction (endothelial dysfunction; sICAM-1 [soluble intercellular adhesion molecule-1], sVCAM-1 [soluble vascular adhesion molecule-1], sE-selectin [soluble E-selectin], and vWF [Von Willebrand Factor]). Depressive symptoms were assessed with the 9-item Patient Health Questionnaire (PHQ-9) at baseline and annually over 4 years of follow-up (n=3029; mean age 59.6±8.2 years, 49.5% were women, n=132 and n=251 with prevalent and incident depressive symptoms [PHQ-9≥10]). We used logistic, negative binominal and Cox regression analyses, and adjusted for demographic, cardiovascular, and lifestyle factors. Retinal venular dilatation and plasma markers of endothelial dysfunction were associated with the more prevalent depressive symptoms after full adjustment (PHQ-9 score, RR, 1.05 [1.00–1.11] and RR 1.06 [1.01–1.11], respectively). Retinal venular dilatation was also associated with prevalent depressive symptoms (PHQ-9≥10; odds ratio, 1.42 [1.09–1.84]), after full adjustment. Retinal arteriolar dilatation and plasma markers of endothelial dysfunction were associated with incident depressive symptoms (PHQ-9≥10; HR, 1.23 [1.04–1.46] and HR, 1.19 [1.05–1.35]), after full adjustment. These findings support the concept that microvascular dysfunction in the retina, and plasma markers of endothelial dysfunction is involved in the etiology of LLD and might help in finding additional targets for the prevention and treatment of LLD.

Incessant food safety scandals in China have given rise to a loss of public trust in food safety, stimulating a series of studies focussing on food safety governance, accountability, and trust restoration. Against this backdrop, Chinese scholars are keen to reflect on different strategies for ensuring food safety public accountability and credibility, presenting different perspectives on issues like responsibility, trust, risk communication, and transparency. In this paper, we aim to get more in-depth insight into how Chinese scholarly debates co-construct public accountability for food safety as a public issue. We selected 51 articles from 10,790 candidates drawn from four Chinese academic databases for content analysis. Drawing from political theories on public accountability as well as science and technology studies, the analysis shows that arguments for a specific public accountability model (more or less centralised, more or less stakeholder participation) are intertwined with the specific role of scientific expertise (more or less authoritative, more or less democratising). As such, the analysis shows how scholarly debates on public accountability for food safety in China co-construct a public forum for discussing supervision and accountability, risk assessment, and transparency.

With dual-income families on the increase, combining work and family obligations is a daily reality for many individuals. Unsatisfactory combinations of work and home duties can result in various unfavourable individual and organisational outcomes. Therefore, its proper understanding is essential in order to create adequate recommendations for interventions and prevention. There is a need for the development of theoretical frameworks that take cultural context into account in relation to work-home interface (WHI). In this paper a new framework is proposed; 'the pyramid of intersecting domains of WHI' that incorporates cultural context and other important work-life interface aspects. It builds on empirical findings of the intersectionality and work/family border theories. The pyramid consists of the following domains: the domain of work and home characteristics, the roles domain and the cultural domain, which intersect to determine the fourth side of the pyramid, that is, the observed WHI. Based on the pyramid several research propositions can be formulated. Implications for researchers and HR professionals are provided.

Almost half of men who have sex with men visiting Dutch sexually transmitted disease clinics reported sex abroad in the past 6 months, mainly in Western countries. One in 4 men who have sex with men who had sex abroad used drugs during sex ("chemsex") abroad. Having sex abroad was associated with having multiple sex partners and casual sex partner(s).

The mechanisms underlying cognitive impairment are incompletely understood but may include arterial stiffness and microvascular dysfunction. In the population-based Maastricht Study, we investigated the association between arterial stiffness and cognitive performance, and whether any such association was mediated by microvascular dysfunction. We included cross-sectional data of 2544 participants (age, 59.7 years; 51.0% men; 26.0% type 2 diabetes mellitus). We used carotid-femoral pulse wave velocity and carotid distensibility coefficient as measures of aortic and carotid stiffness, respectively. We calculated a composite score of microvascular dysfunction based on magnetic resonance imaging features of cerebral small vessel disease, flicker light-induced retinal arteriolar and venular dilation response, albuminuria, and plasma biomarkers of microvascular dysfunction (sICAM-1 [soluble intercellular adhesion molecule-1], sVCAM-1 [soluble vascular adhesion molecule-1], sE-selectin [soluble E-selectin], and vWF [von Willebrand factor]). Cognitive domains assessed were memory, processing speed, and executive function. A cognitive function score was calculated as the average of these domains. Higher aortic stiffness (per m/s) was associated with lower cognitive function (β, −0.018 SD [95% CI, −0.036 to −0.000]) independent of age, sex, education, and cardiovascular risk factors, but higher carotid stiffness was not. Higher aortic stiffness (per m/s) was associated with a higher microvascular dysfunction score (β, 0.034 SD [95% CI, 0.014 to 0.053]), and a higher microvascular dysfunction score (per SD) was associated with lower cognitive function (β, −0.089 SD [95% CI, −0.124 to −0.053]). Microvascular dysfunction significantly explained 16.2% of the total effect of aortic stiffness on cognitive function. The present study showed that aortic stiffness, but not carotid stiffness, is independently associated with worse cognitive performance, and that this association is in part explained by microvascular dysfunction.

BACKGROUND & AIMS: Establishment of the gastrointestinal microbiota during infancy affects immune system development and oral tolerance induction. Perturbations in the microbiome during this period can contribute to development of immune-mediated diseases. We monitored microbiota maturation and associations with subsequent development of allergies in infants and children. METHODS: We collected 1453 stool samples, at 5, 13, 21, and 31weeks postpartum (infants), and once at school age (6-11 years), from 440 children (49.3% girls, 24.8% born by cesarean delivery; all children except for 6 were breastfed for varying durations; median 40 weeks; interquartile range, 30-53 weeks). Microbiota were analyzed by amplicon sequencing. Children were followed through 3 years of age for development of atopic dermatitis; data on allergic sensitization and asthma were collected when children were school age. RESULTS: Diversity of fecal microbiota, assessed by Shannon index, did not differ significantly among children from 5 through 13 weeks after birth, but thereafter gradually increased to 21 and 31 weeks. Most bacteria within the Bacteroidetes and Proteobacteria phyla were already present at 5 weeks after birth, whereas many bacteria of the Firmicutes phylum were acquired at later times in infancy. At school age, many new Actinobacteria, Firmicutes, and Bacteroidetes bacterial taxa emerged. The largest increase in microbial diversity occurred after 31 weeks. Vaginal, compared with cesarean delivery, was most strongly associated with an enrichment of Bacteroides species at 5 weeks through 31 weeks. From 13 weeks onward, diet became the most important determinant of microbiota composition; cessation of breast-feeding, rather than solid food introduction, was associated with changes. For example, Bifidobacteria, staphylococci, and streptococci significantly decreased on cessation of breastfeeding, whereas bacteria within the Lachnospiraceae family (Pseudobutyrivibrio, Lachnobacterium, Roseburia, and Blautia) increased. When we adjusted for confounding factors, we found fecal microbiota composition to be associated with development of atopic dermatitis, allergic sensitization, and asthma. Members of the Lachnospiraceae family, as well as the genera Faecalibacterium and Dialister, were associated with a reduced risk of atopy. CONCLUSIONS: In a longitudinal study of fecal microbiota of children from 5 weeks through 6 to 11 years, we tracked changes in diversity and composition associated with the development of allergies and asthma.

Background: Glucose variability (GV) measured by continuous glucose monitoring (CGM) has become an accepted marker of glycemic control. Nevertheless, several methodological aspects of GV assessment require further study. We, therefore, investigated the minimum number of days needed to reliably measure GV, assessed GV reference values, and studied the correlation of GV with established glycemic indices (i.e., HbA(1c), seven-point oral glucose tolerance test [OGTT]-derived indices). Methods: We used cross-sectional data from The Maastricht Study, an observational population-based cohort enriched with type 2 diabetes. Participants with more than 48 h of CGM (iPro2; Medtronic) were included for analysis (n = 851; age: 60 +/- 9years; 49% women; 23% type 2 diabetes). We used mean sensor glucose (MSG), standard deviation (SD), and coefficient of variation (CV) as CGM-derived indices (the latter two for GV quantification). We calculated reliability using the Spearman-Brown prophecy formula, established reference values by calculating 2.5th-97.5th percentiles, and studied correlations using Spearman's rho. Results: Sufficient reliability (R > 0.80) was achieved with two (MSG and SD), or three monitoring days (CV). The reference ranges, assessed in individuals with normal glucose metabolism (n = 470), were 90.5-120.6 mg/dL (MSG), 7.9-24.8 mg/dL (SD), and 7.74%-22.45% (CV). For MSG, the strongest correlation was found with fasting plasma glucose (rho = 0.65 [0.61; 0.69]); for SD, with the 1-h OGTT value (rho = 0.61 [0.56; 0.65]); and for CV, with both the incremental glucose peak (IGP) during the OGTT (rho = 0.50 [0.45; 0.55]) and the 1-h OGTT value (rho = 0.50 [0.45; 0.55]). Conclusions: The reliability findings and reference values are relevant for studies that aim to investigate CGM-measured GV. One-hour OGTT and IGP values can be used as GV indices when CGM is unavailable.

OBJECTIVE Low heart rate variability (HRV), a marker for cardiac autonomic dysfunction, is a known feature of type 2 diabetes, but it remains incompletely understood whether this also applies to prediabetes or across the whole glycemic spectrum. Therefore, we investigated the association among prediabetes, type 2 diabetes, and measures of glycemia and HRV. RESEARCH DESIGN AND METHODS In the population-based Maastricht Study (n = 2,107; mean ± SD age 59 ± 8 years; 52% men; normal glucose metabolism [n = 1,226], prediabetes [n = 331], and type 2 diabetes [n = 550, oversampled]), we determined 24-h electrocardiogram-derived HRV in time and frequency domains (individual z-scores, based upon seven and six variables, respectively). We used linear regression with adjustments for age, sex, and major cardiovascular risk factors. RESULTS After adjustments, both time and frequency domain HRV were lower in prediabetes and type 2 diabetes as compared with normal glucose metabolism (standardized β [95% CI] for time domain: −0.15 [−0.27; −0.03] and −0.34 [−0.46; −0.22], respectively, P for trend CONCLUSIONS Both prediabetes and type 2 diabetes were independently associated with lower HRV. This is further substantiated by independent continuous associations between measures of hyperglycemia and lower HRV. These data strongly suggest that cardiac autonomic dysfunction is already present in prediabetes.

Background Ambulance dispatches could be useful for syndromic surveillance of severe respiratory infections. We evaluated whether ambulance dispatch calls of highest urgency reflect the circulation of influenza A virus, influenza B virus, respiratory syncytial virus (RSV), rhinovirus, adenovirus, coronavirus, parainfluenzavirus and human metapneumovirus (hMPV). Methods We analysed calls from four ambulance call centres serving 25% of the population in the Netherlands (2014‐2016). The chief symptom and urgency level is recorded during triage; we restricted our analysis to calls with the highest urgency and identified those compatible with a respiratory syndrome. We modelled the relation between respiratory syndrome calls (RSC) and respiratory virus trends using binomial regression with identity link function. Results We included 211 739 calls, of which 15 385 (7.3%) were RSC. Proportion of RSC showed periodicity with winter peaks and smaller interseasonal increases. Overall, 15% of RSC were attributable to respiratory viruses (20% in out‐of‐office hour calls). There was large variation by age group: in

Background In countries with out-of-pocket (OOP) payment systems for healthcare, the combination of chronic disease and poverty can have damaging socio-economic and health impacts for affected households. Using a life course perspective, this article aims to explore how Nepalese people struggle with, experience and adapt to chronic disease, poverty and their consequences, and how chronic diseases and poverty reinforce each other. Methods In-depth semi-structured interviews were conducted with 21 chronically ill Nepalese people with one or more chronic diseases and/or their caretakers. Data were transcribed and analysed thematically. Results The adaptation strategies for the consequences of the huge OOP costs make patients and their households financially disadvantaged. The impoverishment has major social impacts and often persists across generations. The situation forces people to choose between avoiding medical treatment or further impoverishing their families. Conclusions This study explored how chronically ill Nepalese people struggle with socio-economic and health consequences of OOP payments for their disease. The article sheds light on circumstances and adaptation strategies that obstruct every attempt to escape from the vicious cycle of the poverty trap. Hence poverty and health adversities accumulate across generations and contribute to greater health expenditures, worse health outcomes and severely compromised social life.