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The roles and responsibilities of radiation therapists (RTTs) are many and varied. Professional expectations are influenced by the technology available, as well as the level of autonomy RTTs have in their daily practice. This professional range requires RTTs to possess a unique set of ever evolving skills, posing challenges from an educational perspective.Teaching these “advanced skills” has been the ambition the ESTRO Advanced Skills in Modern Radiotherapy course. In the 10th year of this course, the Faculty look back and reflect on how our programme has evolved and what it has achieved.

Abstract Background Urgent daily hassles, which are more common among people with a lower socioeconomic position (SEP), might limit one’s ability to address less pressing goals, such as goals related to health promotion. Consequently, health goals may be viewed as less focal, which could jeopardize one’s health. This study examined an understudied pathway: whether a higher severity of daily hassles resulted in a lower perceived importance of health and whether these two factors sequentially mediate socioeconomic inequalities in self-assessed health (SAH) and food consumption. Methods A cross-sectional survey among 1,330 Dutch adults was conducted in 2019. Participants self-reported SEP (household income, educational level), the severity of eleven daily hassles (e.g., financial hassles, legal hassles), the perceived importance of health (not being ill, living a long life), SAH, and food consumption. Structural equation modeling was used to examine whether daily hassles and the perceived importance of health sequentially mediated income and educational inequalities in SAH, fruit and vegetable consumption (FVC) and snack consumption. Results No evidence of sequential mediation through daily hassles and the perceived importance of health was found. Daily hassles individually mediated income inequalities in SAH (indirect effect: 0.04, total effect: 0.06) and in FVC (indirect effect: 0.02, total effect: 0.09). The perceived importance of not being ill and living a long life both individually mediated educational inequalities in SAH (indirect effects: 0.01 and -0.01, respectively, total effect: 0.07). Conclusions Income inequalities in SAH and FVC were explained by daily hassles, and educational inequalities in SAH were explained by the perceived importance of health. Socioeconomic inequalities may not be sequentially explained by a more severe experience of daily hassles and a lower perceived importance of health. Interventions and policies addressing challenging circumstances associated with a low income may improve SAH and healthy food consumption among lower-income groups.

Background: Current European Association of Urology (EAU) guidelines discriminate between high- and low-risk upper urinary tract urothelial carcinoma (UTUC) to determine treatment by means of radical nephroureterectomy (RNU) or kidney-sparing surgery (KSS). Objective: To compare long-term oncological outcomes and renal function for patients with UTUC treated by RNU versus KSS. Design, setting, and participants: A retrospective cohort study, including 186 renal units with nonmetastatic UTUC treated in a tertiary referral centre between 2010 and 2021, was conducted. Intervention: RNU, ureterorenoscopy, percutaneous tumour resection, and segmental ureteral resection. Outcome measurements and statistical analysis: Recurrence-free survival, metastasis-free survival (MFS), overall survival (OS), cancer-specific survival (CSS), and renal function were analysed by means of the log-rank test and the independent-sample t test. Results and limitations: OS was 71.1% for the RNU group and 81.9% for the KSS group. In a cohort matched for propensity weight based on EAU risk stratification progression-free survival (PFS; RNU 96.0%; KSS 86.0%), MFS (RNU 72.0%; KSS 84.0%), CSS (RNU 84.0%; KSS 86.0%), and OS (RNU 76.0%; KSS 76.0%) were all similar between both groups. No significant differences in renal function were seen at 2 and 5 yr after the intervention. Although this series represents the largest cohort of (high-risk) UTUC patients treated by means of KSS to date, it is not suitable for performing a multivariate analysis. Conclusions: PFS, MFS, CSS, and OS were all comparable when analysing the RNU and KSS groups. Similar results for groups with evenly distributed risk factors and a large percentage of high-risk disease suggest that current risk stratification might not be accurate in discriminating low-risk from high-risk disease. Patient summary: In this report, we looked at outcomes for upper urinary tract urothelial carcinoma in a specialised hospital. We conclude that kidney-sparing surgery and radical nephroureterectomy have comparable outcomes and that risk factors for worse outcome might not be identified correctly.

Context: The refined mechanics of a flexible ureteroscope (fURS) are vulnerable to damage. Sending the fURS for repair is costly and has driven interest toward estimating the resources used for fURS repairs. Objective: To systematically review available literature and to estimate the total weighted repair rate of an fURS and the average repair cost per ureteroscopy. Evidence acquisition: A systematic review was conducted by searching the MEDLINE, Embase, Web of Science, and Cochrane Library databases. The average costs of all repairs identified in the included studies were extracted. A random-effect model was used to calculate the pooled total fURS repair rate. The total weighted repair rate and average cost per repair were multiplied to provide an average cost of repair per ureteroscopy procedure. Evidence synthesis: We identified 18 studies that fulfilled the inclusion criteria, which included 411 repairs from 5900 investigated ureteroscopy procedures. The calculated weighted repair rate was 6.5% ± 0.745% (95% confidence interval: 5.0–7.9%; I2 = 75.3%), equivalent to 15 ureteroscopy procedures before repair. The average cost per repair was 6808 USD; according to the weighted repair rate of 6.5%, this corresponds to an average repair cost of 441 USD per procedure. Egger’s regression test did not reveal a significant publication bias (p = 0.07). Conclusions: This is the first meta-analysis to estimate the repair rate of the fURS used for ureteroscopy. Our analysis demonstrates a repair rate of 6.5%, equivalent to 15 ureteroscopy procedures between fURS repairs and a repair cost of 441 USD per procedure. Ureteroscopy practices should consider fURS breakage rates and repair costs to optimize the use of reusable versus disposable devices. Patient summary: We reviewed available literature investigating the repair rate of a flexible ureteroscope (fURS). We found that fURSs are sent for repair after every 15 ureteroscopy procedures, corresponding to 441 USD per procedure in repair cost.

Abstract Socioeconomic inequalities in diets need to be tackled to improve population diets and prevent obesity and diet-related non-communicable diseases. The potential of food environment policies to reduce such inequalities has to date however not been appraised. The objective of this umbrella review was to assess the impact of food environment policies on socioeconomic inequalities in diets and to identify knowledge gaps in the existing literature, using the Healthy Food Environment Policy Index as a conceptual framework. The policies considered in the umbrella review are within six domains: 1) food composition 2) food labelling 3) food promotion 4) food provision 5) food retail 6) food pricing. A systematic search for systematic literature reviews on the effect of food environment policies on dietary-related outcomes across socioeconomic groups and published in English between 2004 and 2019 was conducted. Sixteen systematic literature reviews encompassing 159 primary studies were included, covering food composition (n = 2), food labelling (n = 3), food provision (n = 2), food prices (n = 13) and food in retail (n = 4). Quality assessment using the “Assessing the Methodological Quality of Systematic Reviews” quality rating scale showed that review quality was mainly low or critically low. Results suggest that food taxation may reduce socioeconomic inequalities in diets. For all other policy areas, the evidence base was poor. Current research largely fails to provide good quality evidence on impacts of food environment policies on socioeconomic inequalities in diets. Research to fill this knowledge gap is urgently needed.

Abstract Background Socioeconomic inequalities in health behaviors have been attributed to both structural and individual factors, but untangling the complex, dynamic pathways through which these factors influence inequalities requires more empirical research. This study examined whether and how two factors, material conditions and time orientation, sequentially impact socioeconomic inequalities in health behaviors. Methods Dutch adults 25 and older self-reported highest attained educational level, a measure of socioeconomic position (SEP); material conditions (financial strain, housing tenure, income); time orientation; health behaviors including smoking and sports participation; and health behavior-related outcomes including body mass index (BMI) and self-assessed health in three surveys (2004, 2011, 2014) of the longitudinal GLOBE (Dutch acronym for “Health and Living Conditions of the Population of Eindhoven and surroundings”) study. Two hypothesized pathways were investigated during a ten-year time period using sequential mediation analysis, an approach that enabled correct temporal ordering and control for confounders such as baseline health behavior. Results Educational level was negatively associated with BMI, positively associated with sports participation and self-assessed health, and not associated with smoking in the mediation models. For smoking, sports participation, and self-assessed health, a pathway from educational level to the outcome mediated by time orientation followed by material conditions was observed. Conclusions Time orientation followed by material conditions may play a role in determining socioeconomic inequalities in certain health behavior-related outcomes, providing empirical support for the interplay between structural and individual factors in socioeconomic inequalities in health behavior. Smoking may be determined by prior smoking behavior regardless of SEP, potentially due to its addictive nature. While intervening on time orientation in adulthood may be challenging, the results from this study suggest that policy interventions targeted at material conditions may be more effective in reducing socioeconomic inequalities in certain health behaviors when they account for time orientation.

Abstract Background Inequalities in obesity pertain in part to differences in dietary intake in different socioeconomic groups. Examining the economic, social, physical and political food environment of low-income groups as a complex adaptive system – i.e. a system of multiple, interconnected factors exerting non-linear influence on an outcome, can enhance the development and assessment of effective policies and interventions by honouring the complexity of lived reality. We aimed to develop and apply novel causal loop diagramming methods in order to construct an evidence-based map of the underlying system of environmental factors that drives dietary intake in low-income groups. Methods A systematic umbrella review was conducted on literature examining determinants of dietary intake and food environments in low-income youths and adults in high/upper-middle income countries. Information on the determinants and associations between determinants was extracted from reviews of quantitative and qualitative studies. Determinants were organised using the Determinants of Nutrition and Eating (DONE) framework. Associations were synthesised into causal loop diagrams that were subsequently used to interpret the dynamics underlying the food environment and dietary intake. The map was reviewed by an expert panel and systems-based analysis identified the system paradigm, structure, feedback loops and goals. Results Findings from forty-three reviews and expert consensus were synthesised in an evidence-based map of the complex adaptive system underlying the food environment influencing dietary intake in low-income groups. The system was interpreted as operating within a supply-and-demand, economic paradigm. Five sub-systems (‘geographical accessibility’, ‘household finances’, ‘household resources’, ‘individual influences’, ‘social and cultural influences’) were presented as causal loop diagrams comprising 60 variables, conveying goals which undermine healthy dietary intake. Conclusions Our findings reveal how poor dietary intake in low-income groups can be presented as an emergent property of a complex adaptive system that sustains a food environment that increases the accessibility, availability, affordability and acceptability of unhealthy foods. In order to reshape system dynamics driving unhealthy food environments, simultaneous, diverse and innovative strategies are needed to facilitate longer-term management of household finances and socially-oriented practices around healthy food production, supply and intake. Ultimately, such strategies must be supported by a system paradigm which prioritises health.

Objectives: Government policies are essential to create food environments that support healthy diets. The aims of this study were 1) to benchmark the implementation of Dutch government policies influencing food environments, and 2) to identify and prioritize actions to improve food environments in the Netherlands.Methods: The Healthy Food Environment Policy Index (Food-EPI) was applied. The Food-EPI includes 46 indicators of food environment policy and infrastructure support. Independent experts (n = 28) rated the extent of implementation on these indicators against international best practices, and formulated and prioritized policy and infrastructure support actions to improve food environments.Results: Most policy indicators were rated as having a low (50%) or very low (41%) level of implementation. Most infrastructure support indicators were rated as having a fair (42%) or medium (42%) level of implementation. 18 policy and 11 infrastructure support actions were recommended by experts to improve food environments in the Netherlands.Conclusion: There is large potential for the Dutch national government to strengthen its policy action and infrastructure support in order to improve the healthiness of food environments in the Netherlands.

Abstract Background Anthracycline-induced cardiac dysfunction (ACD) is a notorious side effect of anticancer treatment. It has been described as a phenomenon of a continuous progressive decline of cardiac function, eventually leading to dilated cardiomyopathy (DCM). This progressive nature suggests that patients with a delayed ACD diagnosis have greater compromise of cardiac function and more adverse remodeling, with a poor response to heart failure (HF) treatment. This study aimed to delineate the impact of a delayed ACD diagnosis on echocardiographic characteristics and response to HF treatment. Methods and results From the population of our cardio-oncology outpatient clinic, 92 ACD patients were included in this study (age 51.6 ± 16.2 years, median cumulative anthracycline dose 329 [200–329] mg/m2), and a median follow-up of 25.0 [9.6–37.2] months after ACD diagnosis. Median time to ACD diagnosis for patients diagnosed early ( 1 year) was 4.0 vs. 47.7 months respectively. There were no echocardiographic differences between patients diagnosed early vs. late (LVEF 43.6 ± 4.9% vs. 43.0 ± 6.2% and iEDV 63.6 vs. 62.9 mL/m2). Eighty-three percent of patients presented with mild LV dysfunction and in 79% the LV was not dilated. Patients diagnosed early were more likely to have (partial) recovery of cardiac function upon HF treatment initiation (p = 0.015). Conclusions In the setting of a cardio-oncology outpatient clinic, patients with ACD presented with a hypokinetic non-dilated cardiomyopathy, rather than typical DCM. Timing of ACD diagnosis did not impact HF disease severity. However, in patients receiving an early diagnosis, cardiac function was more likely to recover upon HF treatment.

Abstract Background The association between the residential fast food environment and diet has gained growing attention. However, why the food environment affects food consumption is under-examined. This study aimed to investigate neighbourhood social norms with respect to fast food consumption as a potential mediating pathway between residential fast food outlet exposure and residents’ fast food consumption. Methods A correlational study was conducted in which a nationwide sample of 1038 respondents living across The Netherlands completed a survey. Respondents reported their fast food consumption (amount/week) as well as perceived descriptive and injunctive norms regarding fast food consumption in their neighbourhood. Fast food outlet exposure was measured by the average count of fast food outlets within a 400 m walking distance buffer around the zip-codes of the respondents, using a retail outlet database. Regression models were used to assess associations between residential fast food outlet exposure, fast food consumption, and social norm perceptions, and a bootstrapping procedure was used to test the indirect -mediation- effect. Separate analyses were performed for descriptive norms and injunctive norms. Results There was no overall or direct association between residential fast food outlet exposure and residents’ fast food consumption. However, fast food outlet exposure was positively associated with neighbourhood social norms (descriptive and injunctive) regarding fast food consumption, which in turn were positively associated with the odds of consuming fast food. Moreover, results of the bootstrapped analysis provided evidence of indirect effects of fast food outlet exposure on fast food consumption, via descriptive norms and injunctive norms. Conclusions In neighbourhoods with more fast food outlets, residents were more likely to perceive fast food consumption in the neighbourhood as more common and appropriate. In turn, stronger neighbourhood social norms were associated with higher fast food consumption. Acknowledging the correlational design, this study is the first that implies that neighbourhood social norms may be a mediating pathway in the relation between the residential fast food environment and fast food consumption. Future research may examine the role of neighbourhood social norms in other contexts and explore how the changing food environment may shift our consumption norms.

Abstract Background Social capital is an important determinant of health, but how specific sub-dimensions of social capital affect health and health-related behaviors is still unknown. To better understand its role for health inequalities, it is important to distinguish between bonding social capital (connections between homogenous network members; e.g. similar educational level) and bridging social capital (connections between heterogeneous network members). In this study, we test the hypotheses that, 1) among low educational groups, bridging social capital is positively associated with health-behavior, and negatively associated with overweight and obesity, and 2) among high educational groups, bridging social capital is negatively associated with health-behavior, and positively with overweight and obesity. Methods Cross-sectional data on educational level, health-behavior, overweight and obesity from participants (25–75 years; Eindhoven, the Netherlands) of the 2014-survey of the GLOBE study were used (N = 2702). Social capital (“How many of your close friends have the same educational level as you have?”) was dichotomized as: bridging (‘about half’, ‘some’, or ‘none of my friends’), or bonding (‘all’ or ‘most of my friends’). Logistic regression models were used to study whether bridging social capital was related to health-related behaviors (e.g. smoking, food intake, physical activity), overweight and obesity, and whether these associations differed between low and high educational groups. Results Among low educated, having bridging social capital (i.e. friends with a higher educational level) reduced the likelihood to report overweight (OR 0.73, 95% CI 0.52–1.03) and obesity (OR 0.58, 95% CI 0.38–0.88), compared to low educated with bonding social capital. In contrast, among high educated, having bridging social capital (i.e. friends with a lower educational level) increased the likelihood to report daily smoking (OR 2.11, 95% CI 1.37–3.27), no leisure time cycling (OR 1.55, 95% CI 1.17–2.04), not meeting recommendations for vegetable intake (OR 2.09, 95% CI 1.50–2.91), and high meat intake (OR 1.39, 95% CI 1.05–1.83), compared to high educated with bonding social capital. Conclusions Bridging social capital had differential relations with health-behavior among low and high educational groups. Policies aimed at reducing segregation between educational groups may reduce inequalities in overweight, obesity and unhealthy behaviors.

Abstract Purpose Improving the physical and social conditions of residential neighbourhoods may increase walking, especially among older people. Evidence on the effects of physical and social environmental interventions, and particularly the combination of both, on walking behaviour is scarce. We evaluated the effects of a small-scale physical environmental intervention (designated walking route), a social environmental intervention (neighbourhood walking group) and the combination of both on walking behaviour of older adults living in deprived neighbourhoods. Methods Survey data of 644 older adults residing in four deprived neighbourhoods of Rotterdam, the Netherlands, were used to compare changes in walking behaviour over time (weekly minutes spent recreational walking, utilitarian walking and total walking) of those exposed to 1) a designated walking route (physical condition), 2) walking groups (social condition), 3) walking routes and walking groups (combined condition), and 4) no intervention (control condition). Measurements took place at baseline (T0), and 3 months (T1) and 9 months (T2) after the intervention. Data were analysed on a multiple imputed dataset, using multi-level negative binomial regression models, adjusting for clustering of observations within individuals. All models were adjusted for demographic covariates. Results Total time spent walking per week increased between T0 and T1 for all conditions. The Incidence Rate Ratio (IRR) for the physical condition was 1.46 (95% CI:1.06;2.05) and for the social intervention 1.52 (95%CI:1.07;2.16). At T2, these differences remained significant for the physical condition, but not for the social condition and the combined condition. These findings were mirrored for utilitarian walking. No evidence was found for an effect on recreational walking. Conclusion Implementing small scale, feasible, interventions in a residential neighbourhood may increase total and utilitarian walking behaviour among older adults.

Background and purpose — Anterior knee pain is common after tibial nailing. Its origin is poorly understood. Injury of the infrapatellar nerve is a possible cause. In this randomized controlled trial we compared changes in knee pain after an infrapatellar nerve block with lidocaine or placebo in patients with persistent knee pain after tibial nailing. Patients and methods — Patients with chronic knee pain after tibial nailing were randomized to an infrapatellar nerve block with 5 ml 2% lidocaine or placebo (sodium chloride 0.9%), after which they performed 8 daily activities. Before and after these activities, pain was recorded using a numeric rating scale (NRS; 0–10). Primary endpoint was the change in pain during kneeling after the infrapatellar nerve block. Secondary outcomes were changes in pain after the nerve block during the other activities. Results — 34 patients (age 18–62 years) were equally randomized. A significant reduction of the NRS for kneeling pain with an infrapatellar nerve block with lidocaine was found compared with placebo (–4.5 [range –10 to –1] versus –1 [–9 to 2]; p = 0.002). There were no differences between the treatments for the NRS values for pain during other activities. Interpretation — Compared with placebo, an infrapatellar nerve block with lidocaine was more effective in reducing pain during kneeling in patients with chronic knee pain after tibial nailing. Our findings support the contention that kneeling pain after tibial nailing is a peripheral nerve-related problem.

Abstract Background Running has become one of the most popular sports and has proven benefits for public health. Policy makers are increasingly aware that attractively designed public spaces may promote running. However, little is known about what makes a running environment attractive and restorative for runners and to what extent this depends on characteristics of the runner. This study aims to investigate 1) to what extent intrapersonal characteristics (i.e. motives and attitudes) and perceived environmental characteristics (e.g. quality of the running surface, greenness of the route, feelings of safety and hinderance by other road users) are associated with the perceived attractiveness and restorative capacity of the running environment and 2) to what extent the number of years of running experience modify these associations. Methods Cross-sectional data were collected through the online Eindhoven Running Survey 2015 (ERS15) among half marathon runners (N = 2477; response rate 26.6%). Linear regression analyses were performed for two outcomes separately (i.e. perceived attractiveness and perceived restorative capacity of the running environment) to investigate their relations with motives and attitudes, perceived environmental characteristics and interactions between perceived environmental characteristics and number of years of running experience. Results Perceived environmental characteristics, including green and lively routes and a comfortable running surface were more important for runners’ evaluation of the attractiveness and restorative capacity of the running environment than runners’ motives and attitudes. In contrast to experienced runners, perceived hinder from unleashed dogs and pedestrians positively impacted the attractiveness and restorative capacity for less experienced runners. Conclusions Perceived environmental characteristics were important determinants of the attractiveness and restorative capacity of the running environment for both novice and experienced runners. However, green and lively elements in the running environment and hinderances by cars were more important for less experienced runners. In order to keep novice runners involved in running it is recommended to design comfortable running tracks and routes and provide good access to attractive, green and lively spaces.

Abstract Purpose To evaluate whether immunomodulation can eliminate high sustained antibody levels, and thereby improve clinical outcome in classic infantile Pompe patients receiving enzyme replacement therapy (ERT) with recombinant human alpha-glucosidase (rhGAA). Methods Three patients (two cross-reactive immunologic material (CRIM) negative) with high sustained antibodies received a three-week treatment protocol with Rituximab and Bortezomib, followed by daily Rapamycin and monthly IVIG. Patients received 40 mg/kg/week rhGAA. Antibody titers were measured using ELISA. Neutralizing effects on cellular uptake were determined. Clinical efficacy was measured in terms of (ventilator-free) survival, reduction in left ventricular mass index (LVMI) and improvement in motor function. Results Before immunomodulation anti-rhGAA antibody titers ranged from 1:156,250 to 1:781,250 and at last assessment from 1:31,250 to 1:156,250. Neutralizing effects of anti-rhGAA antibody titers (observed in two patients) disappeared. Infusion-associated reactions were no longer present. Immunomodulation resulted in substantial increases of aspartate transaminase, alanine transaminase, and creatine kinase levels. The two CRIM-negative patients who could walk at start of immunomodulation maintained their ability to walk; the patient who had lost this ability did not regain it. Conclusions To some extent, the immunomodulation protocol used in our study reduced antibody titers, but it did not eliminate them. Overall, there have been few reports on secondary immunomodulation, and various protocols have been applied. Future research should seek to identify the most successful immunomodulation protocol in patients with high sustained titers.

Abstract Background The importance of culture for food consumption is widely acknowledged, as well as the fact that culture-based resources (“cultural capital”) differ between educational groups. Since current explanations for educational inequalities in healthy and unhealthy food consumption (e.g. economic capital, social capital) are unable to fully explain this gradient, we aim to investigate a new explanation for educational inequalities in healthy food consumption, i.e. the role of cultural capital. Methods Data were obtained cross-sectionally by a postal survey among participants of the GLOBE study in the Netherlands in 2011 (N = 2953; response 67.1%). The survey measured respondents’ highest attained educational level, food-related cultural capital (institutionalised, objectivised and incorporated cultural capital), economic capital (e.g. home ownership, financial strain), social capital (e.g. social support, health-related social leverage, interpersonal relationships), and frequency of consumption of healthy and unhealthy food products. Two general outcomes (overall healthy food consumption, and overall unhealthy food consumption), and seven specific food consumption outcomes were constructed, and prevalence ratios (PR) were estimated in Poisson regression models with robust variance. Results Cultural capital was significantly associated with all food outcomes, also when social and economic capital were taken into account. Those with low levels of cultural capital were more likely to have a lower overall healthy food consumption (PR 1.35, 95% CI 1.22–1.49), a lower consumption of whole wheat bread (PR 1.21, 95% CI 1.05–1.38), vegetables (PR 1.55, 95% CI 1.40–1.71), and meat-substitutes and fish (PR 1.74, 95% CI 1.53–1.97), and a higher consumption of fried food (PR 1.59, 95% CI 1.31–1.93). Social capital was positively associated with overall healthy food consumption, whole wheat bread consumption, and the consumption of fish and meat-substitutes, and economic capital with none of the outcomes. The PR of the lowest educational group to have a low overall healthy food consumption decreased from 1.48 (95% CI 1.28–1.73) to 1.22 (95% CI 1.04–1.43) when cultural, social and economic capital were taken into account. Conclusions Cultural capital contributed to the explanation of educational inequalities in food consumption in The Netherlands, over and above economic and social capital. The socialisation processes through which cultural capital is acquired could offer new entry-points for the promotion of healthy food consumption among low educational groups.

Introduction Fetal and neonatal alloimmune thrombocytopenia (FNAIT) may lead to severe fetal or neonatal bleeding and/or perinatal death. Maternal alloantibodies, targeted against fetal human platelet antigens (HPAs), can result thrombocytopenia and bleeding complications. In pregnancies with known immunisation, fetal bleeding can be prevented by weekly maternal intravenous immunoglobulin infusions. Without population-based screening, immunisation is only detected after birth of an affected infant. Affected cases that might have been prevented, when timely identified through population-based screening. Implementation is hampered by the lack of knowledge on incidence, natural history and identification of pregnancies at high risk of bleeding. We designed a study aimed to obtain this missing knowledge.Methods and analysis The HIP (HPA-screening in pregnancy) study is a nationwide, prospective and observational cohort study aimed to assess incidence and natural history of FNAIT as well as identifying pregnancies at high risk for developing bleeding complications. For logistic reasons, we invite rhesus D-negative or rhesus c-negative pregnant women, who take part in the Dutch population-based prenatal screening programme for erythrocyte immunisation, to participate in our study. Serological HPA-1a typing is performed and a luminex-based multiplex assay will be performed for the detection of anti-HPA-1a antibodies. Results will not be communicated to patients or caregivers. Clinical data of HPA-1a negative women and an HPA-1a positive control group will be collected after birth. Samples of HPA-1a immunised pregnancies with and without signs of bleeding will be compared with identify parameters for identification of pregnancies at high risk for bleeding complications.Ethics and dissemination Ethical approval for this study has been obtained from the Medical Ethical Committee Leiden-The Hague-Delft (P16.002). Study enrolment began in March 2017. All pregnant women have to give informed consent for testing according to the protocol. Results of the study will be disseminated through congresses and publication in relevant peer-reviewed journals.Trial registration number NCT04067375.

Abstract Background Cycling for transportation has the potential to contribute to an increase in people’s physical activity levels. A growing body of evidence links the natural and the built environment to cycling. Whereas previous studies were mostly done within one city or one region, the present study covers the whole of the Netherlands, allowing an investigation of whether associations between environmental characteristics and cycling are context-specific. The study examines the extent to which objectively measured natural and built environment characteristics contribute to cycling duration in the Netherlands, as well as the differential effect of environmental characteristics on cycling duration by municipality size. Methods Our sample from the Dutch National Travel Survey 2010–2014 comprised 110,027 people aged 20–89 years, residing in 3163 four-digit postal code areas, nested within 387 municipalities across the whole of the Netherlands. Multilevel Tobit regression models were fitted to assess the associations between the natural and the built environment with average daily cycling duration (in minutes), while adjusting for individual and household characteristics. Interaction effects of natural and built environment characteristics and municipality size on cycling duration were also investigated. Results Higher address density, more bus stops, and shorter distance from home to the nearest train station were positively related to cycling duration. Respondents were more likely to cycle on days with higher temperatures, less wind, and less precipitation. Interaction tests showed that increased street density and address density were less cycling-promotive in small urban areas compared to medium or large cities. On the other hand, the positive association between number of bus stops and cycling duration was weaker in the largest and medium-sized cities compared to small urban and rural areas. Conclusions Interactions suggest that relations between environmental characteristics and cycling duration are context-specific (i.e., dependent on circumstances that differ between highly urbanized and less urbanized areas). Our findings need to be replicated in other countries to gain more insight into the interplay between environmental factors and municipality size.

Abstract Background Many adolescents drop out of organized sports. Lack of motivation and competing priorities are known as important reasons for dropout. However, time use factors as well as environmental determinants have been largely neglected in the current literature on dropout from youth sports. The aim of this study is to investigate how (changes in) time use and characteristics of the physical environment determine dropout from football and tennis among adolescents. Methods Data on time use and background characteristics were collected through online surveys in 2015 and 2016 among adolescents aged 13–21 (N = 2555), including both the dropped outs and those who still continued membership of their football or tennis clubs. Physical environmental determinants (travel distance to the sports club, and neighbourhood density) were measured objectively. Binary logistic regression analyses were carried out for football and tennis separately to examine the associations between time use (time spent on various activities and changes related to the school and job situation), and environmental factors on the probability of dropping out from sports. Results Time spent on sports outside the context of the sports club, and time spent on social or voluntary activities at the sports club was positively associated with continuing being football and tennis members. Tennis players who changed schools or participated in two sports at the same time had a higher probability of dropping out, whereas tennis players who travelled greater distances from home to the tennis club were less likely to drop out. Conclusions Determinants of dropout differed between football and tennis. However, time use variables were important predictors of dropout from football as well as tennis, whereas environmental determinants hardly contributed to the prediction of dropout. To keep youths involved in organized sports, this study recommends that sports professionals should: 1) offer flexibility in training and competition schedules, 2) stimulate participation in social activities and voluntary work at the sports club, 3) pay special attention to their needs and preferences, and 4) encourage possibilities to practice and play sports outside of regular training hours, for instance at the sports club or at playgrounds or parks in the neighbourhood.

Abstract Background Food literacy refers to the capability to make healthy food choices in different contexts, settings and situations. The aim of this study is to develop and validate the self-perceived food literacy (SPFL) scale, to assess individuals’ level of food literacy, including a knowledge, skills and behavior to plan, manage, select, prepare and eat food healthfully. Methods An initial set of 50 items for the SPFL scale were generated based on expert insights and literature. A cross-sectional online survey was conducted among a sample of Dutch adults (n = 755) in order to determine convergent, divergent and criterion validation against psychosocial variables that were expected to correlate with food literacy (self-control, impulsiveness) and against the expected outcome of high food literacy, namely healthy food consumption. Principal Component Analyses (PCA), Pearson correlation tests and linear regression analyses were conducted. The capacity to distinguish of the SPFL scale was determined by comparing SPFL scores of the general population with that of a sample of dieticians (n = 207). Results The participants in the general sample had an average age of 44.8 (SD:16.1), the majority were women (90.7%), they had a healthy weight (61.4%) and were highly educated (59.1%). Of the initial 50 items, 29 items remained after PCA and reflected eight domains of food literacy. SPFL was positively correlated with self-control (r = 0.51, p =

Abstract Background To improve our understanding of the neighborhood environment – physical activity (PA) relationship, it is of importance to assess associations between neighborhood environmental characteristics and neighborhood-based PA. Methods Participants’ (N = 308; 45–65 years) light PA (LPA) and moderate-vigorous PA (MVPA) within a 400, 800, and 1600 m buffer around adults’ homes was measured using accelerometers and GPS-devices. Land use data in ArcGIS provided neighborhood characteristics for the same buffers. Multilevel linear regression models, adjusted for socio-demographic variables and attitude towards PA, were used to assess associations of objective neighborhood characteristics with neighborhood-based LPA and MVPA. Results LPA was positively associated with the proportions of roads (within a 400 m buffer), and negatively associated with the proportions of recreational areas (within an 800 m buffer), and the proportion of green space (within the 800 m and 1600 m buffers). Multiple characteristics of 400 m buffers were positively associated with MVPA, i.e. proportions of green space, blue space, residences, shops and foodservice industry, sports terrain, and public social-cultural facilities. Also, characteristics of larger buffers were positively associated with MVPA, i.e. the proportions of shops and foodservice industry, sports terrain, and blue space (within an 800 m buffer), and the proportion of public social-cultural facilities (within the 800 m and 1600 m buffers). Conclusions Objective neighborhood characteristics of smaller as well as larger sized buffers were associated with neighborhood-based LPA and MVPA. Green and blue spaces seem to be of particular importance for PA in the smallest buffer, i.e. in the direct surrounding of adults’ homes.

Abstract Background The number of sports facilities, sports clubs, or city parks in a residential neighbourhood may affect the likelihood that people participate in sports and their preferences for a certain sports location. This study aimed to assess whether objective physical and socio-spatial neighbourhood characteristics relate to sports participation and preferences for sports locations. Methods Data from Dutch adults (N = 1201) on sports participation, their most-used sports location, and socio-demographic characteristics were collected using an online survey. Objective land-use data and the number of sports facilities were gathered for each participant using a 2000-m buffer around their home locations, whereas socio-spatial neighbourhood characteristics (i.e., density, socio-economic status, and safety) were determined at the neighbourhood level. A discrete choice-modelling framework (multinomial probit model) was used to model the associations between neighbourhood characteristics and sports participation and location. Results Higher proportions of green space, blue space, and the number of sports facilities were positively associated with sports participation in public space, at sports clubs, and at other sports facilities. Higher degrees of urbanization were negatively associated with sports participation at public spaces, sports clubs, and other sports facilities. Conclusions Those with more green space, blue space or sports facilities in their residential neighbourhood were more likely to participate in sports, but these factors did not affect their preference for a certain sports location. Longitudinal study designs are necessary to assess causality: do active people choose to live in sports-facilitating neighbourhoods, or do neighbourhood characteristics affect sports participation?

Abstract Background The key mechanisms underlying socioeconomic inequalities in dietary intake are still poorly understood, hampering the development of interventions. An important, but sparsely mentioned mechanism is that of ‘social distinction’, whereby those in a higher socioeconomic position adopt dietary patterns by which they can distinguish themselves from lower socioeconomic groups. We investigated the importance of distinction as a mechanism, by testing the socioeconomic gradient in the consumption of so-called ‘superfoods’ and the contribution of a well-established indicator of distinction, cultural participation. Methods Data from participants (25–75 years) of the 2014 survey of the Dutch population-based GLOBE study were used (N = 2812). Multivariable regression models were used to analyse the association between education, income and cultural participation (e.g. visits to museums, opera, theatre, concerts) and the consumption of superfoods (spelt, quinoa and goji berries, chia seeds or wheatgrass). Results The consumption of superfoods is far more prevalent among higher socioeconomic groups. Adjusting for cultural participation strongly attenuated the educational and income gradient in superfoods consumption, whereas cultural participation remained strongly associated with superfoods consumption. Those in the highest quintile of cultural participation reported the highest consumption of spelt products (OR = 2.97, 95% CI = 2.10;4.18), quinoa (OR = 3.50, 95% CI = 2.12;5.79) and goji berries, chia seeds or wheatgrass (OR = 2.69, 95% CI = 1.73;4.17). Conclusions The associations between socioeconomic position and the consumption of ‘superfoods’ seem to be partially driven by a process of social distinction. These findings suggest that distinction may be an important, but currently neglected mechanism in generating socioeconomic inequalities in dietary intake. It deserves a more prominent role in interventions to reduce these inequalities.

Abstract Background This study examined whether characteristics of the residential built environment (i.e. population density, level of mixed land use, connectivity, accessibility of facilities, accessibility of green) contributed to educational inequalities in walking and cycling among adults. Methods Data from participants (32–82 years) of the 2011 survey of the Dutch population-based GLOBE study were used (N = 2375). Highest attained educational level (independent variable) and walking for transport, cycling for transport, walking in leisure time and cycling in leisure time (dependent variables) were self-reported in the survey. GIS-systems were used to obtain spatial data on residential built environment characteristics. A four-step mediation-based analysis with log-linear regression models was used to examine to contribution of the residential built environment to educational inequalities in walking and cycling. Results As compared to the lowest educational group, the highest educational group was more likely to cycle for transport (RR 1.13, 95% CI 1.04–1.23), walk in leisure time (RR 1.12, 95% CI 1.04–1.21), and cycle in leisure time (RR 1.12, 95% CI 1.03–1.22). Objective built environment characteristics were related to these outcomes, but contributed minimally to educational inequalities in walking and cycling. On the other hand, compared to the lowest educational group, the highest educational group was less likely to walk for transport (RR 0.91, 95% CI 0.82–1.01), which could partly be attributed to differences in the built environment. Conclusion This study found that objective built environment characteristics contributed minimally to educational inequalities in walking and cycling in the Netherlands.

Abstract Background Moderate to vigorous physical activity (MVPA) is considered important to prevent disability among community-dwelling older people. To develop MVPA programs aimed at reducing or preventing disability more insight is needed in the contributions of exercise duration and intensity and the interplay between the two. Methods Longitudinal data of 276 Dutch community-dwelling persons aged 65 years and older participating in the Elderly And their Neighbourhood (ELANE) study were used. MVPA exercise (yes/no), duration (hours per two weeks), intensity (Metabolic Equivalent of Task; METs), and energy expenditure (MET-hours per two weeks), and disability in instrumental activities of daily living (range 0–8) were measured twice within 9 months to account for fluctuations over time. Associations between the four exercise measures and disability were tested with longitudinal tobit regression analyses. Results MVPA exercise was associated with fewer disabilities. While exercise duration was not associated with disability, whereas an increase of one MET in exercise intensity was associated with 0.14 fewer disabilities (95 % CI: -0.26 to -0.02). For exercise energy expenditure, an increase of one MET-hour exercise per two weeks was associated with 0.03 fewer disabilities (95 % CI: -0.05 to -0.01). Conclusions Higher-intensity exercise may help to prevent disability among community-dwelling older people. Further investigation is needed to explore the preventive effects in more detail.

Abstract Background Living longer independently may be facilitated by an attractive and safe residential area, which stimulates physical activity. We studied the association between area characteristics and disabilities and whether this association is mediated by transport-related physical activity (TPA). Methods Longitudinal data of 271 Dutch community-dwelling adults aged 65 years and older participating in the Elderly And their Neighbourhood (ELANE) study in 2011–2013 were used. Associations between objectively measured aesthetics (range 0–22), functional features (range 0–14), safety (range 0–16), and destinations (range 0–15) within road network buffers surrounding participants’ residences, and self-reported disabilities in instrumental activities of daily living (range 0–8; measured twice over a 9 months period) were investigated by using longitudinal tobit regression analyses. Furthermore, it was investigated whether self-reported TPA mediated associations between area characteristics and disabilities. Results A one unit increase in aesthetics within the 400 m buffer was associated with 0.86 less disabilities (95% CI −1.47 to −0.25; p

Abstract Background Physical activity is important for healthy ageing, and daily walking is seen as a feasible way to be active at older ages. Yet, many older persons, particularly in lower socioeconomic groups and residing in deprived neighbourhoods, are insufficiently active. Creating a physical and social neighbourhood environment that is more supportive for walking has the potential to improve walking behaviour. Current evidence of the impact of changes to the physical and/or social environmental on walking behaviour is scarce. The aim of the NEW.ROADS study is to design, implement and evaluate changes to the physical and social environment for the purpose of increasing walking behaviour among older residents of deprived neighbourhoods. Methods Physical and social environmental interventions were developed by matching scientific evidence on environmental determinants of walking, with input from the target population and stakeholders, and ongoing neighbourhood activities. Specifically, a neighbourhood walking route was designed and marked, and neighbourhood walking groups were organised. These environmental interventions were evaluated in a four-armed experimental study. In addition, the design of the study to evaluate the effect of these environmental changes on walking behaviour is described. Discussion Designing and implementing environmental interventions is a complex endeavour, challenged by limited available theory and evidence. Input from the target population and professional stakeholders is essential, but may also put constraints on the evaluation. Trial registration NTR3800 (registered 9/1/2013)

BACKGROUND:To develop targeted policy strategies to increase sports participation, more insight is needed into the behavioural patterns and preferences of users of different club-organized (i.e., sports clubs) and non-club organized (i.e., gyms, health centres or swimming pools) or informal sports settings such as public spaces. This study investigates 1) how users of different settings differ regarding self-determined motivations and goals, and sociodemographic and sports-related characteristics, and 2) how the association of motivations and goals with sports participation may differ between users of different sports settings. METHODS:Data were collected through online surveys among Dutch adults aged 18-80 years (N = 910). Ordinal regression analyses were used to investigate the effects of sports settings, the level of self-determined motivations and goals, and interaction effects of motivations and goals with different sports settings, on sports frequency. RESULTS:Users of different sports settings differed in their personal characteristics, motivations and goals. In general, controlled motivations were negatively associated with sports frequency (B = -0.46). However, among club members, extrinsic goals related to image (B = 0.44), as well as intrinsic goals related to skill development (B = 0.40) and social affiliation (B = 0.47) had significant positive associations with sports frequency. Health-related goals significantly increased sports frequency among users of informal settings, such as public spaces. CONCLUSION:The association of motivational variables with sports participation differs between settings. This implies that sports frequency is higher when participants engage in settings that better fit their motivations and goals. Because of the growing importance of informal and flexible settings and health goals, professionals in the sports and health domains should take into account the motivations, goals and needs of different target groups who (want to) use unorganized, informal sports settings including public spaces.