School health promotion and the consumption of water and sugar-sweetened beverages in secondary schools: a cross-sectional multilevel study.

BACKGROUND: Overweight among adolescents remains a serious concern worldwide and can have major health consequences in later life, such as cardiovascular diseases and cancer. Still, 33% of secondary school adolescents in the Netherlands consume sugar-sweetened beverages daily and over 26% do not consume water every day. The Dutch Healthy School program was developed to support schools in stimulating healthier lifestyles by focusing on health education, school environments, identifying students' health problems, and school policy. We examined the variation between secondary schools regarding the daily consumption of water and sugar-sweetened beverages and whether this variation can be explained by differences between schools regarding Healthy School certification, general school characteristics, and the school population. METHODS: We performed a cross-sectional multilevel study. We used data from the national Youth Health Monitor of 2019 on secondary schools (grades 8 and 10, age range about 12 to 18 years) of seven Public Health Services and combined these with information regarding Healthy School certification and general school- and school population characteristics. Our outcomes were daily consumption of water and sugar-sweetened beverages. In total, data from 51,901 adolescents from 191 schools were analysed. We calculated the intraclass correlation to examine the variation between schools regarding our outcomes. Thereafter, we examined whether we could explain this variation by the included characteristics. RESULTS: The school-level explained 4.53% of the variation in the consumption of water and 2.33% of the variation in the consumption of sugar-sweetened beverages. This small variation in water and sugar-sweetened consumption could not be explained by Healthy School certification, yet some general school- and school population characteristics did: the proportion of the school population with at least one parent with high educational attainment, the educational track of the adolescents, urbanicity (only for water consumption) and school type (only for sugar-sweetened beverages consumption). CONCLUSIONS: The low percentages of explained variation indicate that school-level characteristics in general (including Healthy School certification) do not matter substantially for the daily consumption of water and sugar-sweetened beverages. Future research should examine whether school health promotion can contribute to healthier lifestyles, and if so, under which level of implementation and school conditions.

Correction: Effectiveness of a Web-Based Tailored Intervention With Virtual Assistants Promoting the Acceptability of HPV Vaccination Among Mothers of Invited Girls: Randomized Controlled Trial.

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MR Imaging Features of Retinoblastoma: Association with Gene Expression Profiles.

Purpose To identify associations between magnetic resonance (MR) imaging features and gene expression in retinoblastoma. Materials and Methods A retinoblastoma MR imaging atlas was validated by using anonymized MR images from referral centers in Essen, Germany, and Paris, France. Images were from 39 patients with retinoblastoma (16 male and 18 female patients [the sex in five patients was unknown]; age range, 5-90 months; inclusion criterion: pretreatment MR imaging). This atlas was used to compare MR imaging features with genome-wide messenger RNA (mRNA) expression data from 60 consecutive patients obtained from 1995 to 2012 (35 male patients [58%]; age range, 2-69 months; inclusion criteria: pretreatment MR imaging, genome-wide mRNA expression data available). Imaging pathway associations were analyzed by means of gene enrichment. In addition, imaging features were compared with a predefined gene expression signature of photoreceptorness. Statistical analysis was performed with generalized linear modeling of radiology traits on normalized log2-transformed expression values. P values were corrected for multiple hypothesis testing. Results Radiogenomic analysis revealed 1336 differentially expressed genes for qualitative imaging features (threshold P = .05 after multiple hypothesis correction). Loss of photoreceptorness gene expression correlated with advanced stage imaging features, including multiple lesions (P = .03) and greater eye size (P < .001). The number of lesions on MR images was associated with expression of MYCN (P = .04). A newly defined radiophenotype of diffuse-growing, plaque-shaped, multifocal tumors displayed overexpression of SERTAD3 (P = .003, P = .049, and P = .06, respectively), a protein that stimulates cell growth by activating the E2F network. Conclusion Radiogenomic biomarkers can potentially help predict molecular features, such as photoreceptorness loss, that indicate tumor progression. Results imply a possible role for radiogenomics in future staging and treatment decision making in retinoblastoma.

Specific agreement on ordinal and multiple nominal outcomes can be calculated for more than two raters.

OBJECTIVE: The concept of specific agreement (SA) has been proposed for dichotomous outcomes for two or more raters. We aim to extend this concept for variables with more than two ordinal or nominal categories and more than two raters. STUDY DESIGN AND SETTING: We used two data sets: four plastic surgeons classifying photographs after breast reconstruction on a 5-point ordinal scale and six raters classifying psychiatric patients into five diagnostic categories. For m raters, all (i.e., m(m-1)/2) pairwise agreement tables were summed to calculate the observed agreement (OA), SA and conditional probabilities. The 95% confidence intervals were obtained by bootstrapping. RESULTS: SA was calculated for each ordinal or nominal category to examine when one of the raters scored in a specific category, what is the probability that the other raters scored in that same category. And suppose one of the raters scored X1, what is the probability that the other raters scored X1 or any of the other categories (conditional probability). It appeared, for example, that among the psychiatric disorders, depression and personality disorders were often mixed up, whereas neurosis was rarely mixed up with schizophrenia. CONCLUSION: The concept of SA for variables with ordinal and multiple nominal categories provides relevant clinical information. The extension to conditional probabilities of alternative categories broadens the clinical application with examining which categories are most often mixed up.

Effectiveness of a Web-Based Tailored Intervention With Virtual Assistants Promoting the Acceptability of HPV Vaccination Among Mothers of Invited Girls: Randomized Controlled Trial.

BACKGROUND: In 2010, the human papillomavirus (HPV) vaccination was introduced in the Dutch National Immunization Program for 12-year-old girls, aiming to reduce the incidence of cervical cancer in women. HPV vaccination uptake turned out to be lower than expected: 61% versus 70%, respectively. Mothers were shown to play the most important role in the immunization decision about this vaccination. They had also expressed their need for interactive personal information about the HPV vaccination over and above the existing universal general information. To improve the effectiveness of the existing education about the HPV vaccination, we systematically developed a Web-based tailored intervention with virtual assistants providing mothers of girls to be invited with tailored feedback on their decision making about the HPV vaccination. OBJECTIVE: The aim of this study was to evaluate the effectiveness of the Web-based tailored intervention for promoting HPV vaccination acceptance by means of a randomized controlled trial (RCT). METHODS: Mothers were recruited via the Dutch vaccination register (Praeventis) (n=36,000) and three Web-based panels (n=2483). Those who gave informed consent (N=8062) were randomly assigned to the control (n=4067) or intervention condition (n=3995). HPV vaccination uptake, as registered by Praeventis once the HPV vaccination round was completed, was used as the primary outcome. Secondary outcomes were differential scores across conditions between baseline (before the provided access to the new tailored intervention) and follow-up (just before the first vaccination) regarding the mothers' degree of informed decision making (IDM), decisional conflict, and critical determinants of HPV vaccination uptake among which are intention, attitude, risk perception, and outcome beliefs. RESULTS: Intention-to-treat analysis (N=8062) showed a significant positive effect of the intervention on IDM, decisional conflict, and nearly all determinants of HPV vaccination uptake (P<.001). No effect was found on uptake (P=.60). This may be attributed to the overall high uptake rates in both conditions. Mothers evaluated the intervention as highly positive, including the website as well as the virtual assistants that were used to deliver the tailored feedback. CONCLUSIONS: This computer-tailored intervention has the potential to improve HPV vaccination acceptability and IDM and to decrease decisional conflict among mothers of invited girls. Implications for future research are discussed. TRIAL REGISTRATION: Trialregister.nl NTR4935; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4935 (Archived by WebCite at http://www.webcitation.org/6srT7l9EM).

Motivational and contextual determinants of HPV-vaccination uptake: A longitudinal study among mothers of girls invited for the HPV-vaccination.

BACKGROUND: In the Netherlands, HPV-vaccination uptake among 12-year-old girls remains to be lower (61% in 2016) than expected. The present study is about 1) replicating the extent to which social-psychological determinants found in earlier cross-sectional studies explain HPV-vaccination intention, and 2) testing whether HPV-vaccination intention, as well as other social-psychological determinants, are good predictors of future HPV-vaccination uptake in a longitudinal design. METHODS: A random sample of mothers of girls invited for the vaccination in 2015 was drawn from the Dutch vaccination register (Praeventis) (N=36,000) and from three online panels (N=2483). Two months prior to the vaccination of girls, their mothers were requested to complete a web-based questionnaire by letter (Praeventis sample) or by e-mail (panel samples). HPV-vaccination uptake was derived from Praeventis. Backward linear and logistic regression analyses were conducted to examine most dominant predictors of HPV-vaccination intention and uptake, respectively. The total sample used for data analyses consisted of 8062 mothers. Response rates were 18% for the Praeventis sample and 47% for the panel samples. RESULTS: HPV-vaccination intention was best explained by attitude, beliefs, subjective norms, habit, and perceived relative effectiveness of the vaccination; they explained 83% of the variance in HPV-vaccination intention. Intention appeared to be the only stable predictor of HPV-vaccination uptake and explained 43% of the variance in HPV-vaccination uptake. CONCLUSIONS: These results confirm what was found by earlier cross-sectional studies, and provide strong leads for selecting relevant targets in the planning of future communication strategies aiming to improve HPV-vaccination uptake.

Specific agreement on dichotomous outcomes can be calculated for more than two raters.

OBJECTIVE: For assessing interrater agreement, the concepts of observed agreement and specific agreement have been proposed. The situation of two raters and dichotomous outcomes has been described, whereas often, multiple raters are involved. We aim to extend it for more than two raters and examine how to calculate agreement estimates and 95% confidence intervals (CIs). STUDY DESIGN AND SETTING: As an illustration, we used a reliability study that includes the scores of four plastic surgeons classifying photographs of breasts of 50 women after breast reconstruction into "satisfied" or "not satisfied." In a simulation study, we checked the hypothesized sample size for calculation of 95% CIs. RESULTS: For m raters, all pairwise tables [ie, m (m - 1)/2] were summed. Then, the discordant cells were averaged before observed and specific agreements were calculated. The total number (N) in the summed table is m (m - 1)/2 times larger than the number of subjects (n), in the example, N = 300 compared to n = 50 subjects times m = 4 raters. A correction of n√(m - 1) was appropriate to find 95% CIs comparable to bootstrapped CIs. CONCLUSION: The concept of observed agreement and specific agreement can be extended to more than two raters with a valid estimation of the 95% CIs.

The long-term burden of military deployment on the health care system.

Health care providers need to be aware that stress complaints that result from deployment can emerge even after many years. This has important implications for health care policies. The main aim of this study is to investigate the relation between the development of posttraumatic stress and other mental health complaints and the burden on (mental) health care after a deployment. For this study we used data from a large prospective cohort study on stress-factors related to deployment in 1007 Dutch soldiers, who were deployed to Afghanistan. Participants were assessed at six follow up times up until five years after deployment. In a Generalized Estimated Equations model we estimated the relation between mental health complaints and the utilization of psychological treatment and a general practitioner, respectively. Moreover, we studied the relation between mental health complaints and health care costs using bootstrap techniques. The results showed that higher scores for PTSD, depression and fatigue relate to increased use of a psychologist. And lower PTSD scores and higher depression, anxiety and somatization scores relate to increased odds to visit a GP. Furthermore, mental health complaints relate to higher costs. In conclusion, monitoring soldiers is important in order to be informed on the current demand for (mental) health care to satisfy the health care need of veterans. Early treatment, which is enabled by lowering barriers to care, relates to positive results and therefore, lower health care costs.

The association of eating styles with weight change after an intensive combined lifestyle intervention for children and adolescents with severe obesity.

UNLABELLED: The main purpose of this prospective intervention study was to determine whether eating styles after an intensive, partly inpatient, one year combined lifestyle intervention are associated with weight change in the following year in severely obese children and adolescents. A total of 120 participants (8-19 years) with an average SDS-BMI of 3.41 (SD = 0.38) was included. Measurements were conducted at baseline (T0), at the end of treatment (T12) and at the end of follow up two years after baseline (T24). The primary outcome measurement was the ΔSDS-BMI between T12 and T24. As primary determinant of weight change after treatment, the participants eating styles were evaluated with the Dutch Eating Behavior Questionnaire - child report that measures external, emotional and restraint eating. The association between outcome and determinant was assessed in linear regression analyses. Complete data were available for 76 of the 120 participants. This study shows that for girls a higher score on restraint eating at T12 and a higher score on external eating at T12 were associated with more weight (re)gain in the year after treatment. No statistically significant association with emotional eating at T12 was found. In addition for girls a higher score on external eating at T0 was associated with more weight (re)gain in the year after treatment. Furthermore, the observed changes in eating styles suggest that on average it is possible to influence these with treatment, although the detected changes were different for girls and boys and for the different eating styles. More generally, this study indicates that for girls the levels of restraint and external eating after treatment were associated with the weight change during the following year. TRIAL REGISTRATION: Netherlands Trial Register (NTR1678, registered 20-Feb-2009).

Multiple imputation strategies for zero-inflated cost data in economic evaluations: which method works best?

Cost and effect data often have missing data because economic evaluations are frequently added onto clinical studies where cost data are rarely the primary outcome. The objective of this article was to investigate which multiple imputation strategy is most appropriate to use for missing cost-effectiveness data in a randomized controlled trial. Three incomplete data sets were generated from a complete reference data set with 17, 35 and 50 % missing data in effects and costs. The strategies evaluated included complete case analysis (CCA), multiple imputation with predictive mean matching (MI-PMM), MI-PMM on log-transformed costs (log MI-PMM), and a two-step MI. Mean cost and effect estimates, standard errors and incremental net benefits were compared with the results of the analyses on the complete reference data set. The CCA, MI-PMM, and the two-step MI strategy diverged from the results for the reference data set when the amount of missing data increased. In contrast, the estimates of the Log MI-PMM strategy remained stable irrespective of the amount of missing data. MI provided better estimates than CCA in all scenarios. With low amounts of missing data the MI strategies appeared equivalent but we recommend using the log MI-PMM with missing data greater than 35 %.