Quality of life measurement in teledermatology. Position statement of the European Academy of Dermatology and Venereology Task Forces on Quality of Life and Patient Oriented Outcomes and Teledermatology

Many events, including the COVID-19 pandemic, have accelerated the implementation of teledermatology pathways within dermatology departments and across healthcare organizations. Quality of Life (QoL) assessment in dermatology is also a rapidly developing field with a gradual shift from theory to practice. The purpose of this paper organized jointly by the European Academy of Dermatology and Venereology (EADV) Task Force (TF) on QoL and patient-oriented outcomes and the EADV TF on teledermatology is to present current knowledge about QoL assessment during the use of teledermatology approaches, including data on health-related (HR) QoL instruments used in teledermatology, comparison of influence of different treatment methods on HRQoL after face-to-face and teledermatology consultations and to make practical recommendations concerning the assessment of QoL in teledermatology. The EADV TFs made the following position statements: HRQoL assessment may be an important part in most of teledermatology activities; HRQoL assessment may be easily and effectively performed during teledermatology consultations. It is especially important to monitor HRQoL of patients with chronic skin diseases during lockdowns or in areas where it is difficult to reach a hospital for face-to-face consultation; regular assessment of HRQoL of patients with skin diseases during teledermatology consultations may help to monitor therapy efficacy and visualize individual patient's needs; we recommend the use of the DLQI in teledermatology, including the use of the DLQI app which is available in seven languages; it is important to develop apps for dermatology-specific HRQoL instruments for use in children (for example the CDLQI and InToDermQoL) and for disease-specific instruments.

Quality of life measurement in rosacea. Position statement of the European Academy of Dermatology and Venereology Task Forces on Quality of Life and Patient Oriented Outcomes and Acne, Rosacea and Hidradenitis Suppurativa

The European Academy of Dermatology and Venereology (EADV) Task Forces (TFs) on Quality of Life (QoL) and Patient-Oriented Outcomes and Acne, Rosacea and Hidradenitis Suppurativa (ARHS) do not recommend the use of any generic instrument as a single method of Health Related (HR) QoL assessment in rosacea, except when comparing quimp (quality of life impairment) in rosacea patients with that in other non-dermatologic skin diseases and/or healthy controls. The EADV TFs on QoL and Patient-Oriented Outcomes and ARHS recommend the use of the dermatology-specific HRQoL instrument the Dermatology Life Quality Index (DLQI) and the rosacea-specific HRQoL instrument RosaQoL in rosacea patients. The DLQI minimal clinically important difference may be used as a marker of clinical efficacy of the treatment and DLQI score banding of 0 or 1 corresponding to no effect on patients' HRQoL could be an important treatment goal. This information may be added to consensuses and guidelines for rosacea.

Quality of life measurement in vitiligo. Position statement of the European Academy of Dermatology and Venereology Task Force on Quality of Life and Patient Oriented Outcomes with external experts

Members of the European Academy of Dermatology and Venereology (EADV) Task Force on Quality of Life (QoL) and Patient Oriented Outcomes reviewed the instruments available for health-related (HR) QoL assessment in vitiligo and together with external vitiligo experts (including representatives of the EADV Vitiligo Task Force) have made practical recommendations concerning the assessment of QoL in vitiligo patients. The Dermatology Life Quality Index (DLQI) was the most frequently used HRQoL instrument, making comparison of results between different countries possible. Several vitiligo-specific instruments were identified. The vitiligo Impact Scale (VIS) is an extensively validated vitiligo-specific HRQoL instrument with proposed minimal important change and clinical interpretation for VIS-22 scores. VIS-22 was developed for use in India, where there are some specific cultural beliefs concerning vitiligo. The EADV Task Force on QoL and Patient Oriented Outcomes recommends use of the DLQI and the Children's Dermatology Life Quality Index (CDLQI) as dermatology-specific instruments in vitiligo. There is a strong need for a valid (including cross-cultural validation) vitiligo-specific instrument that can be either a new instrument or the improvement of existing instruments. This validation must include the proof of responsiveness.

Systemic treatment of children and adolescents with atopic dermatitis aged ≥2 years: a Delphi consensus project mapping expert opinion in Northern Europe

BACKGROUND

Paediatric atopic dermatitis (AD) can be burdensome, affecting mental health and impairing quality of life for children and caregivers. Comprehensive guidelines exist for managing paediatric AD, but practical guidance on using systemic therapy is limited, particularly for new therapies including biologics and Janus kinase (JAK) inhibitors, recently approved for various ages in this indication.

OBJECTIVES

This expert consensus aimed to provide practical recommendations within this advancing field to enhance clinical decision-making on the use of these and other systemics for children and adolescents aged ≥2 years with moderate-to-severe AD.

METHODS

Nineteen physicians from Northern Europe were selected for their expertise in managing childhood AD. Using a two-round Delphi process, they reached full or partial consensus on 37 statements.

RESULTS

Systemic therapy is recommended for children aged ≥2 years with a clear clinical diagnosis of severe AD and persistent disease uncontrolled after optimizing non-systemic therapy. Systemic therapy should achieve long-term disease control and reduce short-term interventions. Recommended are cyclosporine A for short-term use (all ages) and dupilumab or methotrexate for long-term use (ages ≥6 years). Consensus was not reached on the best long-term systemics for children aged 2-6 years, although new systemic therapies will likely become favourable: New biologics and JAK inhibitors will soon be approved for this age group, and more trial and real-world data will become available.

CONCLUSIONS

This article makes practical recommendations on the use of systemic AD treatments for children and adolescents, to supplement international and regional guidelines. It considers the systemic medication that was available for children and adolescents with moderate-to-severe AD at the time this consensus project was done: azathioprine, cyclosporine A, dupilumab, methotrexate, mycophenolate mofetil and oral glucocorticosteroids. We focus on the geographically similar Northern European countries, whose healthcare systems, local preferences for AD management and reimbursement structures nonetheless differ significantly.

Arrhythmogenic right ventricular cardiomyopathy – evolution of electrocardiographic markers during long-term follow-up prior to ascertainment of diagnosis

Background

Depolarization and repolarization abnormalities are part of the diagnostic Task Force Criteria of 2010 (TFC2010) for arrhythmogenic right ventricular cardiomyopathy (ARVC). These abnormalities are thought to be progressive but have also been described as dynamic and sometimes reversible. Evolution of ECG abnormalities prior to clinical ARVC diagnosis is poorly studied.

Objective

To assess the evolution of ECG depolarization and repolarization characteristics in patients with ARVC prior to diagnosis and to identify markers of disease progression at a preclinical stage.

Methods

353 patients with definite ARVC from Sweden, Denmark, the Netherlands and Canada with at least one 12-lead digital ECG (65% males, 67% probands, 56% mutation carriers, median age at diagnosis 42 [IQR 29–53] years and median age at first ECG 44 [30–55] years) were included. Digital ECGs were extracted from regional ECG archives. ECGs with left bundle branch block, ventricular pacing or recorded either prior to 15 years of age or after heart transplantation were excluded. Remaining 6,871 ECGs were digitally processed and automatically analysed using the Glasgow algorithm. Median values for overall QRS duration, terminal activation delay (TAD) in lead V1 as well as amplitudes of QRS-T-components in precordial leads per patient per year were used for analyses and graphically represented using Lowess smoothing with cubic splines (Figure 1). Blue lines indicate smoothed conditional mean with 95% confidence interval (shadow). Time “0” (red line) indicates the time when TFC2010 were fulfilled for definite diagnosis.

A database of 18,564 anonymized digital ECGs (58% males, median age at latest ECG 41 years [IQR 32–52]) who were in contact with health care during 2020–2021 was processed using the same exclusion criteria and signal-processing methodology as in the ARVC group and used as a reference (black line).

Results

TAD in lead V1 and overall QRS duration demonstrated a significant increase years before ARVC diagnosis, and significant reductions were seen in QRS-T voltages measured as R wave amplitude, QRS amplitude (the absolute sum of R wave and S wave), and T wave amplitude (Table 1 and Figure 1). The changes were seen in all precordial leads, not only the right-sided, and visually diverging from the controls.

Conclusion

Development of the ARVC ECG phenotype started several years before diagnosis and continued afterwards. QRS duration and TAD increased, QRS voltages decrease, and T wave amplitude decreased eventually leading to T wave inversion. These changes might be visually assessed but also measured with available ECG software. These findings may be clinically useful in the screening and follow-up of ARVC relatives.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Governmental funding of clinical research (ALF), Region Ostergotland, Sweden.The Swedish Heart-Lung Foundation.

Greenland Ice Core Record of Last Glacial Dust Sources and Atmospheric Circulation

Abrupt and large-scale climate changes have occurred repeatedly and within decades during the last glaciation. These events, where dramatic warming occurs over decades, are well represented in both Greenland ice core mineral dust and temperature records, suggesting a causal link. However, the feedbacks between atmospheric dust and climate change during these Dansgaard-Oeschger events are poorly known and the processes driving changes in atmospheric dust emission and transport remain elusive. Constraining dust provenance is key to resolving these gaps. Here, we present a multi-technique analysis of Greenland dust provenance using novel and established, source diagnostic isotopic tracers as well as results from a regional climate model including dust cycle simulations. We show that the existing dominant model for the provenance of Greenland dust as sourced from combined East Asian dust and Pacific volcanics is not supported. Rather, our clay mineralogical and Hf-Sr-Nd and D/H isotopic analyses from last glacial Greenland dust and an extensive range of Northern Hemisphere potential dust sources reveal three most likely scenarios (in order of probability): direct dust sourcing from the Taklimakan Desert in western China, direct sourcing from European glacial sources, or a mix of dust originating from Europe and North Africa. Furthermore, our regional climate modeling demonstrates the plausibility of European or mixed European/North African sources for the first time. We suggest that the origin of dust to Greenland is potentially more complex than previously recognized, demonstrating more uncertainty in our understanding dust climate feedbacks during abrupt events than previously understood.

AB1560-HPR NURSE-DRIVEN DIAGNOSTIC PROCESS OF PATIENTS WITH SJÖGREN’S SYNDROME (SS) A CLINICAL DEVELOPMENT PROJECT

Background

Sjögren’s Syndrome (SS) is a chronic autoimmune disease that affects the body’s glandular functions, especially the lacrimal and salivary glands, causing the mucous membranes to dry out (1). There are no diagnostic criteria, and classification criteria are often used to support the diagnosis (2).

We identified a need to unify and consolidate the diagnostic process of patients with SS in the Capital Region of Denmark. A medical working group supervised the nurse-driven diagnostic process at Rigshospitalet, Glostrup. Here an interdisciplinary working group with physicians, nurses, and secretaries developed a diagnostic process and logistic based on the American-European Consensus Group Classification Criteria 2002 (3). The nurse’s took medical history and performed sicca tests and made sure that the patient received adequate guidance.

With input from three patients, the nurses at the outpatient clinic developed - written material on eye and mouth dryness. We developed a “smart phrase” for our documentation platform in the interdisciplinary working group. The purpose of the ‘smart phrase”, was to unify the documentation and ensure continuity in the conversation with the patient. The Rheumatologists task was to disprove or confirm the diagnosis and perform a risk stratification especially in relation to the development of lymphoma, but also interstitial lung disease.

Objectives

The aim of this project was to examine and evaluate the patients’ experience of nurse-driven diagnostic process.

Methods

To evaluate the new patient course, we performed a survey. The questions selected for the survey were primarily based on the patients experience of meaning and coherence in the diagnostic process. The questions were developed by the nurses in the Outpatient Clinic; “Do you feel safe going home after the consultation today?” “Did you get answers to the questions you asked while you were in the consultation?” “Did the staff take the time to listen to you?”. Also, the patients could add comments.

Results

A total of 34 consecutives responded to the questionnaire. 88% felt safe when returning home from the Outpatient Clinic, 85% received answers to their questions during the consultation. Altogether, 94% answered that the health care professionals were present and listened to them.

The patients had the following comments: “The diagnostic process contained a lot of unresolved waiting time “ and “There has been some confusion about the division of tasks in the different hospital wards”.

Conclusion

We found that the patients were satisfied with the nurse-driven diagnostic process. The diagnostic process created a feeling of safety in the patients and the patients found that they were listened to and allowed to ask questions. In addition, by evaluating the process investigation, we could change practice and further unify the diagnostic process. The result of the questionnaire supports the justification of the nurse competencies, by preforming a high level of information and guidance as well as the need for recognition of the patient’s symptoms.

Therefore, the working group chose to meet again and evaluate. We decided that the nurse and rheumatologist consultation should be performed on the same day. Such consultation made it possible for the nurse to ensure continuity in the process, as the same nurse could follow the patient throughout the day. This optimized the opportunity for the nurse to guide the patient in the symptomatic treatment of eye and mouth dryness. Also, the nurse had the opportunity to guide in oral hygiene, fatigue, and lifestyle factors.

The next step in our development project is to evaluate our revised nurse-led diagnostic process. In addition, the working group is currently working on material for a course in SS, where 4-6 patients and relatives can have the opportunity to participate.

References

[1]A.Voss et al. Reumatologi. FADL’s Forlag 2018. 238-251

[2]Troldborg, A et al. National behandlingsvejledning, Sjögrens syndrom. 2020.

[3]Troldborg, A et al. Sjögrens Syndrom, Dansk Reumatologisk Selskab 2010.

Acknowledgements

I would like to thank the patients for the contribution to this project.

Disclosure of Interests

None declared

Neutrophil extracellular traps promote cancer-associated inflammation and myocardial stress

Cancer is associated with systemic pathologies that contribute to mortality, such as thrombosis and distant organ failure. The aim of this study was to investigate the potential role of neutrophil extracellular traps (NETs) in myocardial inflammation and tissue damage in treatment-naïve individuals with cancer. Mice with mammary carcinoma (MMTV-PyMT) had increased plasma levels of NETs measured as H3Cit-DNA complexes, paralleled with elevated coagulation, compared to healthy littermates. MMTV-PyMT mice displayed upregulation of pro-inflammatory markers in the heart, myocardial hypertrophy and elevated cardiac disease biomarkers in the blood, but not echocardiographic heart failure. Moreover, increased endothelial proliferation was observed in hearts from tumor-bearing mice. Removal of NETs by DNase I treatment suppressed the myocardial inflammation, expression of cardiac disease biomarkers and endothelial proliferation. Compared to a healthy control group, treatment-naïve cancer patients with different malignant disorders had increased NET formation, which correlated to plasma levels of the inflammatory marker CRP and the cardiac disease biomarkers NT-proBNP and sTNFR1, in agreement with the mouse data. Altogether, our data indicate that NETs contribute to inflammation and myocardial stress during malignancy. These findings suggest NETs as potential therapeutic targets to prevent cardiac inflammation and dysfunction in cancer patients.

Use of systemic therapies in adults with atopic dermatitis: 12-month results from the European prospective observational study in patients eligible for systemic therapy for atopic dermatitis (EUROSTAD)

BACKGROUND

The European Prospective Observational Study in Patients Eligible for Systemic Therapy for Atopic Dermatitis (EUROSTAD) is an ongoing observational study aiming to describe characteristics of patients with atopic dermatitis (AD) treated with systemic therapy over time and the management of their disease in a real-world setting.

METHODS

Data from patients enrolled in EUROSTAD between March 2017 and April 2019 were analyzed for systemic therapy use and treatment change over 12 months.

RESULTS

288 patients reported taking systemic medications; 42.7% received cyclosporine, 35.3% dupilumab, 28.1% methotrexate, 25.4% oral corticosteroids, 6.8% azathioprine, 6.1% injectable corticosteroids, and 3.4% mycophenolate. The median duration of treatment was 1.1 months for oral systemic corticosteroids, 3.2 months for injectable corticosteroids, 4.8 months for cyclosporine, 7.3 months for methotrexate, and 14.9 months for dupilumab. The most frequent reasons for stopping treatment included lack of efficacy, patient decision, adverse events, and disease well controlled.

CONCLUSION

The 12-month interim EUROSTAD study analysis highlights the current trends and outcomes of systemic treatments for moderate-to-severe AD. Among all systemic treatments for AD, dupilumab was the least likely to be discontinued, whereas cyclosporine and corticosteroids, whilst effective, were primarily limited to episodic flare management consistent with treatment guidelines.

Quality of life measurement in alopecia areata. Position statement of the European Academy of Dermatology and Venereology Task Force on Quality of Life and Patient Oriented Outcomes

New treatment options may lead to an increased interest in using reliable and sensitive instruments to assess health-related quality of life in people with alopecia areata (AA). The purpose of this paper is to present current knowledge about quality of life assessment in AA. The dermatology-specific Dermatology Life Quality Index (DLQI) was the most widely reported health-related quality of life instrument used in AA. Three AA-specific (Alopecia Areata Symptom Impact Scale, Alopecia Areata Quality of Life Index and Alopecia Areata Patients' Quality of Life) and three hair disease-specific instruments (Hairdex, Scalpdex and 'hair-specific Skindex-29') were identified with a range of content and validation characteristics: there is little evidence yet of the actual use of these measures in AA. Scalpdex is the best-validated hair disease-specific instrument. Further extensive validation is needed for all of the AA-specific instruments. The European Academy of Dermatology and Venereology Task Force on Quality of Life and Patient Oriented Outcomes recommends the use of the dermatology-specific DLQI questionnaire, hair disease-specific Scalpdex and the alopecia areata-specific instruments the Alopecia Areata Symptom Impact Scale or Alopecia Areata Quality of Life Index, despite the limited experience of their use. We hope that new treatment methods will be able to improve both clinical signs and health-related quality of life in patients with AA. In order to assess the outcomes of trials on these new treatment methods, it would be helpful when further development and validation of AA-specific instruments is being encouraged and also conducted.

Disease burden and treatment history among adults with atopic dermatitis receiving systemic therapy: baseline characteristics of participants on the EUROSTAD prospective observational study

BACKGROUND

Insights into the real-world treatment paradigm and long-term burden of atopic dermatitis (AD) are needed to inform clinical and health policy decisions.

METHODS

The prospective, observational EUROSTAD study enrolled adults with moderate-to-severe AD starting or switching systemic therapy (51 sites in 10 European countries). We report the baseline characteristics, treatment patterns, and outcomes of these patients using descriptive statistics.

RESULTS

A 12-month enrollment period of EUROSTAD was completed and 308 patients were enrolled: average age 37 years, AD duration 25 years, 43% were female. Most patients reported use of systemic therapy (93%) and ≥1 atopic comorbidity (82%). Mean [standard deviation] disease severity/burden measures were high: Investigator's Global Assessment (3.1 [0.8]), Eczema Area and Severity Index (16.2 [10.9]), Peak Pruritus Numerical Rating Scale (5.5 [2.5]), sleep impairment Visual Analog Scale (49.8 [31.6]) scores, and time lost from work (4.1 [13.7] days/year) or usual activities (16.8 [38.7] days/year). Most patients showed borderline or clinical levels of anxiety (59%) and/or depression (63%) using the Hospital Anxiety and Depression Scale.

CONCLUSIONS

Adults with moderate-to-severe AD starting/switching systemic treatment enrolled in EUROSTAD have a high burden of longstanding disease despite continuous use of topical drugs, emollients, and systemic therapies.

Progressive ECG changes over time in arrhythmogenic right ventricular cardiomyopathy precede diagnosis and continue – indices of disease substrate development?

Background

Depolarization and repolarization abnormalities are common in arrhythmogenic right ventricular cardiomyopathy (ARVC), and are included in the diagnostic 2010 Task Force criteria (TFC2010). However, first ARVC symptoms commonly occur before ECG abnormalities reach the diagnostic thresholds and the time course of ECG abnormalities during initial phase of the disease remains obscure. Regional digital ECG archives allow computerized signal-processing and assessment of ECG phenotype during different disease phases, including the time prior to ascertainment of ARVC diagnosis.

Purpose

We aimed to assess the natural course of ECG characteristics associated with ARVC, hypothesizing that ARVC is a progressive disease and that ECG parameters progress over time due to disease substrate development.

Methods

Definite ARVC patients with at least one digital ECG recruited in three tertiary care hospitals in Sweden and Denmark were included (n=102, 66% males, 68% probands, 52% carrying a pathogenic genetic variant, 74% ICD carriers and 25% physically active >4 hours/week). Median age at diagnosis was 41 years (IQR 30–55). 12-lead digital ECGs were extracted from the regional ECG archives, containing all recordings in the hospital catchment areas since 1988. After excluding ECGs with heart rate <40 or >100/min, left bundle branch block or ventricular pacing, and those recorded prior to 14 years of age, the remaining 2067 ECGs were digitally processed and automatically analyzed using the Glasgow algorithm (median 3 [IQR 0–9] ECGs prior to diagnosis and 6 [IQR 2–14] ECGs during follow-up). Overall QRS duration as well as the right precordial lead indices exemplified by the lead V2 (terminal activation delay [TAD], area under the T-wave [T-wave area] and R-prime amplitude) were calculated and graphically represented using generalized additive model (GAM) with cubic splines (Figure 1). A median value for each measurement per patient per year was used for analysis. Blue line indicates smoothed conditional mean with 95% confidence interval (shadow). Time “0” (red line) indicates the time when TFC2010 criteria were fulfilled.

Results

Marked and consistent changes are seen in all studied depolarization and repolarization parameters over 10 years preceding ARVC diagnosis and continue afterwards. TAD demonstrates gradual increase, while T-wave area demonstrates consistent decrease over time before and after diagnosis indicating amplitude reduction and transition to T-wave inversion. The R-prime curve indicates that the terminal part of QRS complex demonstrate abnormalities first late in the course of the disease (Figure 1).

Conclusion

Electrocardiographic ARVC phenotype appears to become detectable long before the time of ARVC diagnosis indicating the progressive nature of ARVC and may explain arrhythmic events that may occur during the subclinical phase before ECG criteria are fulfilled.

Funding Acknowledgement

Type of funding source: None

Methods to improve quality of life, beyond medicines. Position statement of the European Academy of Dermatology and Venereology Task Force on Quality of Life and Patient Oriented Outcomes

The pharmaceutical approach to skin disease has been hugely successful, but despite effective drugs being available and used, there are still vast numbers of people who continue to have some level of persisting skin disease and continue to experience quality of life (QoL) impairment. So the question that needs to be answered, while we await further advances in our drug-based armamentarium, is how can we improve patients' QoL, beyond drugs? A working group was formed from members of the EADV Task Force on QoL and Patient Oriented Outcomes. Participants were asked to suggest all the ways in which they considered patients' QoL may be improved beyond medicines. Four groups of management approaches that may improve QoL in dermatology were identified: interventions within the dermatology service (hospitalization, multidisciplinary teams, patch testing and establishing relevant allergens and education), external services (corrective make-up, climatotherapy and balneotherapy), psychological (psychological intervention, cognitive therapy, hypnosis), lifestyle (lifestyle behavioural changes, religion and spirituality and music). The ultimate aim of therapy is to eradicate a disease in an individual and return the person's life to normal. But until the day comes when this has been achieved for every skin disease and for every patient there will be a need to support and assist many patients in additional non-pharmaceutical ways. These 'adjuvant' approaches receive too little attention while dermatologists and researchers strive for better pharmacological therapy. The different ways in which patients may benefit have been reviewed in our paper, but the reality is that most have a very poor evidence base. The research challenges that we have to meet are to identify those approaches that might be of value and to provide evidence for their optimal use. In the meantime, clinicians should consider the use of these approaches where QoL remains impaired despite optimal use of standard therapy.

Quality of life measurement in occupational skin diseases. Position paper of the European Academy of Dermatology and Venereology Task Forces on Quality of Life and Patient Oriented Outcomes and Occupational Skin Disease

The European Academy of Dermatology and Venereology (EADV) has started the 'Healthy Skin @ Work' campaign aimed to raise awareness among the public and EU authorities on the frequency and impact of occupational skin diseases (OSDs). The EADV Task Forces (TFs) on Quality of Life and Patient Oriented Outcomes (QoL/PO) and on OSD present their mutual position statement on QoL assessment in OSDs. The EADV TFs recommend the use of the DLQI as a dermatology-specific instrument and SF-36 as a generic instrument in health-related (HR) QoL studies on OSDs. The OSD-specific questionnaire, LIOD, is not recommended for general use in its present form because of its three months recall period. The EADV TFs discourage the use of non-validated and of non-validated modifications of previously validated HRQoL instruments. The EADV TFs wish to encourage research into: the HRQoL impact of OSDs other than occupational contact dermatitis and hand eczema; comparisons between the effects of different treatments and other interventions on HRQoL in OSDs; and into the HRQoL impairment of patients with OSDs from different countries, and with different provoking factors, to predict if the results of successful therapeutic and educational interventions may be generalized across countries and between occupations.

Position statement of the European Academy of Dermatology and Venereology Task Force on Quality of Life and Patient Oriented Outcomes on quality of life issues in dermatologic patients during the COVID-19 pandemic

The pandemic of COVID‐19 is a global challenge for health care, and dermatologists are not standing apart from trying to meet this challenge. The European Academy of Dermatology and Venereology (EADV) has collected recommendations from its Task Forces (TFs) related to COVID‐19. The Journal of the EADV has established a COVID‐19 Special Forum giving free access to related articles. The psychosocial effects of the pandemic, an increase in contact dermatitis and several other skin diseases because of stress, disinfectants and protective equipment use, especially in healthcare workers, the temporary limited access to dermatologic care, the dilemma whether or not to pause immunosuppressive therapy, and, finally, the occurrence of skin lesions in patients infected by COVID‐19 all contribute to significant quality of life (QoL) impairment. Here, we present detailed recommendations of the EADV TF on QoL and patient‐oriented outcomes on how to improve QoL in dermatologic patients during the COVID‐19 pandemic for several different groups of patients and for the general population.

Anti-Müllerian hormone (AMH) concentrations are maximal at puberty in male donkeys and secretion is redirected from the blood stream to seminal plasma

Sertoli cells produce anti-Müllerian hormone (AMH) and number of these cells is associated with numbers of sperm produced. The study aim was to quantify AMH concentrations in serum and seminal plasma of donkeys during puberty, and to correlate the values with those for testicular width and semen quality of sexually mature males. Blood was collected from five donkeys every second month from 4 to 24 months of age, and then once at 40 months of age. Semen was collected once monthly, from 13 to 19 and 23-25 months of age. There was quantification of AMH concentrations in serum and seminal plasma. During puberty, there was a redirection of AMH secretion from the blood stream into seminal plasma. In serum, AMH concentrations increased during puberty with a maximal concentration at 16 months and the changes were similar for seminal plasma with a maximal concentration at 18 months of age. Serum AMH concentrations from 14-20 were greater than at 12 or 22 months of age. Maximal serum AMH concentrations were associated with testicular width at 24 months (r = 0.97, P = 0.005), but not with sperm count, sperm motility or percentage of sperm with normal morphology at 42 months of age. There were no significant correlations among values for AMH concentrations in seminal plasma during puberty and values for any of the seminal variables.

P5653Atrial fibrillation in arrhythmogenic right ventricular cardiomyopathy and its association with left atrial volume index

Background

Recent studies in arrhythmogenic right ventricular cardiomyopathy (ARVC) support atrial involvement in the disease progression and consider atrial fibrillation (AF) as one of the primary manifestations of ARVC. We aimed to assess clinical factors, components of 2010 Task Force criteria (TFC2010) and echocardiographic characteristics of atria associated with AF in the Scandinavian cohort of ARVC patients.

Methods

Study sample comprised of 106 definite ARVC patients by TFC2010 from three tertiary care centers participating in the Nordic ARVC Registry (33% females, median age at ARVC diagnosis 41 years [IQR 30–54 years]). No concomitant diseases were observed in 90 patients (85%) while 16 patients had one or more comorbidities: hypertension (n=6), diabetes mellitus (n=5), coronary artery disease (n=5) or congestive heart failure (n=9). AF was included in the registry protocol as a pre-specified clinical event and verified by processing of the electronic ECG databases which contains all ECG recordings from the involved hospitals catchment areas (earliest ECG from 1988). Left (LA) and right atrial (RA) dimensions were obtained by revisiting cardiac ultrasound examinations performed at the time of ARVC diagnosis. Association between AF and clinical characteristics was assessed using multivariable logistic regression analysis adjusted for age and gender.

Results

AF was diagnosed in 29 patients (27%) at a median age of 53 (IQR 38–63) years, 7 females (24%). Median time from ARVC diagnosis to AF onset was 8 (IQR 2–12) years. AF was univariately associated with right ventricular structural abnormalities meeting the definition of major imaging criterion by 2010TFC, ventricular tachycardia (VT) with superior axis (major criterion) and LA volume index. Significantly associated variables were included in a multivariate model, in which LA volume index (OR=1.07, 95% CI 1.01–1.14, p=0.021) and superior axis VT (OR=7.45, 95% CI 1.82–30.55, p=0.005) remained independently associated with AF. In receiver operating characteristic (ROC) curve analysis, LA volume index was significantly associated with AF (AUC=0.703, p=0.005) and with superior axis VT (AUC=0.703, p=0.021). AF was not associated with either RA volume index (univariate OR=1.03, 95% CI 0.99–1.06, p=0.203) or left ventricular ejection fraction (OR=0.97, 95% CI 0.92–1.03, p=0.299).

Conclusion

In patients with ARVC,AF is primarily associated with LA structural abnormalities without indication of RA involvement and is strongly associated with ventricular arrhythmias thus indicating parallel development of atrial and ventricular arrhythmic substrate.

P2247Pregnancies and childbirth in women with arrhythmogenic right ventricular cardiomyopathy are associated with low risk of ventricular arrhythmias

Background

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is associated with a risk of ventricular arrhythmias (VA) and sudden cardiac death (SCD). Even though female patients with ARVC are considered to be at lower risk of VA, the impact of pregnancy and child birth on the arrhythmic risk and development of arrhythmic substrate in the context of ARVC remains insufficiently studied.

Objective

To assess the risk of VA in relation to childbirth in women with ARVC and the impact of multiple pregnancies on progression of arrhythmic manifestations of the disease.

Methods

The study included 186 females with definite ARVC (n=107, 70 probands) or unaffected mutation-carriers (n=79) with median age at the end of follow up of 48 (IQR 34–60) years. Seventeen women had 1, 59 had 2 and 29 had ≥3 child births by the age of 40 years. VA was defined as ventricular tachycardia, appropriate ICD therapy, aborted cardiac arrest or SCD. Proportions of patients who experienced VA by the age of 40 years were compared between nulliparous women (n=81) and those with reported child births (n=105). VA-free survival after accomplished pregnancies was assessed for women ≥40 years of age (n=119). Cumulative probability of VA for each pregnancy (n=230) was assessed from conception through 2 years after child birth and compared between those that occurred before ARVC diagnosis (Pre-Ds, n=164), after it (Post-Ds, n=11) and in unaffected mutation carriers (No-Ds, n=55).

Results

The nulliparous women had lower age at ARVC diagnosis (37 vs 44, p=0.023) and more often had VA before the age of 40 (31% vs 13%, p=0.003) while the number of child births was not related to the prevalence of VA (18% among women with 1 childbirth, 12% in those with 2 and 14% in those with 3 or more, ns). Three women suffered SCD before the age of 40. VA-free survival after 40 years did not differ between nulliparous and those who gave birth (Figure A). Only four pregnancy-related events were documented (Figure B): 1 in the Post-Ds group and three in the Pre-Ds group. No pregnancy-related events were reported in the unaffected mutation carriers.

Conclusion

In this Scandinavian cohort of women with ARVC we observed no indication of an increased VA risk either associated with pregnancies or during long-term follow up after the last child birth.

P992Incidence, predictors, and success of ventricular tachycardia catheter ablation in arrhythmogenic right ventricular cardiomyopathy (ARVC): A long-term cohort study from the Nordic ARVC registry

Background

Catheter ablation may reduce ventricular tachycardia (VT) burden in arrhythmogenic right ventricular cardiomyopathy (ARVC) patients. However, little is known about factors predicting need for ablation and various outcomes have been reported.

Purpose

We sought to investigate predictors and use of VT ablation and to evaluate the post-procedural outcome in ARVC patients.

Methods

We studied 435 patients from the Nordic ARVC registry including 220 probands with definite ARVC according to the 2010 task force criteria and 215 mutation-carrying relatives identified through cascade screening. Patients were followed until first-time VT ablation, death, heart transplantation, or January 1st 2018. Additionally, patients undergoing VT ablation were further followed from the time of ablation for recurrent ventricular arrhythmias.

Results

Cumulative use of VT ablation was 4% (95% CI 3%-6%) and 11% (95% CI 8%-15%) after 1 and 10 years. All procedures were performed in probands in whom the cumulative use was 8% (95% CI 5%-12%) and 20% (95% CI 15%-26%). In adjusted analyses restricted to probands, only young age predicted need for ablation. In patients undergoing ablation, risk of recurrent arrhythmias was 59% (95% CI 44%-71%) and 74% (95% CI 59%-84%) 1 and 5 years after the procedure. Despite high recurrence rates, the burden of ventricular arrhythmias was reduced after ablation (p=0.0042). Young age, use of several antiarrhythmic drugs and inducibility to VT immediately after ablation were associated with an unfavorable outcome.

Conclusions

Twenty percent of ARVC probands developed a clinical indication for VT ablation within 10 years after diagnosis whereas mutation-carrying relatives were without such need. Although the burden of ventricular arrhythmias decreased after ablation, risk of recurrence was substantial.

Elevated non-esterified fatty acids impair survival and promote lipid accumulation and pro-inflammatory cytokine production in bovine endometrial epithelial cells

Elevated non-esterified fatty acids (NEFAs) are associated with negative effects on bovine theca, granulosa and oviductal cells but the effects of NEFAs on bovine endometrial epithelial cells (bEECs) are not as well documented. The objective of this study was to define the effects of NEFAs on bEECs. Postprimary bEECs were treated with 150, 300 or 500µM of either palmitic acid (PA), stearic acid (SA) or oleic acid (OA) or a mixture of NEFAs (150µM of each FA) or 0.5% final concentration of vehicle ethanol (control). Viability and proliferation of bEECs exposed to 150µM of each NEFA or a mixture of NEFAs were unaffected. Increased lipid accumulation was found in all treated groups (P<0.01). In cells exposed to 500µM of each NEFA and 300µM PA decreased cell viability (P<0.001), proliferation (P<0.05) and increased apoptosis (P<0.05) were observed. Treatment with 500µM OA, PA and SA had the strongest effects on cell viability, proliferation and apoptosis (P<0.05). Treatment with PA and OA increased interleukin-6 (IL-6) concentrations (P<0.05), whereas only the highest concentration of PA, OA and SA stimulated IL-8 production (P<0.05). These results suggest that high concentrations of NEFAs may impair endometrial function with more or less pronounced effects depending on the type of NEFA and time of exposure.

Metal solubility and transport at a contaminated landfill site - From the source zone into the groundwater

Risks associated with metal contaminated sites are tightly linked to material leachability and contaminant mobility. In this study, metal solubility and transport were characterized within a glass waste landfill through i) lysimeter-collection of pore water and standardized batch leaching tests, ii) soil profiles extending from the landfill surface, through unsaturated soil underneath, and into the groundwater zone, and iii) groundwater samples upstream, at, and downstream of the landfill. The soil analyzes targeted both pseudo-total and geochemically active concentrations of contaminant metals (As, Cd, Pb, Sb) and basic soil geochemistry (pH, org. C, Fe, Mn). Water samples were analyzed for dissolved, colloid-bound and particulate metals, and speciation modelling of the aqueous phase was conducted. The results revealed a highly contaminated system, with mean metal concentrations in the waste zone between 90 and 250 times the regional background levels. Despite severe contamination of the waste zone and high geochemically active fractions (80-100%) of all contaminant metals as well as elevated concentrations in landfill pore water, the concentrations of Cd and Pb decrease abruptly at the transition between landfill and underlying natural soil and no indication of groundwater contamination was found. The efficient cation retention is likely due to the high pH. However, the sorption of As and Sb is weaker at such high pH, which explains their higher mobility from the pore water zone into groundwater. The field soil:solution partitioning (Kd) displayed a high spatial variability within the waste zone (the highest Kd variability was seen for Pb, ranging from 140 to 2,900,000 l kg^-1), despite little variability in basic geochemical variables, which we suggest is due to waste material heterogeneity.

Quality of life measurement in hidradenitis suppurativa: position statement of the European Academy of Dermatology and Venereology task forces on Quality of Life and Patient-Oriented Outcomes and Acne, Rosacea and Hidradenitis Suppurativa

This paper is organized jointly by the European Academy of Dermatology and Venereology (EADV) Task Force (TF) on Quality of Life (QoL) and Patient-Oriented Outcomes and the EADV TF on acne, rosacea and hidradenitis suppurativa (ARHS). The purpose of this paper was to present current knowledge about QoL assessment in HS, including data on HS-specific health-related (HR) QoL instruments and HRQoL changes in clinical trials, and to make practical recommendations concerning the assessment of QoL in people with HS. HS results in significant quimp that is higher than in most other chronic skin diseases. HS impact in published studies was assessed predominantly (84% of studies) by the Dermatology Life Quality Index (DLQI). There is a lack of high-quality clinical trials in HS patients where HRQoL instruments have been used as outcome measures. One double-blind randomized placebo-controlled trial on infliximab with low number of participants reported significantly better HRQoL improvement in the treatment group than in the placebo group. Well-designed clinical studies in HS patients to compare different treatment methods, including surgical methods and assessing long-term effects, are needed. Because of lack of sufficient validation, the Task Forces are not at present able to recommend existing HS-specific HRQoL instruments for use in clinical studies. The EADV TFs recommend the dermatology-specific DLQI questionnaire for use in HS patients. The EADV TFs encourage the further development, validation and use of other HS-specific, dermatology-specific and generic instruments but such use should be based on the principles presented in the previous publications of the EADV TF on QoL and Patient-Oriented Outcomes.

Quality of life measurement in skin cancer patients: literature review and position paper of the European Academy of Dermatology and Venereology Task Forces on Quality of Life and Patient Oriented Outcomes, Melanoma and Non-Melanoma Skin Cancer

The European Academy of Dermatology and Venereology (EADV) Task Forces (TFs) on Quality of Life (QoL) and Patient Oriented Outcomes, Melanoma and Non-Melanoma Skin Cancer (NMSC) present a review of the literature and position statement on health-related (HR) QoL assessment in skin cancer patients. A literature search was carried out to identify publications since 1980 that included information about the impact of SC on QoL. Generic, dermatology-specific, cancer-specific, SC-specific, facial SC-specific, NMSC-specific, basal cell carcinoma-specific and melanoma-specific QoL questionnaires have been used to assess HRQoL in SC patients. HRQoL was assessed in the context of creation and validation of the HRQoL instruments, clinical trials, comparison of QoL in SC and other cancers, other diseases or controls, HRQoL assessment after treatment, comorbidities, behaviour modification, predictors of QoL and survival, supportive care needs, coping strategies and fear of cancer recurrence. The most widely used instruments for HRQoL assessment in SC patients are the European Organisation for Research and Treatment of Cancer Core Questionnaire (EORTC QLQ-C30), the Functional Assessment of Cancer Therapy-Melanoma (FACT-M), Skin Cancer Index (SCI), Short Form 36 Item Health Survey (SF-36) and the Dermatology Life Quality Index (DLQI). The TFs recommend the use of the cancer-specific EORTC QLQ-C30, especially in late stages of disease, and the melanoma-specific FACT-M and SC-specific SCI questionnaires. These instruments have been well validated and used in several studies. Other HRQoL instruments, also with good basic validation, are not currently recommended because the experience of their use is too limited. Dermatology-specific HRQoL instruments can be used to assess the impact of skin-related problems in SC. The TFs encourage further studies to validate HRQoL instruments for use in different stages of SC, in order to allow more detailed practical recommendations on HRQoL assessment in SC.

Factor Xa and VIIa inhibition by tissue factor pathway inhibitor is prevented by a monoclonal antibody to its Kunitz-1 domain

Essentials Activated FVII (FVIIa) and FX (FXa) are inhibited by tissue factor pathway inhibitor (TFPI). A monoclonal antibody, mAb2F22, was raised against the N-terminal fragment of TFPI (1-79). mAb2F22 bound exclusively to the K1 domain of TFPI (KD ∼1 nm) and not to the K2 domain. mAb2F22 interfered with inhibition of both FVIIa and FXa activities and restored clot formation.

SUMMARY

Background Initiation of coagulation is induced by binding of activated factor VII (FVIIa) to tissue factor (TF) and activation of factor X (FX) in a process regulated by tissue factor pathway inhibitor (TFPI). TFPI contains three Kunitz-type protease inhibitor domains (K1-K3), of which K1 and K2 block the active sites of FVIIa and FXa, respectively. Objective To produce a monoclonal antibody (mAb) directed towards K1, to characterize the binding epitope, and to study its effect on TFPI inhibition. Methods A monoclonal antibody, mAb2F22, was raised against the N-terminal TFPI(1-79) fragment. Binding data were obtained by surface plasmon resonance analysis. The Fab-fragment of mAb2F22, Fab2F22, was expressed and the structure of its complex with TFPI(1-79) determined by X-ray crystallography. Effects of mAb2F22 on TFPI inhibition were measured in buffer- and plasma-based systems. Results mAb2F22 bound exclusively to K1 of TFPI (KD ~1 nm) and not to K2. The crystal structure of Fab2F22/TFPI (1-79) mapped an epitope on K1 including seven residues upstream of the domain. TFPI inhibition of TF/FVIIa amidolytic activity was neutralized by mAb2F22, although the binding epitope on K1 did not include the P1 residue. Binding of mAb2F22 to K1 blocked TFPI inhibition of the FXa amidolytic activity and normalized hemostasis in hemophilia human A-like plasma and whole blood. Conclusion mAb2F22 blocked TFPI inhibition of both FVIIa and FXa activities and mapped a FXa exosite for binding to K1. It reversed TFPI feedback inhibition of TF/FVIIa-induced coagulation and restored clot formation in FVIII-neutralized human plasma and blood.

Greenland records of aerosol source and atmospheric lifetime changes from the Eemian to the Holocene

The Northern Hemisphere experienced dramatic changes during the last glacial, featuring vast ice sheets and abrupt climate events, while high northern latitudes during the last interglacial (Eemian) were warmer than today. Here we use high-resolution aerosol records from the Greenland NEEM ice core to reconstruct the environmental alterations in aerosol source regions accompanying these changes. Separating source and transport effects, we find strongly reduced terrestrial biogenic emissions during glacial times reflecting net loss of vegetated area in North America. Rapid climate changes during the glacial have little effect on terrestrial biogenic aerosol emissions. A strong increase in terrestrial dust emissions during the coldest intervals indicates higher aridity and dust storm activity in East Asian deserts. Glacial sea salt aerosol emissions in the North Atlantic region increase only moderately (50%), likely due to sea ice expansion. Lower aerosol concentrations in Eemian ice compared to the Holocene are mainly due to shortened atmospheric residence time, while emissions changed little.

Past climate changes in Greenland ice were accompanied by large aerosol concentration changes. Here, the authors show that by correcting for transport effects, reliable source changes for biogenic aerosol from North America, sea salt aerosol from the North Atlantic, and dust from East Asian deserts can be derived.

Quality of life measurement in acne. Position Paper of the European Academy of Dermatology and Venereology Task Forces on Quality of Life and Patient Oriented Outcomes and Acne, Rosacea and Hidradenitis Suppurativa

Acne causes profound negative psychological and social effects on the quality of life (QoL) of patients. The European Dermatology Forum S3-Guideline for the Treatment of Acne recommended adopting a QoL measure as an integral part of acne management. Because of constantly growing interest in health-related QoL assessment in acne and because of the high impact of acne on patients' lives, the European Academy of Dermatology and Venereology Task Force on QoL and Patient Oriented Outcomes and the Task Force on Acne, Rosacea and Hidradenitis Suppurativa have documented the QoL instruments that have been used in acne patients, with information on validation, purposes of their usage, description of common limitations and mistakes in their usage and overall recommendations.

Dose related effects of LPS on endometrial epithelial cell populations from dioestrus cows

Lipopolysaccharides (LPS) from Gram negative bacteria are involved in the pathogeny of uterine diseases in cows. This study aimed to investigate LPS effects on the growth of bovine endometrial epithelial cells (bEEC) and relationships between LPS response and tissue characteristics. Uteri from 35 females were characterized for parity and stage of oestrous cycle. Densities of glandular tissue (dGT), CD11b+ cells and Ki67+ cells were measured in the endometrial tissue. Cells from 13 dioestrus cows were exposed to 0, 2, 4, 8, 12, 16 or 24μg/mL LPS. Effects of parity and stage of the oestrous cycle on tissue characteristics and effects of LPS dosage, cow and tissue characteristics on changes in cell numbers were analyzed by ANOVA. The dGT was higher in metoestrus and dioestrus samples than in pro-oestrus ones whereas densities of CD11b+ and Ki67+ cells were higher at pro-oestrus (p<0.05-p<0.01). LPS influenced bEEC populations in a dose related manner. An increase in number of live cells was observed for dosages ranging from 2 to 12μg/mL LPS (p<0.0001 vs controls). No effect was found on numbers and frequencies of dead cells. With higher dosages, the numbers of live cells did not increase but the numbers of dead did increase. No relationships were observed between cow or tissue characteristics and growth patterns or frequencies of viable bEEC in controls nor in the response to LPS. To conclude this model is suitable for further studies on dysregulations induced by LPS in endometrial tissue.

Migration and smoking: An epidemiological study of Finnish twins in Sweden

Background: Male migrants from Finland to Sweden have been found to have a reduced risk of coronary heart disease after several years in Sweden. Changes in smoking habits may contribute to this reduced risk. Aims: A study was undertaken to compare smoking habits in Finnish migrants to Sweden and subjects always living in Finland and to analyse whether the migration may have influenced smoking. Methods: The study population consisted of same-sex twin pairs born in Finland younger than 76 years with at least one twin that had migrated to Sweden (n=1,083 pairs). Smoking habits obtained by mailed questionnaire were compared in migration-discordant twin pairs to take into account early childhood and genetic factors. Results: Immigrants and returnees with a history of smoking had predominantly started to smoke before the migration. Among women, immigrants to Sweden smoked more than never migrants in Finland, odds ratio (OR) 2.1 for current smokers (95% confidence interval CI 1.4—3.3) but this difference was already present before migration. In men there were essentially no differences in smoking prevalence between immigrants and never migrants but heavy smoking was less common among immigrants than among never migrant smokers, OR 0.5 (95% CI 0.2—0.9) and migration was associated with a greater propensity to cease smoking. Conclusions: Migration from Finland to Sweden does not seem to have had a strong influence on smoking among migrants. A favourable trend in smoking habits after migration may in part have contributed to reduced mortality and incidence of coronary heart disease in male Finnish migrants after several years in Sweden.

Underestimated risks of recurrent long-range ash dispersal from northern Pacific Arc volcanoes

Widespread ash dispersal poses a significant natural hazard to society, particularly in relation to disruption to aviation. Assessing the extent of the threat of far-travelled ash clouds on flight paths is substantially hindered by an incomplete volcanic history and an underestimation of the potential reach of distant eruptive centres. The risk of extensive ash clouds to aviation is thus poorly quantified. New evidence is presented of explosive Late Pleistocene eruptions in the Pacific Arc, currently undocumented in the proximal geological record, which dispersed ash up to 8000 km from source. Twelve microscopic ash deposits or cryptotephra, invisible to the naked eye, discovered within Greenland ice-cores, and ranging in age between 11.1 and 83.7 ka b2k, are compositionally matched to northern Pacific Arc sources including Japan, Kamchatka, Cascades and Alaska. Only two cryptotephra deposits are correlated to known high-magnitude eruptions (Towada-H, Japan, ca 15 ka BP and Mount St Helens Set M, ca 28 ka BP). For the remaining 10 deposits, there is no evidence of age- and compositionally-equivalent eruptive events in regional volcanic stratigraphies. This highlights the inherent problem of under-reporting eruptions and the dangers of underestimating the long-term risk of widespread ash dispersal for trans-Pacific and trans-Atlantic flight routes.

Report from the third international consensus meeting to harmonise core outcome measures for atopic eczema/dermatitis clinical trials (HOME)

This report provides a summary of the third meeting of the Harmonising Outcome Measures for Eczema (HOME) initiative held in San Diego, CA, U.S.A., 6-7 April 2013 (HOME III). The meeting addressed the four domains that had previously been agreed should be measured in every eczema clinical trial: clinical signs, patient-reported symptoms, long-term control and quality of life. Formal presentations and nominal group techniques were used at this working meeting, attended by 56 voting participants (31 of whom were dermatologists). Significant progress was made on the domain of clinical signs. Without reference to any named scales, it was agreed that the intensity and extent of erythema, excoriation, oedema/papulation and lichenification should be included in the core outcome measure for the scale to have content validity. The group then discussed a systematic review of all scales measuring the clinical signs of eczema and their measurement properties, followed by a consensus vote on which scale to recommend for inclusion in the core outcome set. Research into the remaining three domains was presented, followed by discussions. The symptoms group and quality of life groups need to systematically identify all available tools and rate the quality of the tools. A definition of long-term control is needed before progress can be made towards recommending a core outcome measure.

European children's sugar intake on weekdays versus weekends: the IDEFICS study

OBJECTIVES

To compare the intake of total sugars, foods and drinks rich in added sugar, and energy in children on weekdays (Monday-Thursday), Fridays and weekends.

METHODS

Dietary intake (g, kJ, energy %) was assessed using a computerized 24-h recall method in a sample of 2- to 9-year-old children from Belgium, Cyprus, Estonia, Germany, Hungary, Italy, Spain and Sweden who were participating in the IDEFICS baseline study (2007-2008). Analyses were performed in 9497 children by selecting one 24-h recall per child (for comparison of weekdays vs weekends, and Fridays vs weekdays and weekends). Selected stratified analyses were performed by country and age group.

RESULTS

Intake of total sugars exceeded 20 energy % in all countries but one. In the non-stratified analyses, the intakes of total sugars and foods and drinks rich in added sugar were found to be higher on weekends compared with weekdays (both P<0.001), and intakes on Fridays were a mix between intakes on weekdays and weekends. Energy intake did not differ between weekdays and weekends. RESULTS were somewhat heterogeneous, both across countries and age groups.

CONCLUSIONS

High intake of sugar remains an important nutritional problem in children of many European countries. Interventions aiming to prevent this diet pattern may optimize their impact by targeting dietary habits on Fridays and weekends. Furthermore, when conducting dietary assessment in children, data from weekends and Fridays in combination with a selection of Mondays to Thursdays are needed to capture habitual sugar intake. Age and dietary cultures should also be considered in dietary intervention and assessment as effect modifications were seen for both age and country.

Psychological differences between early- and late-onset psoriasis: a study of personality traits, anxiety and depression in psoriasis

BACKGROUND

Onset of psoriasis may occur at any age. Early negative experiences often influence personality development, and may lead to physical disease, anxiety and depression in adulthood. Knowledge about onset of psoriasis and psychopathology is limited.

OBJECTIVES

To examine whether patients with early-onset psoriasis differ psychologically from patients with late-onset psoriasis, regarding personality traits, anxiety and depression.

METHODS

A descriptive cross-sectional study was conducted among 101 consecutively recruited outpatients with psoriasis. A psychosocial interview was performed followed by self-assessment of validated questionnaires: Swedish Universities Scales of Personality (SSP), Spielberger State-Trait Anxiety Inventory and Beck Depression Inventory. Psoriasis severity was assessed by the Psoriasis Area and Severity Index.

RESULTS

Patients with early-onset psoriasis (age < 20 years) were significantly more anxious and depressed than patients with late-onset psoriasis. In multiple linear regression models, younger age at onset of psoriasis was a significant determinant of higher scores of four personality traits: SSP-embitterment, -trait irritability, -mistrust and -verbal trait aggression.

CONCLUSIONS

Our results indicate that early detection of psychological vulnerability when treating children and adolescents with psoriasis seems to be of great importance. Traits of psychological vulnerability and pessimistic personality traits were found to be significantly associated with the early onset of psoriasis, but not with disease duration in this study. These traits may be seen as a consequence of psoriasis, and/or as individual traits modulating and impairing clinical course and efforts to cope with psoriasis.