The natural history of Chlamydia trachomatis infection in women: a multi-parameter evidence synthesis

Postnatal instead of normally-timed cervical screening (PINCS-1): a protocol for a feasibility study of paired-sample cervical screening and urine self-sampling at 6 weeks and 12 weeks postnatal in the UK

INTRODUCTION

Cervical screening rates in the UK are falling, limiting our ability to prevent cervical cancer. Peak incidence of cervical cancer coincides with average age of childbirth, and women with young children are less likely to be screened. Current UK guidelines advise waiting 12 weeks after delivery to perform cervical screening, but this recommendation is not based on evidence from the era of liquid-based cytology or high-risk human papillomavirus (HPV) testing. New mums suggested offering cervical screening at 6 weeks postdelivery, in conjunction with the postnatal check-up with the general practice team in primary care. This study aims to assess the feasibility and acceptability of a paired-sample study design for cervical screening at 6 weeks and 12 weeks postnatal.

METHODS AND ANALYSIS

A study of 100 participants will be performed to assess feasibility and acceptability of cervical screening at both 6 weeks and 12 weeks postnatal, with urine self-sampling using a Colli-pee collection device at each time point. This will inform whether women are prepared to undergo cervical screening at 6 weeks postnatal and the feasibility of a future pair-wise diagnostic test accuracy (of HPV and abnormal cervical cytology) study or whether alternative study designs are needed. Participants must be aged 24.5-64 years old and eligible for the National Health Service Cervical Screening Programme (NHS CSP). At each appointment, participants will complete a questionnaire about their experience and thoughts regarding screening. Substudies ask participants who withdraw or decline to participate their reasons, to identify barriers. The study will be closed for recruitment once 100 participants have completed the 6-week screen in Postnatal Instead of Normally-Timed Cervical Screening (PINCS-1) or if recruitment is poor and 50% not recruited by 6 months, indicating that a paired-sample design is not feasible.

ETHICS AND DISSEMINATION

Ethical approval for PINCS-1 was given by the Stanmore Research Ethics Committee. The results, including participant feedback at each stage, built into the trial design, will inform the design of large studies to determine accuracy and clinical impact of cervical screening at 6 weeks postnatal, identifying whether giving choice (eg, from timing of appointments and/or offering self-sampling) will improve screening uptake. Data will inform the sample size needed for future studies to have adequate power. Results will also inform future NHS CSP management. Results will be shared via scientific publication and via conventional and social media channels accessed by young women.

TRIAL REGISTRATION NUMBER

ISRCTN10071810.

Enteral and parenteral nutrition in patients with cancer: complication rates compared-updated systematic review and meta-analysis

BACKGROUND

The aim of this systematic review and meta-analysis is to compare the complication rates of enteral nutrition (EN) (oral or tube feeding (TF)) and parenteral nutrition (PN) in patients with any cancer.

METHODS

A systematic review of the literature until 2024 was conducted, including randomised controlled trials comparing EN and PN with respect to one or more of four endpoints: (1) infection, (2) nutrition support complications, (3) major complications and (4) mortality. A meta-analysis was conducted to generate summary effect estimates. Analysis was stratified by paediatric (≤21 years old) versus adults (>21 years old) patients. Subgroup analyses were conducted, based on including patients with (vs without) protein-energy malnutrition (PEM) and type of EN. Cumulative meta-analysis and leave-one-out analysis was conducted. Type I error was set at 0.05.

RESULTS

49 studies reporting on 6361 patients were included: 41 reported on adults and 8 on children. Among adults, the infection rate was higher for PN compared with EN (risk ratio=1.07, 95% CI: 1.00 to 1.14), with no differences in rates of nutrition support complications, major complications or mortality. Among children, there were no differences in all four endpoints. On cumulative meta-analysis, EN was overall marginally superior to PN for infection, although results fluctuated over time between superiority and no difference. Subgroup analysis found no differences in effects among patients with (vs without) PEM and patients provided with EN options of standard care versus TF.

DISCUSSION

From the perspective of complications, EN and PN are equivalent, with EN demonstrating marginal superiority for infection among adults.

Future risk projection to engage 'near-miss' individuals in lung cancer screening eligibility: an analysis of ILST data

INTRODUCTION

Lung cancer risk increases with time, and participants who are initially ineligible for lung cancer screening (LCS) could become eligible later. The aim of this study was to determine the proportion of people (initially ineligible) who may become eligible in a risk model-based LCS programme and the impact smoking cessation could have on this cohort.

METHODS

All potential participants for the International Lung Screening Trial aged 55-80 years, ineligible for Low-dose CT screening at baseline (PLCOm2012<1.5% 6-year risk), were included. Assuming annual increments of change in age, smoking duration and quit time, and under the assumption of other risk variables being constant, projections of risk were made using the PLCOm2012 model from evaluation to the upper age limit of 80 years.

RESULTS

4451 subjects with a median age of 61 (IQR: 57-66) years were included. Assuming no change in smoking status post evaluation, 2239 participants (50.3%) became eligible (PLCOm2012≥1.51%) by age 80, with 26.9% and 38.7% of the cohort reaching eligibility by age 70 and 75 years, respectively. Among participants with a baseline risk≥0.6%, 1518 (34.1%) reached eligibility within 10 years of initial evaluation. Smoking cessation after first evaluation can reduce the proportion of individuals who may become eligible for LCS by age 70 from 68.7% to 24.9%.

CONCLUSIONS

Future risk projection of eligibility could provide a time window for reassessment of risk on an individual level. It is important to provide smoking cessation services to individuals who are ineligible for LCS at the initial programme contact.

Long-term disability trajectories in multiple sclerosis: a group-based trajectory analysis of the AusLong cohort

BACKGROUND

Previous natural history studies highlighted a consistent heterogeneity of disability trajectories among individuals with primary or secondary progressive multiple sclerosis (MS). However, evidence on disability progression in relapsing onset MS is scarce.The aim of this study was to investigate heterogeneity in disability accumulation over 10 years following a first clinical diagnosis of central nervous system demyelination (FCD) and identify genetic, demographic, environmental and clinical factors associated with these trajectories.

METHODS

We used group-based trajectory models to measure heterogeneity in disability trajectories based on the Expanded Disability Status Scale (EDSS) in a prospectively assessed cohort of 263 participants. To capture sustained neurological impairments and avoid issues related to significant changes in EDSS associated with relapse, we did not consider EDSS points recorded within 3 months of a relapse.

RESULTS

We identified three distinct and clinically meaningful disability trajectories: No/minimal, moderate and severe. Those in the no/minimal disability trajectory showed no appreciable progression of disability (median EDSS∼1 at 10-year review) while those in the moderate and severe disability trajectories experienced disability worsening (median time to reach EDSS 4 was 9 and 7 years, respectively). Compared with the no/minimal disability trajectory, those with older age, a higher number of relapses within the first 5 years post-FCD, and a higher number of comorbidities at baseline were more likely to be in the worse disability trajectory. Surprisingly, baseline MRI and anatomical site of initial symptoms did not influence long-term outcomes.

CONCLUSIONS

Those at higher risk of faster MS disability progression can be identified based on their early clinical characteristics with potential therapeutic implications for early intervention and treatment escalation.

What are the broader impacts and value from a randomised controlled trial conducted in six public hospital antenatal clinics in Australia? An impact assessment using the Framework to Assess the Impact from Translational health research

OBJECTIVES

The Breathing for Life Trial (BLT) was a multicentre randomised controlled trial testing the hypothesis that a fractional exhaled nitric oxide-based intervention to guide asthma therapy in pregnancy improves perinatal outcomes. While BLT was negative based on selected outcomes, the conduct of the trial over 7 years showed potential for assessing the broader research impacts and returns on investment in BLT. The aim of this study was to retrospectively assess and report on the impact and value of BLT to show accountability for the research investment in what was deemed a 'negative' trial.

METHODS

The Framework to Assess the Impact from Translational health research (FAIT) was selected as the preferred method. FAIT combines three validated methods, including a modified Payback framework, an economic analysis of return on investment and a narrative account of the impact generated from the research. Data collection was done via document analysis of BLT administrative and research records and review of relevant websites/databases.

RESULTS

BLT delivered a return on investment of $6.7 million in leveraged grants, fellowships and consultancies and conservatively returned $2.44 for every dollar invested. The research trained and upskilled 18 midwives and obstetricians in evidence-based asthma management in pregnancy and improved research capability of six PhD students. Specialised equipment purchased by BLT is now being repurposed to undertake other research in regional Australia, saving further research investment. Of the 1200 mothers who were part of BLT, 508 now have written asthma plans, 268 had a clinically significant improvement in their asthma control score and the proportion who improved their asthma plan knowledge increased by 58 percentage points from 12 to 70%.

CONCLUSION

This case example in the developing field of impact assessment illustrates how researchers can use evidence to demonstrate and report more broadly on the impact of and returns on research investment in a clinical trial.

TRIAL REGISTRATION NUMBER

ACTRN12613000202763; Post results.

Deficiency of mitophagy mediator Parkin in aortic smooth muscle cells exacerbates abdominal aortic aneurysm

Abdominal aortic aneurysms (AAAs) are a degenerative aortic disease and associated with hallmarks of aging, such as mitophagy. Despite this, the exact associations among mitophagy, aging, and AAA progression remain unknown. In our study, gene expression analysis of human AAA tissue revealed downregulation of mitophagy pathways, mitochondrial structure, and function-related proteins. Human proteomic analyses identified decreased levels of mitophagy mediators PINK1 and Parkin. Aged mice and, separately, a murine AAA model showed reduced mitophagy in aortic vascular smooth muscle cells (VSMCs) and PINK1 and Parkin expression. Parkin knockdown in VSMCs aggravated AAA dilation in murine models, with elevated mitochondrial ROS and impaired mitochondrial function. Importantly, inhibiting USP30, an antagonist of the PINK1/Parkin pathway, increased mitophagy in VSMCs, improved mitochondrial function, and reduced AAA incidence and growth. Our study elucidates a critical mechanism that proposes AAAs as an age-associated disease with altered mitophagy, introducing new potential therapeutic approaches.

Is health technology assessment value for money? Estimating the return on investment of health technology assessment in India (HTAIn)

An increasing investment in health technology assessment (HTA) in low-income and middle-income countries has generated greater interest from policy-makers about the value and return on investment (ROI) of HTA. Few studies have, however, quantified the benefits of HTA in terms of its value to the health system. This evaluation aims to quantify the impact and ROI achieved by the HTA agency in India (HTAIn).A framework developed by the University of Glasgow was used to review three 'hta's commissioned by HTAIn between 2018 and 2020, taking into account the opportunity cost of investing in these processes. Costs included fixed costs for HTAIn and costs for undertaking each 'hta'. Attributable benefits are calculated by subtracting the counterfactual (benefits that might have been realised without an HTA) from realised benefits.HTAIn sits under the Department of Health Research, Ministry of Health and Family Welfare, Government of India. It was set up to facilitate the process of transparent and evidence-informed decision-making in healthcare in India.HTA helps decision-makers to understand the consequences of alternative courses of action and to select the options that produce the best outcomes at the lowest cost. Institutionalisation of HTA is seen as pivotal to supporting universal health coverage as a means of supporting a better allocation of finite resources, cost containment and the maximisation of health.Net health benefits are our measure of value. The ROI of HTAIn is calculated by aggregating attributable benefits and offsetting them against the costs of investment.Our findings show that investing in HTAIn yields a return of 9:1, with potential to increase to 71:1 with full implementation of HTA recommendations. Variability of ROI ranged from 5:1 to 40:1 between the different interventions and diseases.While HTAIn requires financial investment, it is an efficient use of resources. The potential for greater impact and the variability of the ROI between interventions underline the importance of planning for implementation and good topic selection in HTA.

Chlamydia trachomatis: a model for intracellular bacterial parasitism

Chlamydia comprises a diverse group of obligate intracellular bacteria that cause infections in animals, including humans. These organisms share fascinating biology, including distinct developmental stages, non-canonical cell surface structures, and adaptations to intracellular parasitism. Chlamydia trachomatis is of particular interest due to its significant clinical importance, causing both ocular and sexually transmitted infections. The strain L2/434/Bu, responsible for lymphogranuloma venereum, is the most common strain used to study chlamydial molecular and cell biology because it grows readily in cell culture and is amenable to genetic manipulation. Indeed, this strain has enabled researchers to tackle fundamental questions about the molecular mechanisms underlying Chlamydia's developmental transitions and biphasic lifecycle and cellular adaptations to obligate intracellular parasitism, including characterizing numerous conserved virulence genes and defining immune responses. However, L2/434/Bu is not representative of C. trachomatis strains that cause urogenital infections in humans, limiting its utility in addressing questions of host tropism and immune evasion in reproductive organs. Recent research efforts are shifting toward understanding the unique attributes of more clinically relevant C. trachomatis genovars.

Cost-effectiveness analysis comparing QuantiFERON test and tuberculin skin test for the diagnosis of latent tuberculosis infection in immunocompetent children under 15 years of age in Colombia

OBJECTIVE

To determine the cost-effectiveness of the QuantiFERON (QFT) test versus the tuberculin skin test (TST) in diagnosing latent tuberculosis infection (LTBI) in immunocompetent children under 15 years of age who are in contact with active tuberculosis (TB) patients in the context of the Colombian healthcare system.

DESIGN

Health economic evaluation. Decision tree over a horizon of <1 year.

SETTING

From the perspective of the Colombian healthcare system, the direct healthcare costs related to tests were considered, and diagnostic performance was used as a measure of effectiveness. The currency was the US dollar (US$) for the year 2022, with a cost-effectiveness threshold of US$6666.

PARTICIPANTS

A simulated hypothetical cohort of 2000 immunocompetent children under 15 years of age who are in contact with active TB patients and were vaccinated with BCG at birth.

INTERVENTIONS

QFT test and TST to detect LTBI.

PRIMARY OUTCOME MEASURE

The incremental cost-effectiveness ratio (ICER) was estimated, and univariate deterministic and probabilistic sensitivity analyses were conducted using 5000 simulations.

RESULTS

QFT was found to be cost-effective with an ICER of US$705 for each correctly diagnosed case. In the one-way deterministic sensitivity analysis, QFT remained cost-effective across nearly all proposed scenarios; however, the QFT was considered 'potentially cost-effective' when TST specificity reached its highest value. The ICER was unaffected by variations in LTBI prevalence. In the probabilistic sensitivity analysis, QFT was cost-effective in 85.06% of the simulated scenarios, while TST was dominant in 11.8%.

CONCLUSIONS

This study provides evidence of the cost-effectiveness of QFT compared with TST in diagnosing LTBI among immunocompetent children under 15 years who have been in contact with active TB patients in the Colombian context.

Sexually transmitted infections (Chlamydia trachomatis, genital HSV, and HPV) and female fertility: A scoping review

More than one million sexually transmitted infections (STIs) are acquired every day worldwide. They are commonly caused by Chlamydia trachomatis (CT), herpes simplex virus (HSV), or human papillomavirus (HPV) and are suggested to contribute to female infertility. This scoping review aims to map and summarize existing literature on the association between a pre-pregnancy infection with CT, genital HSV, or HPV and female fertility. We searched two databases (PubMed, Embase) to identify published literature on the association between CT, genital HSV, or HPV infection and female fertility. We included full-text articles, published from 2002 to 2022, on pre-pregnancy infection with either CT, genital HSV, or HPV within a population of women of reproductive age. The study endpoint was either pregnancy, time-to-pregnancy, or infertility. The included studies were evaluated according to the Critical Appraisal Tool by Joanna Briggs Institute. Eight studies were eligible for the review. All of them investigated the association between a CT infection and fertility, while none of them investigated infections with genital HSV or HPV. Three studies found that a CT infection was associated with poorer female fertility, and one study found a similar association in a subgroup analysis of women with a pregnancy intention. Four studies indicated no association, although methodological differences between the studies preclude firm conclusions. This review revealed sparse literature investigating the association between CT, HPV, and HSV and subsequent female fertility. Prospective cohort studies with preconception assessments of these STIs are needed to determine the relation between STIs and subsequent fertility.

Development and validation of a machine learning model to predict cognitive behavioral therapy outcome in obsessive-compulsive disorder using clinical and neuroimaging data

Cognitive behavioral therapy (CBT) is a first-line treatment for obsessive-compulsive disorder (OCD), but clinical response is difficult to predict. In this study, we aimed to develop predictive models using clinical and neuroimaging data from the multicenter Enhancing Neuro-Imaging and Genetics through Meta-Analysis (ENIGMA)-OCD consortium. Baseline clinical and resting-state functional magnetic imaging (rs-fMRI) data from 159 adult patients aged 18-60 years (88 female) with OCD who received CBT at four treatment/neuroimaging sites were included. Fractional amplitude of low frequency fluctuations, regional homogeneity and atlas-based functional connectivity were computed. Clinical CBT response and remission were predicted using support vector machine and random forest classifiers on clinical data only, rs-fMRI data only, and the combination of both clinical and rs-fMRI data. The use of only clinical data yielded an area under the ROC curve (AUC) of 0.69 for predicting remission (p=0.001). Lower baseline symptom severity, younger age, an absence of cleaning obsessions, unmedicated status, and higher education had the highest model impact in predicting remission. The best predictive performance using only rs-fMRI was obtained with regional homogeneity for remission (AUC=0.59). Predicting response with rs-fMRI generally did not exceed chance level. Machine learning models based on clinical data may thus hold promise in predicting remission after CBT for OCD, but the predictive power of multicenter rs-fMRI data is limited.

Protocol for a systematic review and individual participant data meta-analysis for risk factors for lung cancer in individuals with lung nodules identified by low-dose CT screening

BACKGROUND

Worldwide, lung cancer (LC) is the second most frequent cancer and the leading cause of cancer related mortality. Low-dose CT (LDCT) screening reduced LC mortality by 20-24% in randomised trials of high-risk populations. A significant proportion of those screened have nodules detected that are found to be benign. Consequently, many individuals receive extra imaging and/or unnecessary procedures, which can have a negative physical and psychological impact, as well as placing a financial burden on health systems. Therefore, there is a need to identify individuals who need no interval CT between screening rounds.

METHODS AND ANALYSIS

The aim of this study is to identify risk factors predictive of LC, which are known at the time of the scan, in patients with LDCT screen-detected lung nodules. The MEDLINE and EMBASE databases will be searched and articles that are on cohorts or mention cohorts of screenees with nodules will be identified. A data extraction framework will ensure consistent extraction across studies. Individual participant data (IPD) will be collected to perform a one-stage IPD meta-analysis using hierarchical univariate models. Clustering will be accounted for by having separate intercept terms for each cohort. Where IPD is not available, the effects of risk factors will be extracted from publications, if possible. Effects from IPD cohorts and aggregate data will be reported and compared. The PROBAST (Prediction model Risk Of Bias ASsessment Tool) will be used for assessment of quality of the studies.

ETHICS AND DISSEMINATION

Ethical approval was not required as this study is a secondary analysis. The results will be disseminated through publication in peer-reviewed journals and presentations at relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42022309515.

Chlamydia trachomatis Serovars from the C-Complex and the B- and C-Related Complexes Are Significantly More Pathogenic than Those from the B-Complex in C3H/HeN but Not in BALB/c Mice

Studies in humans indicate that certain Chlamydia trachomatis serovars are more pathogenic than others. Specifically, several studies concluded that serovars from the C-complex are more pathogenic than those from the B-complex, although there are reports that do not support this finding. To investigate these results in an animal model, the eight genitourinary C. trachomatis serovars were tested in two strains of mice: C3H/HeN and BALB/c. These two strains of mice were investigated because C3H/HeN is more susceptible to Chlamydia muridarum infections than BALB/c, indicative of differences in their immunogenetic background. Mice were infected transcervically with 105 inclusion forming units of each of the C. trachomatis serovars, and vaginal cultures were collected. To determine the pathogenicity and its impact on fertility, at week seven post-infection, female mice were caged with male mice. In the C3H/HeN mice, significant differences in vaginal shedding and fertility were observed between serovars from the B-complex (D and E) and those from the C-complex (H, I, J) and B- and C-related complexes (G, F, and K). The animals infected with serovars F, G, H, I, J, and K shed less but had significantly more infertility than the mice infected with serovars D or E. The experiments in the BALB/c mice, however, did not show major differences in pathogenicity between the eight C. trachomatis serovars. These results support the findings in humans and emphasize the critical importance of the immunogenetic background of the host on the outcome of C. trachomatis infections. The data imply that management of C. trachomatis-infected patients may require a more personalized approach.

No impact of a positive Chlamydia trachomatis serology on live-birth rate after intra-uterine insemination

OBJECTIVE

To study the impact of a CT serology on intrauterine insemination (IUI) cumulative live-birth rate (cLBR) in women with documented bilateral tubal patency.

DESIGN

Cohort study SUBJECTS: Infertile women with documented bilateral tubal patency and medical indication of IUI matched on the following criteria: woman's age, number of cycles completed and number of motile sperm inseminated (NMSI).

EXPOSURE

This retrospective, observational and monocentric cohort study compared women with positive CT serology matched 1:1 to control women with negative CT serology.

MAIN OUTCOME MEASURES

Cumulative LBR, rates of clinical pregnancy, spontaneous abortion, biochemical pregnancy.

RESULTS

A total of 71 women in the CT positive group were matched to 71 women in the negative CT group, leading to compare 136 cycles per group. No statistically significant difference was observed between groups regarding the demographic and medical characteristics of couples. Cumulative LBR per woman was similar in both groups with 32.4% (n = 23) in the negative serology group Vs 25.4% (n = 18) in the positive CT group (NS). The rates of clinical pregnancy, spontaneous abortion, biochemical pregnancy were comparable between the two groups.

CONCLUSION

In a population of infertile women with patent tubes, our study suggests that the serological status for CT has no impact on the IIU cLBR.

How pragmatic are randomised controlled trials evaluating minimally invasive surgery for oesophageal cancer? A methodological review of trial design using the Pragmatic-Explanatory Continuum Indicator Summary-2 (PRECIS-2) tool

BACKGROUND

Surgical interventions are inherently complex and designing and conducting surgical randomised controlled trials (RCTs) can be challenging. Trial design impacts the applicability of trial results to clinical practice. Given the recent growth in numbers of surgical RCTs, there is a need to better understand the validity and applicability of trials in this field.

OBJECTIVES

To examine the applicability and validity of RCTs comparing minimally invasive and open surgery for oesophageal cancer and to delineate areas for future research.

ELIGIBILITY CRITERIA

RCTs comparing open with minimal invasive oesophagectomy, published January 2012-June 2023. Abstracts, pilot and feasibility studies, and systematic reviews were excluded.

SOURCES OF EVIDENCE

Three sequential searches of Ovid MEDLINE, Embase and CENTRAL electronic databases and clinical trials registry databases.

CHARTING METHODS

Two independent reviewers screened the articles and used appropriate, validated tools (Pragmatic-Explanatory Continuum Indicator Summary-2 (PRECIS-2) and Risk of Bias 2) to assess study quality. Trials were considered pragmatic if they were conducted in multiple centres and had a mean score of four or above on the PRECIS-2.

RESULTS

Nine RCTs were identified. One was judged to be pragmatic. The remaining eight were limited by narrow eligibility criteria, being single-centred or having strict intervention protocols. Two studies were low risk of bias, of which one was pragmatic, and three high, due to unblinded outcome assessment. The remaining four studies were of 'some concern' due to poor reporting.

CONCLUSIONS

Only one trial identified in this review was considered pragmatic. More lenient criteria, as used in other reviews, may increase the proportion. There is a need for clearer guidance on the cut-off values that define a trial as pragmatic. It is recommended that the intended purpose of the trial, whether explanatory or pragmatic, receives more attention during surgical trial study design and conduct.

Effect of probiotic supplementation on the gut microbiota in very preterm infants: a systematic review

OBJECTIVE

There is increasing evidence that probiotic supplementation in very preterm infants decreases the risk of necrotising enterocolitis (NEC), sepsis and mortality. The underlying mechanisms, including effects on the gut microbiota, are largely unknown. We aimed to systematically review the available literature on the effects of probiotic supplementation in very preterm infants on gut microbiota development.

DESIGN

A systematic review in Medline, Embase, Cochrane Library, CINAHL and Web of Science.

SETTING

Neonatal intensive care unit.

PATIENTS

Premature infants.

INTERVENTION

Probiotic supplementation.

MAIN OUTCOME MEASURES

Gut microbiota.

RESULTS

A total of 1046 articles were screened, of which 29 were included. There was a large heterogeneity in study design, dose and type of probiotic strains, timepoints of sample collection and analysing techniques. Bifidobacteria and lactobacilli were the most used probiotic strains. The effects of probiotics on alpha diversity were conflicting; however, beta diversity was significantly different between probiotic-supplemented infants and controls in the vast majority of studies. In most studies, probiotic supplementation led to increased relative abundance of the supplemented strains and decreased abundance of genera such as Clostridium, Streptococcus, Klebsiella and Escherichia.

CONCLUSIONS

Probiotic supplementation to preterm infants seems to increase the relative abundance of the supplemented strains with a concurrent decrease of potentially pathogenic species. These probiotic-induced microbial alterations may contribute to the decreased risk of health complications such as NEC. Future trials, including omics technologies to analyse both microbiota composition and function linked to health outcomes, are warranted to identify the optimal mixture and dosing of probiotic strains.

PROSPERO REGISTRATION NUMBER

CRD42023385204.

Advancement in predictive biomarkers for gestational diabetes mellitus diagnosis and related outcomes: a scoping review

OBJECTIVE

Gestational diabetes mellitus (GDM) is a metabolic disorder associated with adverse maternal and neonatal outcomes. While GDM is diagnosed by oral glucose tolerance testing between 24-28 weeks, earlier prediction of risk of developing GDM via circulating biomarkers has the potential to risk-stratify women and implement targeted risk reduction before adverse obstetric outcomes. This scoping review aims to collate biomarkers associated with GDM development, associated perinatal outcome and medication requirement in GDM.

DESIGN

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping reviews was used to guide the study.

DATA SOURCES

This review searched for articles on PubMed, Embase, Scopus, Cochrane Central Register of Controlled Trials, the Cumulative Index to Nursing and Allied Health Literature and the Web of Science from January 2013 to February 2023.

ELIGIBILITY CRITERIA

The eligibility criteria included analytical observational studies published in English, focusing on pregnant women with maternal plasma or serum biomarkers collected between 6 and 24 weeks of gestation. Studies were excluded if they evaluated drug effects, non-GDM diabetes types or involved twin pregnancies, microbiota, genetic analyses or non-English publications.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data. One reviewer extracted data from papers included in the scoping review using Covidence. From the 8837 retrieved records, 137 studies were included.

RESULTS

A total of 278 biomarkers with significant changes in individuals with GDM compared with controls were identified. The univariate predictive biomarkers exhibited insufficient clinical sensitivity and specificity for predicting GDM, perinatal outcomes, and the necessity of medication. Multivariable models combining maternal risk factors with biomarkers provided more accurate detection but required validation for use in clinical settings.

CONCLUSION

This review recommends further research integrating novel omics technology for building accurate models for predicting GDM, perinatal outcome, and the necessity of medication while considering the optimal testing time.

The effects of literacy on health in Gypsies, Roma and Travellers (GRT): a systematic review and narrative synthesis

INTRODUCTION

Gypsies, Roma and Travellers (GRT) frequently experience poorer health outcomes than the general population and represent the most socially and economically disadvantaged individuals in many countries. In general, GRT in OECD (Organisation for Economic Co-operation and Development) countries have lower rates of literacy than the general population. Although 'health literacy' has been examined before, the link between low functional literacy and its effects on health has not yet been explored.

METHODS

Searches were conducted on five large English-language databases for research papers since 2008. Grey literature was included as the number of eligible papers was small. This was complimented by citation 'chaining'. Study findings of qualitative papers were extracted, codes were devised and then analysed thematically. A narrative synthesis was reported, supplemented by the quantitative findings.

RESULTS

15 studies (and two substudies) were analysed. Four strongly overlapping themes were developed: (1) The context of culturally inadequate healthcare systems, (2) psychological impact and disempowerment, (3) intersectional, contextual factors and the unique needs of GRT and (4) considerations for health information resources for GRT patients with low literacy.

CONCLUSION

Although low literacy in GRT groups is a well-recognised issue, this is the first systematic review to analyse the link between low literacy and its effects on health outcomes for GRT. The wide range of socioeconomic and cultural factors present in GRT communities, combined with low literacy, act synergistically to worsen the physical and mental health of GRT groups in different ways than that seen in members of the general population with similar low literacy levels. National intervention is required to improve the literacy of GRT children and adults. There is a clear need to develop policies and processes that facilitate a better understanding of literacy levels and how they interact with other social determinants of GRT health among healthcare professionals.

REGISTRATION NUMBER

CRD42023468449.

Prevalence of gonococcal and chlamydial infections among men who have sex with men in sub-Saharan Africa: a systematic review and meta-analysis

BACKGROUND

Men who have sex with men (MSM) are disproportionately affected by sexually transmitted infections (STI) including Neisseria gonorrhoeae (Ng) and Chlamydia trachomatis (Ct). The lack of robust data on STIs among African MSM has limited the development of evidence-based screening strategies. This study aimed at documenting the pooled prevalence of Ng/Ct among MSM in sub-Saharan Africa (SSA).

METHODS

This systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) 2020 guidelines. Relevant articles from the following databases were searched: PubMed, Scopus, ISI Web of Science, and the Directory of Open Access Journals (DOAJ). Eligible studies reported on the prevalence of Ng/Ct among the MSM population in SSA. Publication bias was assessed using the Hoy tool, Doi plot, and LFK ratio. Due to heterogeneity among studies, subgroup analyses were performed using the MetaXL add-on tool for Microsoft Excel.

RESULTS

Of 525 articles screened, 20 were selected for inclusion. Six were cross-sectional, four had a prospective cohort study design, and one was an epidemiological study. The pooled prevalence of Ng/Ct in MSM was 27% (95% CI, 19-39%), with an I2 of 98% signifying heterogeneity among the studies. Subgroup analysis by country revealed South Africa had the highest prevalence (38%).

DISCUSSION

Interpretation The high prevalence of Ng/Ct infection among MSM in SSA is of concern. Limitations Due to limited data available on Ng/Ct prevalence, the true prevalence of SSA and its associated risk factors is uncertain.

CONCLUSION

As the first study to systematically review the available literature on STI prevalence among the MSM population in SSA, it showed the burden of Ng/Ct is higher than in other regions, warranting the strengthening of health systems to improve education, testing, and treatment in MSM population.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022327095.

Relationship between Chlamydia Trachomatis infection, infertility, and serum 25-hydroxyvitamin D: a cross-sectional study from NHANES 2013-2016

BACKGROUND

Chlamydia trachomatis is a common sexually transmitted disease that is associated with considerable morbidity and harmful sequelae, including pelvic inflammatory disease and infertility. Strategies for prevention and treatment of infertility in women with C. trachomatis infection require further investigation. There is evidence suggesting that vitamin D could be a potential treatment. This study aimed to investigate the relationship between serum 25-hydroxyvitamin D [25(OH)D] levels, chlamydia seropositivity, and the risk of infertility in women.

METHODS

We conducted this cross-sectional study using 2013-2016 National Health and Nutrition Examination Survey data. Women aged 18-39 years with complete serum 25(OH)D and chlamydia Pgp3Ab multiplex bead/enzyme-linked immunosorbent assay data available were included. The correlation between 25(OH)D level, chlamydia seropositivity, and infertility was evaluated using the weighted chi-squared test and the t-test with multivariate logistic regression and moderation effect models.

RESULTS

Among the 1424 women who met our eligibility criteria, the weighted chlamydia seropositivity rate was 36.8%. The 25(OH)D level was significantly lower in the seropositive group compared with seronegative control. (P = 0.009). After adjusting for ethnicity, the effect of 25(OH)D was no longer significant (P = 0.693). Further analysis in the chlamydia-seropositive subset revealed that the vitamin D level was lower in the infertile group (P = 0.024). In an interaction model, 25(OH)D was found to antagonizes the positive relationship between chlamydia and infertility (OR = 0.985, 95% CI: 0.971-0.999, P = 0.040).

CONCLUSION

The serum vitamin D level may be more related to the prognosis in terms of infertility than to the risk of chlamydia infection. This finding may reveal a possible treatment strategy for chlamydia infection.

Healthcare utilisation and costs associated with poor access to diagnosis and treatment for children and young people with tic disorders

BACKGROUND

There are no specific national guidelines in England to guide healthcare professionals in how to assess or treat young people with tic disorders. Access to evidence-based treatment, including behavioural therapy, is of limited availability.

OBJECTIVES

This study examined the economic impact on services arising from a lack of access to appropriate healthcare services for young people with tic disorders, alongside the impact on school attendance.

METHODS

This study used data from the randomised controlled trial 'ORBIT' (Online Remote Behavioural Intervention for Tics). ORBIT compared online exposure and response prevention behavioural therapy for tics with online psychoeducation and recruited 224 young people aged 9-17 years in England. Here, we explore costs of health service use and school absenteeism from children who participated in the ORBIT trial and present these alongside the economic impact of including ORBIT within a tic service. We supplement ORBIT data with findings from two case studies.

FINDINGS

The data showed that patients have care from several healthcare professionals and miss school due to accessing care for tics. The case studies suggest that most of these contacts with specialist services are unlikely to be supportive. However, adding ORBIT could save the National Health Service £1 million.

CONCLUSIONS

Young people with tic disorders are likely to engage in substantial use of healthcare resources because of inadequate care pathways. The availability of an evidence-based online therapy such as ORBIT could save money to the healthcare system.

CLINICAL IMPLICATIONS

There is a need to improve service provision and develop national guidelines for tic disorders.

TRIAL REGISTRATION NUMBER

ISRCTN70758207, NCT03483493.

Reproductive tract complication risks following Chlamydia trachomatis infections: a long-term prospective cohort study from 2008 to 2022

Background

The clinical and public health relevance of widespread testing for asymptomatic Chlamydia trachomatis (chlamydia) infections is under debate. To address uncertainties in screening programs, we estimate reproductive tract complication risks following asymptomatic and symptomatic chlamydia infections in a long-term prospective cohort.

Methods

A cohort of 5704 reproductive-age women recruited from a chlamydia screening study was followed for up to 14 years. Chlamydia positivity was determined using screening polymerase chain reaction test results, self-reported diagnoses (with/without symptoms), and chlamydia Immunoglobulin G antibodies. Outcome data (pregnancies, pelvic inflammatory disease (PID), ectopic pregnancy, and tubal factor infertility) were collected through self-completed questionnaires. Cox regression calculated adjusted hazard ratios (aHR) with confidence intervals (CI) to compare outcomes between time-updated chlamydia groups since sexual debut.

Findings

During 104,612 person-years, 2103 (36.9%) women were chlamydia-positive and 3692 women (64.7%) had been pregnant at least once. Risks for PID, ectopic pregnancy and tubal factor infertility were 1.62 (95% CI 1.20-2.17), 1.84 (95% CI 1.14-2.95) and 2.75 (95% CI 1.53-4.94), compared to chlamydia-negatives. aHRs for PID after symptomatic and asymptomatic infections were 2.29 (95% CI 1.62-3.25) and 1.06 (95% CI 0.66-1.69), respectively. Incidence of PID, ectopic pregnancy and tubal factor infertility after symptomatic chlamydia infection remained low with rates per 1000 person-years of 5.8, 1.9, and 1.8, respectively.

Interpretation

We found a significantly higher risk of PID, ectopic pregnancy and tubal factor infertility in chlamydia-positive women compared to chlamydia-negative women, although the overall incidence rates of complications remained low. Symptomatic, but not asymptomatic, chlamydia infections were associated with PID risk, suggesting the largest disease burden of complications is in this group.

Funding

The Netherlands Organisation for Health Research and Development (ZonMW Netherlands) and Research Funding from the Ministry of Health, Welfare and Sports.

High-flow nasal cannula is an expensive and clunky placebo: myth or maxim?

High-flow nasal cannula (HFNC) is now a commonly used noninvasive method of providing respiratory support to children and young people. Its rapid spread into varied clinical applications has often left assessment of the evidence of its mechanism of action and clinical benefit lagging behind its uptake. This review will discuss the proposed mechanisms of action of HFNC, review the evidence base for its use, cover its applications in paediatrics and outline its limitations.

Māori and Pacific young people's perspectives on testing for sexually transmitted infections via an online service: a qualitative study

Introduction International research suggests free online postal self-sampling for sexually transmitted infection (STI) testing is an acceptable alternative to clinic-based testing. A user-pays online STI testing service exists in Aotearoa New Zealand, but acceptability among priority populations is unknown. Aim To explore Māori and Pacific young people's perspectives on online postal self-sampling for STI testing (as prospective service users). Methods Four wānanga (knowledge-sharing forum) were held between November 2022 and May 2023 with Māori and Pacific participants aged 15-24 years who were recruited via youth-focused community organisations. Three facilitators guided discussions about STI testing and use of an online service. Inductive thematic analysis was used to analyse data generated from audio-recorded discussions, group work notes and facilitator field notes. Results None of the 38 participants were aware of online STI testing and all considered it cost-prohibitive. Perceptions of online testing were mixed, and discussion about concerns outweighed perceived benefits. Three themes were identified: (i) potential to support autonomy (perceived benefits and positive features of self-sample collection kits); (ii) barriers and process-related concerns; and (iii) tailoring online STI testing to young people's needs (facilitating engagement with online testing). Discussion For online STI testing to be an accessible alternative to clinic-based testing for priority populations, cost, low awareness and other barriers in the testing pathway need to be addressed. Clinician follow-up on positive results and free treatment would be critical to ensure the cycle of best practice care is completed. Regardless of where testing is accessed, investment is needed to support young people's knowledge of when, why and how to access a sexual health check.

WHO global research priorities for sexually transmitted infections

Sexually transmitted infections (STIs) are widespread worldwide and negatively affect sexual and reproductive health. Gaps in evidence and in available tools have long hindered STI programmes and policies, particularly in resource-limited settings. In 2022, WHO initiated a research prioritisation process to identify the most important STI research areas to address the global public health need. Using an adapted Child Health and Nutrition Research Initiative methodology including two global stakeholder surveys, the process identified 40 priority STI research needs. The top priorities centred on developing and implementing affordable, feasible, rapid point-of-care STI diagnostic tests and new treatments, especially for gonorrhoea, chlamydia, and syphilis; designing new multipurpose prevention technologies and vaccines for STIs; and collecting improved STI epidemiologic data on both infection and disease outcomes. The priorities also included innovative programmatic approaches, such as new STI communication and partner management strategies. An additional six research areas related to mpox (formerly known as monkeypox) reflect the need for STI-related research during disease outbreaks where sexual transmission can have a key role. These STI research priorities provide a call to action for focus, investment, and innovation to address existing roadblocks in STI prevention, control, and management to advance sexual and reproductive health and wellbeing for all.

Association Between Self-Reported Infections and Seropositivity Among Pregnant Women With Gastroschisis: A Case Control Study, With Emphasis on Chlamydia trachomatis

BACKGROUND

Gastroschisis is a birth defect with the greatest risk among women <20 years of age.

METHODS

Pregnant women attending the University of Utah's Maternal-Fetal Medicine Diagnostic Center between 2011 and 2017 for either their routine diagnostic ultrasound or referral were recruited (cases: pregnant women with fetal gastroschisis, n = 53 participated/57, 93%; controls: pregnant women without fetal abnormalities, n = 102 participated/120, 85%). A clinic coordinator consented and interviewed women and obtained a blood sample and prenatal medical records. We evaluated self-reported maternal characteristics, risk factors, and infections. To assess pathogen seropositivity we used Serimmune's Serum Epitope Repertoire Analysis validated 35 pathogen panels and Chlamydia trachomatis and compared seropositivity to self-report and prenatal medical record screening to assess sensitivity.

RESULTS

Cases were more likely to report a younger age at sexual debut (p = <0.01), more sexual partners (p = 0.02), being unmarried (p < 0.01), changing partners between pregnancies (p = <0.01), smoking cigarettes (<0.01), and a recent sexually transmitted infection (STI) (p = 0.02). No differences were observed for self-report of illicit drug use or periconceptional urinary tract infections. Cases had a higher seropositivity for cytomegalovirus (p = 0.01). No differences were observed for herpes simplex I, II, or Epstein-Barr. Though based on small numbers, C. trachomatis seropositivity was highest in cases (17%) compared to controls (8.8%) with the highest proportion observed in case women <20 years of age (cases 33%; controls 0%). Any STI (self-report or seropositivity) was also highest among cases <20 years of age (cases 47%; controls 0%). Among C. trachomatis seropositive women, self-report and prenatal medical record sensitivity was 27.8% and 3%, respectively.

CONCLUSIONS

Cases were more likely to engage in behaviors that can increase their risk of exposure to sexually transmitted pathogens. Case women <20 years of age had the highest proportion of C. trachomatis seropositivity and any STI. Prenatal medical records and self-report were inadequate to identify a recent chlamydial infection whereas, the SERA assay is a novel approach for evaluating subclinical infections that may impact the developing embryo.

Effect of acceptance and commitment therapy on fear of falling and physical activity in Parkinson's disease: a randomised controlled trial

Introduction

This study aimed to evaluate the efficacy of acceptance and commitment therapy (ACT) in reducing the fear of falling (FOF) and promoting physical activity in individuals diagnosed with Parkinson's disease (PD).

Methods and analysis

This is a prospective, multicentre, rater-blinded and randomised controlled trial. Patients with PD and a history of falls will be randomly assigned to either an 8-week ACT intervention group or a control group receiving standard care. The primary outcomes measured will include FOF assessment using the Falls Efficacy Scale-International and physical activity levels measured via wearable sensor devices. Secondary outcomes will encompass the assessment of motor function, balance and fall frequency using the Movement Disorder Society Unified Parkinson's Disease Rating Scale, Berg Balance Scale and Timed Up and Go test. Objective measures of balance and physical activity will be obtained through static posturography and wearable sensors over a 3-day period, both before and after the intervention. Data will be analysed using mixed-effects models to evaluate the impact of ACT on FOF and physical activity.

Ethics and dissemination

We hypothesised that ACT would lead to a significant reduction in FOF and an increase in physical activity levels compared with standard care. Additionally, this study will also examine the relationship between reduced FOF and improvements in balance and motor function. Our results will provide valuable evidence to support the effectiveness of ACT in reducing FOF and promoting physical activity among patients with PD, and if validated, ACT could be recommended as a beneficial intervention to enhance the quality of life and reduce fall-related morbidity in patients with PD.

Protocol of a cost-effectiveness analysis of a combined intervention for depression and parenting compared with enhanced standard of care for perinatally depressed, HIV-positive women and their infants in rural South Africa

INTRODUCTION

Poverty, HIV and perinatal depression represent a triple threat to public health in sub-Saharan Africa because of their combined negative effects on parenting and child development. In the resource-constrained context of low-income and middle-income countries, a lay-counsellor-delivered intervention that combines a psychological and parenting intervention could offer the potential to mitigate the consequences of perinatal depression while also optimising scarce resources for healthcare.Measuring the cost-effectiveness of such a novel intervention will help decision-makers to better understand the relative costs and effects associated with replicating the intervention, thereby supporting evidence-based decision-making. This protocol sets out the methodological framework for analysing the cost-effectiveness of a cluster randomised controlled trial (RCT) that compares a combined intervention to enhanced standard of care when treating depressed, HIV-positive pregnant women and their infants in rural South Africa.

METHODS AND ANALYSIS

This cost-effectiveness analysis (CEA) protocol complies with the Consolidated Health Economic Evaluation Reporting Standards 2022 checklist. A societal perspective will be chosen.The proposed methods will determine the cost and efficiency of implementing the intervention as per the randomised control trial protocol, as well as the cost of replicating the intervention in a non-research setting. The costs will be calculated using an appropriately adjusted version of the Standardised Early Childhood Development Costing Tool.Primary health outcomes will be used in combination with costs to determine the cost per improvement in maternal perinatal depression at 12 months postnatal and the cost per improvement in child cognitive development at 24 months of age. To facilitate priority setting, the incremental cost-effectiveness ratios for improvements in child cognitive development will be ranked against six other child cognitive-development interventions according to Verguet et al's methodology (2022).A combination of activity-based and ingredient-based costing approaches will be used to identify, measure and value activities and inputs for all alternatives. Outcomes data will be sourced from the RCT team.

ETHICS AND DISSEMINATION

The University of Oxford is the sponsor of the CEA. Ethics approval has been obtained from the Human Sciences Research Council (HSRC, #REC 5/23/08/17), South Africa and the Oxford Tropical Research Ethics Committee (OxTREC #31-17), UK.Consent for publication is not applicable since no participant data are used in this protocol.We plan to disseminate the CEA results to key policymakers and researchers in the form of a policy brief, meetings and academic papers.

TRIAL REGISTRATION DETAILS

ISRCTN registry #11 284 870 (14/11/2017) and SANCTR DOH-27-102020-9097 (17/11/2017).

Improving Miscarriage Prevention Research: a survey exploring the expectations of service users and stakeholders (IMPRESS) - a study protocol for a UK-based survey

INTRODUCTION

Interventional clinical trials in recurrent miscarriage use varying expected effect sizes to inform their sample size calculations. Often these are not informed by what stakeholders consider a meaningful treatment effect. Adaptive trial designs may integrate stakeholder views on trial success and futility but the criteria to inform this is lacking. This study aims to understand relevant stakeholder views of what is considered a worthwhile treatment effect for miscarriage prevention interventions and what is acceptable stopping criteria in miscarriage clinical trials.

METHODS AND ANALYSIS

The study is designed as a cross-sectional online anonymous survey. The survey presents different scenarios to respondents relating to varying target differences and probability thresholds and explores success and futility criteria for clinical trials. The survey was developed with personal and public involvement (PPI) through focus groups and a PPI partner. Eligible participants will be those with a personal history of miscarriage, including partners, and healthcare professionals who manage patients who experience a miscarriage. Convenience, snowball and purposive sampling techniques will be employed to invite eligible participants to complete the survey. The survey will be accepting responses for an initial 2-week pilot to check validity, prior to being open for a further 12 weeks. Descriptive analyses and linear regression analyses will synthesise the survey results.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the NHS Research Ethics Committee North West-Greater Manchester East (23/NW/0322) on 30 January 2024. Informed consent will be obtained prior to survey completion. No personal identifying information will be collected. The results will be published in a relevant scientific journal and communicated through our institutional website.

Foot surgery for adults with Charcot-Marie-Tooth disease

People with Charcot-Marie-Tooth (CMT) disease often undergo foot and ankle surgery, as foot deformities are common and cause a degree of functional limitations impairing quality of life. Surgical approaches are variable and there are no evidence-based guidelines. A multidisciplinary approach involving neurology, physical therapy and orthopaedic surgery is ideal to provide guidance on when to refer for surgical opinion and when to intervene. This review outlines the range of foot deformities associated with CMT, their clinical assessment, and their conservative and surgical and postoperative management.

Should all patients with polymyalgia rheumatica have a vascular ultrasound assessment?

There is a growing appreciation that both giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are closely interrelated conditions that have significant overlap in aetiology, clinical characteristics and treatment regimens. Subclinical GCA in PMR is becoming increasingly recognised, and there is evolving evidence that this may be a more aggressive disease phenotype than PMR. Ultrasound (US) lends itself well as a screening tool for GCA in PMR; it is inexpensive, non-invasive, widely available, lacks ionising radiation, may be performed at the bedside and is recommended by EULAR as a first-line investigation for suspected GCA. There is insufficient evidence to currently recommend that all patients with PMR should have a US assessment for vascular involvement. However, as clinical and laboratory parameters alone do not accurately diagnose patients with subclinical GCA, we suggest that vascular US will be increasingly performed by rheumatologists in practice to identify these patients with PMR, preferably as part of larger prospective outcome studies.

Histopathology reporting of temporal artery biopsy specimens for giant cell arteritis: results of a modified Delphi study

The temporal artery biopsy (TAB) is regarded as the gold-standard test in the diagnosis of giant cell arteritis (GCA). There is a lack of agreement among experienced pathologists regarding the diagnostic features and classification of inflammation observed in TAB sections in the diagnosis of GCA.

AIMS

The aim of this research study was to establish consensus on the key parameters which should be included in a standardised reporting proforma for TAB specimens. We specifically investigated factors pertaining to clinical information, specimen handling and microscopic pathological features.

METHODS

A modified Delphi process, comprising three survey rounds and three virtual consensus group meetings, was undertaken by 13 UK-based pathology or ophthalmology consultants, with a 100% response rate across the three rounds. Initial statements were formulated after a literature review and participants were asked to rate their agreement using a nine-point Likert scale. Consensus was defined a priori as an agreement of ≥70% and individual feedback was provided after each round, together with data on the distribution of group responses.

RESULTS

Overall, 67 statements reached consensus and 17 statements did not. The participants agreed on the core microscopic features to be included in a pathology report and felt that a proforma would facilitate consistent reporting practices.

CONCLUSIONS

Our work revealed uncertainty surrounding the correlation between clinical parameters (eg, laboratory markers of inflammation and steroid therapy duration) and microscopic findings, and we propose areas for future research.

Investigating possibilities for surveillance of long term chlamydia complications in the Netherlands: A qualitative study

OBJECTIVES

Chlamydia trachomatis (chlamydia) is one of the most reported bacterial sexually transmitted infections (STI) worldwide. Chlamydia can cause long term complications such as pelvic inflammatory disease (PID), ectopic pregnancy (EP) and tubal factor infertility (TFI). Changing testing strategies, for example reduced asymptomatic testing, influence chlamydia surveillance, highlighting the need for exploring alternative ways of monitoring chlamydia. We investigated the possibility of introducing routine surveillance of chlamydia related long term complications.

METHODS

A qualitative study including 15 in-depth interviews with a purposive sample of gynaecologists, general practitioners (GP), sexual health and emergency doctors was conducted in the Netherlands in 2021-2022. A semi-structured interview guide focused on experiences with diagnosis and registration of PID, EP and TFI and how a change in asymptomatic chlamydia testing strategy might influence this. Interviews were transcribed and analysed using a thematic approach.

RESULTS

Analysis showed that gynaecologists most frequently reported diagnosing PID, EP and TFI. Other professions rarely diagnose these complications, with emergency doctors only diagnosing EP. Most respondents reported unique registration codes for PID and EP, but the coding for TFI is more ambiguous. They reflected that diagnosis and registration of PID, EP and TFI are handled differently within their professions. Most respondents acknowledged registration in diagnostic codes as a useful surveillance tool. They expressed concerns in representativeness (e.g. differences in interpretation of diagnosis criteria) and data quality for surveillance.

CONCLUSIONS

Patient files of gynaecologists are likely to be most complete for monitoring trends of diagnosed chlamydia related long term complications in the Netherlands. However, when establishing a chlamydia complication surveillance system, professionals should be engaged in further standardizing diagnosis and registration practices. This will improve the quality and interpretability of complication surveillance and facilitate comparison between countries.

Lung cancer screening: where do we stand?

Lung cancer screening (LCS) programmes have emerged over recent years around the world. LCS programmes present differences in delivery, inclusion criteria and resource allocation. On a national scale, only a few LCS programmes have been fully established, but more are anticipated to follow. Evidence has shown that, in combination with a low-dose chest computed tomography scan, smoking cessation should be offered as part of a LCS programme for improved patient outcomes. Promising tools in LCS include further refined risk prediction models, the use of biomarkers, artificial intelligence and radiomics. However, these tools require further study and clinical validation is required prior to routine implementation.

Urinary methotrexate dosage in rheumatoid arthritis, in patients treated for at least 6 months: a potential marker of adherence

OBJECTIVES

Non-adherence to rheumatoid arthritis (RA) treatments must be identified. A methotrexate (MTX) urinary dosage (METU) was recently developed. The aim of our study was to assess adherence to MTX in RA using METU in real-life conditions and to compare it with indirect adherence measurement technics.

METHODS

We performed a cross-sectional study at Reims University Hospital. We included over 18-year-old patients with RA treated by MTX for more than 6 months. Patients were invited to complete demographic, clinical and psychological questionnaires and adherence measurement technics (Compliance Questionnaire of Rheumatology (CQR) and Medication Possession Ratio (MPR)). A urinary sample was collected to measure MTX and information about tolerance was evaluated through Methotrexate Intolerance Severity Score.

RESULTS

84 patients were included, 26 using oral MTX, 58 subcutaneous (SC) MTX. Among them, 73% were female, mean age was 61.5 years, MTX mean dose was 15 mg/week and 61.9% were treated by biological DMARDs (Disease Modifying Antirheumatic Drugs). 77 patients (91.7%) were adherent to treatment according to METU, whereas MPR and CQR reported less adherence (69.5% and 61.9%, respectively). MPR and METU were not significantly different in SC MTX users (p=0.059). Non-adherent patients had a higher number of tender joints and C reactive protein value (p<0.05).

CONCLUSION

This is the first largest study evaluating MTX adherence in patients with RA using a urinary dosage. We identified that indirect adherence measurements did not reflect real-life adherence. It would be appreciable to realise METU, in a new study, in patients with RA with unexplained response to treatment, to consider it before escalating therapeutic strategy.

EULAR recommendations for the use of imaging in large vessel vasculitis in clinical practice: 2023 update

OBJECTIVES

To update the EULAR recommendations for the use of imaging modalities in primary large vessel vasculitis (LVV).

METHODS

A systematic literature review update was performed to retrieve new evidence on ultrasound, MRI, CT and [18F]-fluorodeoxyglucose positron emission tomography (FDG-PET) for diagnosis, monitoring and outcome prediction in LVV. The task force consisted of 24 physicians, health professionals and patients from 14 countries. The recommendations were updated based on evidence and expert opinion, iterating until voting indicated consensus. The level of agreement was determined by anonymous votes.

RESULTS

Three overarching principles and eight recommendations were agreed. Compared to the 2018 version, ultrasound is now recommended as first-line imaging test in all patients with suspected giant cell arteritis, and axillary arteries should be included in the standard examination. As an alternative to ultrasound, cranial and extracranial arteries can be examined by FDG-PET or MRI. For Takayasu arteritis, MRI is the preferred imaging modality; FDG-PET, CT or ultrasound are alternatives. Although imaging is not routinely recommended for follow-up, ultrasound, FDG-PET or MRI may be used for assessing vessel abnormalities in LVV patients with suspected relapse, particularly when laboratory markers of inflammation are unreliable. MR-angiography, CT-angiography or ultrasound may be used for long-term monitoring of structural damage, particularly at sites of preceding vascular inflammation.

CONCLUSIONS

The 2023 EULAR recommendations provide up-to-date guidance for the role of imaging in the diagnosis and assessment of patients with LVV.

Association between bacterial vaginosis, Chlamydia trachomatis infection and tubal factor infertility in Bukavu, Democratic Republic of Congo

BACKGROUND

Tubal factor infertility (TFI) is common in sub-Saharan Africa and often secondary to pelvic inflammatory disease (PID). Anaerobes associated with bacterial vaginosis (BV) are also found in PIDs widely dominated by Chlamydia trachomatis (C. trachomatis), whose role in TFI is better demonstrated than that of BV.

OBJECTIVES

To determine the prevalence of BV and C. trachomatis and to investigate the association between BV, C. trachomatis and TFI.

METHODS

We included 137 patients treated for infertility between January 2020 and November 2021. Cases were defined as women with infertility aged 18-45 years presenting with TFI (n = 52), and controls as infertile women in the same age groups without TFI (n = 85). Data on social habits, life style and infertility parameters were collected, and we performed screening for BV and C. trachomatis. Multiple regression was used to measure associations.

RESULTS

The prevalence of BV and C. trachomatis was 42.3% (58/137) and 23.4% (32/137), respectively. BV (61.5% vs 30.6%, p<0.001) and C. trachomatis (48.1 vs 8.2%, p<0.001) were more frequent in cases of TFI. BV and C. trachomatis increased the risk of TFI approximately 4-fold [aOR: 3.77 (1.61-8.83), p=0.002] and 14-fold [aOR: 13.77 (4.59-41.27), p<0.001], respectively.

CONCLUSION

BV and C. trachomatis infection are strongly associated with TFI in Bukavu. Prevention and screening should be implemented to reduce the risk of TFI.

[First-line management of infertile couple. Guidelines for clinical practice of the French College of Obstetricians and Gynecologists 2022]

OBJECTIVE

To update the 2010 CNGOF clinical practice guidelines for the first-line management of infertile couples.

MATERIALS AND METHODS

Five major themes (first-line assessment of the infertile woman, first-line assessment of the infertile man, prevention of exposure to environmental factors, initial management using ovulation induction regimens, first-line reproductive surgery) were identified, enabling 28 questions to be formulated using the Patients, Intervention, Comparison, Outcome (PICO) format. Each question was addressed by a working group that had carried out a systematic review of the literature since 2010, and followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) methodology to assess the quality of the scientific data on which the recommendations were based. These recommendations were then validated during a national review by 40 national experts.

RESULTS

The fertility work-up is recommended to be prescribed according to the woman's age: after one year of infertility before the age of 35 and after 6months after the age of 35. A couple's initial infertility work-up includes a single 3D ultrasound scan with antral follicle count, assessment of tubal permeability by hysterography or HyFOSy, anti-Mullerian hormone assay prior to assisted reproduction, and vaginal swabbing for vaginosis. If the 3D ultrasound is normal, hysterosonography and diagnostic hysteroscopy are not recommended as first-line procedures. Chlamydia trachomatis serology does not have the necessary performance to predict tubal patency. Post-coital testing is no longer recommended. In men, spermogram, spermocytogram and spermoculture are recommended as first-line tests. If the spermogram is normal, it is not recommended to check the spermogram. If the spermogram is abnormal, an examination by an andrologist, an ultrasound scan of the testicles and hormonal test are recommended. Based on the data in the literature, we are unable to recommend a BMI threshold for women that would contraindicate medical management of infertility. A well-balanced Mediterranean-style diet, physical activity and the cessation of smoking and cannabis are recommended for infertile couples. For fertility concern, it is recommended to limit alcohol consumption to less than 5 glasses a week. If the infertility work-up reveals no abnormalities, ovulation induction is not recommended for normo-ovulatory women. If intrauterine insemination is indicated based on an abnormal infertility work-up, gonadotropin stimulation and ovulation monitoring are recommended to avoid multiple pregnancies. If the infertility work-up reveals no abnormality, laparoscopy is probably recommended before the age of 30 to increase natural pregnancy rates. In the case of hydrosalpinx, surgical management is recommended prior to ART, with either salpingotomy or salpingectomy depending on the tubal score. It is recommended to operate on polyps>10mm, myomas 0, 1, 2 and synechiae prior to ART. The data in the literature do not allow us to systematically recommend asymptomatic uterine septa and isthmoceles as first-line surgery.

CONCLUSION

Based on strong agreement between experts, we have been able to formulate updated recommendations in 28 areas concerning the initial management of infertile couples.

Operational complexities in international clinical trials: a systematic review of challenges and proposed solutions

OBJECTIVE

International trials can be challenging to operationalise due to incompatibilities between country-specific policies and infrastructures. The aim of this systematic review was to identify the operational complexities of conducting international trials and identify potential solutions for overcoming them.

DESIGN

Systematic review.

DATA SOURCES

Medline, Embase and Health Management Information Consortium were searched from 2006 to 30 January 2023.

ELIGIBILITY CRITERIA

All studies reporting operational challenges (eg, site selection, trial management, intervention management, data management) of conducting international trials were included.

DATA EXTRACTION AND SYNTHESIS

Search results were independently screened by at least two reviewers and data were extracted into a proforma.

RESULTS

38 studies (35 RCTs, 2 reports and 1 qualitative study) fulfilled the inclusion criteria. The median sample size was 1202 (IQR 332-4056) and median number of sites was 40 (IQR 13-78). 88.6% of studies had an academic sponsor and 80% were funded through government sources. Operational complexities were particularly reported during trial set-up due to lack of harmonisation in regulatory approvals and in relation to sponsorship structure, with associated budgetary impacts. Additional challenges included site selection, staff training, lengthy contract negotiations, site monitoring, communication, trial oversight, recruitment, data management, drug procurement and distribution, pharmacy involvement and biospecimen processing and transport.

CONCLUSIONS

International collaborative trials are valuable in cases where recruitment may be difficult, diversifying participation and applicability. However, multiple operational and regulatory challenges are encountered when implementing a trial in multiple countries. Careful planning and communication between trials units and investigators, with an emphasis on establishing adequately resourced cross-border sponsorship structures and regulatory approvals, may help to overcome these barriers and realise the benefits of the approach. OPEN SCIENCE FRAMEWORK REGISTRATION NUMBER: osf-registrations-yvtjb-v1.

'Every strategy needs to be contributing to erasing the stigma': Māori and Pacific young people talk about overcoming barriers to testing for sexually transmitted infections

BACKGROUND

Māori and Pacific young people are disproportionately impacted by sexually transmitted infections (STIs). Access to STI screening is important to reduce transmission and reproductive health complications.

METHODS

Between November 2022 and May 2023, we held four wānanga (workshops) with Māori and Pacific participants (15-24years old) to find out what barriers they encounter to STI testing, and hear their ideas about how to overcome these. Participants were recruited via youth-focused community organisations in the Wellington region of Aotearoa New Zealand. Inductive thematic analysis was used to understand data generated from discussions, drawing on Māori and Pacific models of wellbeing to frame themes.

RESULTS

Thirty-eight participants were involved in the wānanga. Barriers to STI testing related to five themes: (1) differences in cultural values and expression; (2) family/friends; (3) educational gaps; (4) psychological factors; and (5) structural obstacles. Suggested strategies to improve access to sexual health care included the need for free, flexible services, education and health promotion activities to reach young people in their spaces (e.g. church, marae, social media). Participants stressed the need for approaches to be community-based, delivered by trusted individuals using culturally appropriate messages, and saw participation in STI testing as beneficial for whānau/family and communities.

CONCLUSIONS

To improve access to STI testing, participants described the need for free services, together with education and health promotion to improve inter-generational sexual health knowledge. Reframing messages around STIs to align with Māori and Pacific models of wellbeing was identified as a way to normalise conversations, in turn reducing the stigma surrounding STI testing.

Health economic evaluations of preventative care for perinatal anxiety and associated disorders: a rapid review

OBJECTIVES

Perinatal mental health problems affect one in five women and cost the UK £8.1 billion for every year of births, with 72% of this cost due to the long-term impact on the child. We conducted a rapid review of health economic evaluations of preventative care for perinatal anxiety and associated disorders.

DESIGN

This study adopted a rapid review approach, using principles of the standard systematic review process to generate quality evidence. This methodology features a systematic database search, Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram, screening of evidence, data extraction, critical appraisal and narrative synthesis.

DATA SOURCES

PubMed, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Applied Social Sciences Index and Abstracts, PsycINFO and MEDLINE.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies that evaluated the costs and cost-effectiveness of preventative care for perinatal anxiety and associated disorders carried out within the National Health Service and similar healthcare systems.

DATA EXTRACTION AND SYNTHESIS

A minimum of two independent reviewers used standardised methods to search, screen, critically appraise and synthesise included studies.

RESULTS

The results indicate a lack of economic evaluation specifically for perinatal anxiety, with most studies focusing on postnatal depression (PND). Interventions to prevent postnatal mental health problems are cost-effective. Modelling studies have also been conducted, which suggest that treating PND with counselling would be cost-effective.

CONCLUSION

The costs of not intervening in maternal mental health outweigh the costs of preventative interventions. Preventative measures such as screening and counselling for maternal mental health are shown to be cost-effective interventions to improve outcomes for women and children.

PROSPERO REGISTRATION NUMBER

CRD42022347859.

Guideline concordance for timely chest imaging after new presentations of dyspnoea or haemoptysis in primary care: a retrospective cohort study

BACKGROUND

Guidelines recommend urgent chest X-ray for newly presenting dyspnoea or haemoptysis but there is little evidence about their implementation.

METHODS

We analysed linked primary care and hospital imaging data for patients aged 30+ years newly presenting with dyspnoea or haemoptysis in primary care during April 2012 to March 2017. We examined guideline-concordant management, defined as General Practitioner-ordered chest X-ray/CT carried out within 2 weeks of symptomatic presentation, and variation by sociodemographic characteristic and relevant medical history using logistic regression. Additionally, among patients diagnosed with cancer we described time to diagnosis, diagnostic route and stage at diagnosis by guideline-concordant status.

RESULTS

In total, 22 560/162 161 (13.9%) patients with dyspnoea and 4022/8120 (49.5%) patients with haemoptysis received guideline-concordant imaging within the recommended 2-week period. Patients with recent chest imaging pre-presentation were much less likely to receive imaging (adjusted OR 0.16, 95% CI 0.14-0.18 for dyspnoea, and adjusted OR 0.09, 95% CI 0.06-0.11 for haemoptysis). History of chronic obstructive pulmonary disease/asthma was also associated with lower odds of guideline concordance (dyspnoea: OR 0.234, 95% CI 0.225-0.242 and haemoptysis: 0.88, 0.79-0.97). Guideline-concordant imaging was lower among dyspnoea presenters with prior heart failure; current or ex-smokers; and those in more socioeconomically disadvantaged groups.The likelihood of lung cancer diagnosis within 12 months was greater among the guideline-concordant imaging group (dyspnoea: 1.1% vs 0.6%; haemoptysis: 3.5% vs 2.7%).

CONCLUSION

The likelihood of receiving urgent imaging concords with the risk of subsequent cancer diagnosis. Nevertheless, large proportions of dyspnoea and haemoptysis presenters do not receive prompt chest imaging despite being eligible, indicating opportunities for earlier lung cancer diagnosis.

In silico design and analysis of a multiepitope vaccine against Chlamydia

Chlamydia trachomatis (Ct) is the most common sexually transmitted bacterial infection worldwide, potentially leading to severe pathologies including pelvic inflammatory disease, ectopic pregnancy, and tubal infertility if left untreated. Current strategies, including screening and antibiotics, have limited effectiveness due to high rates of asymptomatic cases and logistical challenges. A multiepitope prophylactic vaccine could afford long-term protection against infection. Immunoinformatic analyses were employed to design a multiepitope Chlamydia vaccine antigen. B- and T-cell epitopes from five highly conserved and immunogenic Ct antigens were predicted and selected for the vaccine design. The final construct, adjuvanted with cholera toxin A1 subunit (CTA1), was further screened for immunogenicity. CTA1-MECA (multiepitope Chlamydia trachomatis antigen) was identified as antigenic and nonallergenic. A tertiary structure was predicted, refined, and validated as a good quality model. Molecular docking exhibited strong interactions between the vaccine and toll-like receptor 4 (TLR4). Additionally, immune responses consistent with protection including IFN-γ, IgG + IgM antibodies, and T- and B-cell responses were predicted following vaccination in an immune simulation. Expression of the construct in an Escherichia coli expression vector proved efficient. To further validate the vaccine efficacy, we assessed its immunogenicity in mice. Immunization with CTA1-MECA elicited high levels of Chlamydia-specific antibodies in mucosal and systemic compartments.

Chlamydia retesting remains low among young women in Australia: an observational study using sentinel surveillance data, 2018-2022

BACKGROUND

Chlamydia remains the most notified bacterial sexually transmissible infection in Australia with guidelines recommending testing for re-infection at 3months post treatment. This paper aimed to determine chlamydia retesting and repeat positivity rates within 2-4months among young women in Australia, and to evaluate what factors increase or decrease the likelihood of retesting.

METHODS

Chlamydia retesting rates among 16-29-year-old women were analysed from Australian Collaboration for Coordinated Enhanced Sentinel Surveillance of sexually transmissible infection and bloodborne virus (ACCESS) sentinel surveillance data (n =62 sites). Among women with at least one positive test between 1 January 2018 and 31 August 2022, retesting counts and proportions within 2-4months were calculated. Logistic regression was performed to assess factors associated with retesting within 2-4months.

RESULTS

Among 8758 women who were positive before 31 August 2022 to allow time for follow up, 1423 (16.2%) were retested within 2-4months, of whom 179 (12.6%) tested positive. The odds of retesting within 2-4months were 25% lower if tested in a coronavirus disease 2019 (COVID-9) pandemic year (2020-2022) (aOR=0.75; 95% CI 0.59-0.95). Among 9140 women with a positive test before 30 November 2022, 397 (4.3%) were retested too early (within 7days to 1month) and 81 (20.4%) of those were positive.

CONCLUSIONS

Chlamydia retesting rates remain low with around a sixth of women retested within 2-4months in line with guidelines. Re-infection is common with around one in eight retesting positive. An increase in retesting is required to reduce the risk of reproductive complications and onward transmission.

Effects of the enhanced recovery after surgery intervention for preventing postpartum depression: a protocol for systematic review and meta-analysis

INTRODUCTION

Postpartum depression (PPD), a prevalent public health problem, is a debilitating mental disorder for which preventive interventions could yield dramatic benefits. However, viable approach focusing the prevention of PPD for caesarean section (CS) patients remains limited currently. In recent decades, enhanced recovery after surgery (ERAS) has gradually been implemented in CS and appears to be a potential and favourable preventive intervention for PPD, but systematic evidence on this issue is lacking. Therefore, a meta-analysis is designed to systematically explore the potential effect of ERAS on the prevention of PPD in CS patients.

METHODS AND ANALYSIS

Meta-analysis will be performed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses statement. A systematic search across the PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, Chinese Scientific Journal Database, grey literature and Wanfang Database will be conducted from inception to July 2023. Relevant studies investigating the association between ERAS and PPD will be included. Two reviewers will independently carry out the literature selection, data extraction and risk of bias assessment. Disagreements will be resolved by group consensus. Statistical analyses will use the RevMan V.5.3 and STATA V.13 software. The Grading of Recommendations Assessment, Development, and Evaluation system will be used to evaluate the strength of evidence.

ETHICS AND DISSEMINATION

This study raises no ethical issues. The pending meta-analysis may provide reliable evidence supporting ERAS as a viable preventive option for PPD in CS patients, further providing a useful reference for the health authorities and promoting the future clinical practice in this field. The formal results of this study will be submitted to a professional journal for publication.

PROSPERO REGISTRATION NUMBER

CRD42023485929.

Chlamydial YAP activation in host endocervical epithelial cells mediates pro-fibrotic paracrine stimulation of fibroblasts

IMPORTANCE

Chronic or repeated infection of the female upper genital tract by C. trachomatis can lead to severe fibrotic sequelae, including tubal factor infertility and ectopic pregnancy. However, the molecular mechanisms underlying this effect are unclear. In this report, we define a transcriptional program specific to C. trachomatis infection of the upper genital tract, identifying tissue-specific induction of host YAP-a pro-fibrotic transcriptional cofactor-as a potential driver of infection-mediated fibrotic gene expression. Furthermore, we show that infected endocervical epithelial cells stimulate collagen production by fibroblasts and implicate chlamydial induction of YAP in this effect. Our results define a mechanism by which infection mediates tissue-level fibrotic pathology via paracrine signaling and identify YAP as a potential therapeutic target for the prevention of Chlamydia-associated scarring of the female genital tract.

Real-world evaluation of smartphone-based artificial intelligence to screen for diabetic retinopathy in Dominica: a clinical validation study

OBJECTIVE

Several artificial intelligence (AI) systems for diabetic retinopathy screening have been validated but there is limited evidence on their performance in real-world settings. This study aimed to assess the performance of an AI software deployed within the diabetic retinopathy screening programme in Dominica.

METHODS AND ANALYSIS

We conducted a prospective, cross-sectional clinical validation study. Patients with diabetes aged 18 years and above attending the diabetic retinopathy screening in primary care facilities in Dominica from 5 June to 3 July 2021 were enrolled.Grading was done at the point of care by the field grader, followed by counselling and referral to the eye clinic. Images were then graded by an AI system. Sensitivity, specificity with 95% CIs and area under the curve (AUC) were calculated for comparing the AI to field grader as gold standard.

RESULTS

A total of 587 participants were screened. The AI had a sensitivity and specificity for detecting referable diabetic retinopathy of 77.5% and 91.5% compared with the grader, for all participants, including ungradable images. The AUC was 0.8455. Excluding 52 participants deemed ungradable by the grader, the AI had a sensitivity and specificity of 81.4% and 91.5%, with an AUC of 0.9648.

CONCLUSION

This study provides evidence that AI has the potential to be deployed to assist a diabetic screening programme in a middle-income real-world setting and perform with reasonable accuracy compared with a specialist grader.