Anxiety, depression, and body image among infertile women with and without polycystic ovary syndrome

STUDY QUESTION

In women undergoing fertility treatment, do those with polycystic ovary syndrome (PCOS) have a higher prevalence of symptoms of anxiety and depression and lower body appreciation than women without PCOS?

SUMMARY ANSWER

Having PCOS was not associated with symptoms of anxiety and depression but was associated with somewhat lower body appreciation.

WHAT IS KNOWN ALREADY

PCOS has been associated with a higher chance to develop mental health problems, like anxiety, and body image concerns. The International Guidelines on PCOS recommend that all women with PCOS should routinely be screened for anxiety and depressive disorders. In most studies in this field, the comparison group included healthy women without fertility problems.

STUDY DESIGN, SIZE, DURATION

We conducted a cross-sectional survey study between May 2021 and July 2023, using an online questionnaire. We informed women about this study at fertility clinics in the Netherlands through posters and leaflets and on the websites of the Dutch patient organizations Freya and Stichting PCOS.

PARTICIPANTS/MATERIALS, SETTING, METHODS

This study included women with infertility, with and without PCOS, who were undergoing fertility treatment. Women completed two assessment tools: the Hospital Anxiety and Depression Scale (HADS) and the Body Appreciation Scale-2 (BAS-2). Primary outcomes were clinically relevant symptoms of anxiety (score ≥ 11) and depression (score ≥ 11), and BAS-2 scores. Secondary outcomes were mean anxiety and depression scores and anxiety and depression scores of 8 and higher. Dichotomous outcomes and continuous outcomes were analysed using logistic and linear regression analyses adjusted for age, BMI, and duration of infertility.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 1025 women currently undergoing infertility treatment participated, of whom 502 (49.0%) had PCOS and 523 (51.0%) had other infertility diagnoses. We found self-reported clinically relevant symptoms of anxiety in 33.1% of women with PCOS and in 31.0% of women with other infertility diagnoses (adjusted OR: 0.99, 95% CI 0.74-1.31). Clinically relevant symptoms of depression were reported in 15.5% of women with PCOS versus 14.5% of women with other infertility diagnoses (adjusted OR: 1.04, 95% CI 0.71-1.50). Women with PCOS reported slightly less body appreciation (adjusted mean difference: -1.34, 95% CI -2.32 to -0.36).

LIMITATIONS, REASONS FOR CAUTION

Results are based on self-report and may have been affected by sampling bias.

WIDER IMPLICATIONS OF THE FINDINGS

Although guidelines recommend screening women with PCOS, feelings of anxiety and depression can be present in any woman undergoing fertility treatments. We advise fertility clinics to be aware of women's mental health issues and to offer support accordingly, as a part of routine care.

STUDY FUNDING/COMPETING INTEREST(S)

This study did not receive specific funding. All authors report no conflict of interest related to the current research.

TRIAL REGISTRATION NUMBER

This study was pre-registered at OSF: https://osf.io/qbeav.

Evaluating the usability of a co-designed interactive web application for cardiac rehabilitation

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Novartis

Background/significance

The rapid development of information technology is driving the evolution of choices of modes of delivery of healthcare services. The internet is an extremely powerful tool for accessing information, and communication. However, involvement of patients in the assessment of such an intervention is crucial, and can be achieved through a person-centred approach, utilising a co-design process with the aim to increase intervention usability.

Purpose

To assess the usability of the Country Access to Cardiac Health (CATCH) Web, an interactive web application for cardiac rehabilitation (CR), co-designed with rural and remote Australians, following the co-design development phase.

Methods

The User Experience (UX) Design framework was used to co-design the web portal with CR patients through two rounds of six co-design workshops pre (n=39), and post (n=35). Participants and family members living in rural and remote areas of Australia were invited to participate based on their eligibility for CR as outlined by the National Heart Foundation of Australia. As part of the UX Design Framework the System Usability Scale (SUS) was used to measure objective feedback from participants on the website design. The SUS assesses the three core components of a products usability: effectiveness, efficiency and satisfaction using a 10 question Likert scale. Mean scores were compared between the two rounds of workshops using an independent T-Test. The mean SUS score is categorised into poor to moderate (<68), good (68-80.3) and excellent (>=80.3) and categories were compared between the two rounds of workshops through Chi-Square tests.

Results

The 35 participants in the usability workshops had a mean age of 68.6 (SD 11.2) years and 16 (47%) were female (Table 1). The majority had experienced a myocardial infarction (15, 42.8%) and had hyperlipidemia (17, 50%), heart failure (15, 44%), hypertension (14, 41%), and Type II diabetes (7, 21%). Of these participants 20 (59%) used a smart phone, 18 (58%) had access to the National Broadband Network and 20 (59%) engaged with Facebook. From the first to the second round of workshops, there was an improvement in the mean SUS scores from 66.7 (SD16.8) to 73.6 (SD 21.0); p=0.26. The proportion of participants rating it as good or excellent increased from 48.7 to 65.8%; p=0.11 (Figure1).

Conclusion

The usability testing of the interactive CATCH web application showed an improvement in the SUS rating from poor to moderate in the co-design development phase to good or excellent by most of the participants in the usability testing phase. Usability is closely related to engagement with a digital health intervention. Upcoming evaluation of this intervention will report on clinical outcomes.

Telehealth Education And Counselling program to optimise secondary prevention of Heart disease for patients with cardiovascular Disease living in Rural Australia: TEACH-RA study

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): SOLVE CHD Collaboration grant

Introduction

The burden of cardiovascular disease (CVD) is rapidly increasing, however, access to secondary prevention in rural areas is limited. Moreover, rural and remote CVD patients have limited access to primary care and other health services to receive ongoing support and post-discharge follow-up, and this may predispose them to insufficient secondary prevention in terms of a high risk of uncontrolled blood pressure and consequent life-threatening complications including coronary heart disease. Therefore, reform of secondary prevention in rural and remote areas is required to improve reach and access for patients living in such areas, and consequently improve clinical and other health outcomes.

Objective

To evaluate the feasibility of an innovative, tailored telehealth education and counselling program to optimise secondary prevention of CVD in patients living in rural areas in South Australia.

Methods

A quasi experimental study will be conducted by recruiting patients from existing database; country access to cardiac health (CATCH) program. Patients with CVD, aged ≥ 18, enrolled into CATCH program and living in rural and remote South Australia. Sample size is calculated using an online tool and is based on the primary endpoint to detect reduced readmission rate in patients with CVD and cardiac events. Patients with acute coronary syndrome/myocardial infarction, revascularisation procedure, stable and unstable angina, post coronary artery bypass grafting, post cardiac valve replacement surgery, and heart failure will be included. The sample size is calculated using online tool with appropriate statistical assumptions, which gives 113. The intervention of this study consists of two components: 1) delivery of a tailored telehealth counselling and education through telephone by a nurse and 2) use of an iPad application for patient education. Primary outcome is readmission for CVD and cardiac events. Secondary outcomes are knowledge of cardiovascular risk factors, lifestyle modification (e.g. smoking, alcohol, diet and physical exercise), medication adherence, health related quality of life and clinical outcomes such as lipid profile and blood pressure.

Conclusion

TEACH-RA study will test the feasibility of a tailored telehealth education and counselling program in patients with cardiac conditions living in rural and remote areas.

Assessing the quality of cardiac rehabilitation programs by measuring adherence to the Australian quality indicators

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Australian National Health and Medical Research Council (NHMRC)

Background

Cardiac rehabilitation (CR) prevents recurrent cardiac events and supports patients’ return to an active and fulfilling lifestyle. Evidence on the efficacy of CR programs is well established, but variability of quality across programs may compromise patient outcomes. Core components, quality indicators (QIs) and accreditation of programs have been introduced internationally to increase program standardisation, quality and outcomes. (1) The Australian Cardiovascular Health and Rehabilitation Association (ACRA) and National Heart Foundation (NHF) recently published 10 QIs for CR, comprising process and outcome indicators that can guide delivery of evidence-based service content (Figure 1). (2)

Purpose

The aim was to assess the performance of CR programs in Australia through their adherence to the measurement of the Australian QIs.

Methods

A cross-sectional survey design with face validity testing was used to formulate questions to evaluate CR program performance based on adherence to 9 of the 10 Australian QIs. Between October 2020- December 2021, all 23 CR programs across country and metropolitan areas of South Australia (SA) participated. In addition, each QI was weighted by an expert group of clinician researchers and a service performance score was calculated out of 16. According to the score quartiles, programs could be categorised across 4 performance levels: Poor (0-4.5), Low (5-8.5), Medium (9-12.5) or High (13-16).

Results

Among the 23 participating CR programs, median wait time from discharge to enrolment (QI-2) was 27 days, (interquartile range 19.0-46.0) and completions of enrolled were 66% (n=1316 /1972). All QIs were measured, but not by all programs. Pre-program QI adherence was higher than post program for depression, medication adherence, health-related quality of life and comprehensive re-assessment (Figure 1). Health-related quality of life (HRQOL) was poorly measured pre and post program (21.7% versus 17.3%). For functional exercise capacity assessment, the six-minute walk test was used by 69.5% of programs. Mean performance score was 11.4 /16 (SD ±0.79). Most (74%) programs were ranked at a medium level of performance, whereas 13% were ranked at low and high levels and none as poor.

Conclusions

A survey of 23 CR programs showed gaps in adherence to measurement of the ACRA/NHF Quality indicators in SA, including re-assessment (QI9), HRQOL (QI-8), medication adherence (QI-6) and exercise capacity (QI-7). Service performance scores were lower than an Australian national audit for each category, with United Kingdom data showing more services in the high and less in the medium category than SA. These data give us a baseline from which to improve CR service quality and outcomes.

Photoplethysmography telemonitoring during the first week after atrial fibrillation ablation: Feasibility and clinical implications

Funding Acknowledgements

Type of funding sources: None.

The incidence of early atrial fibrillation (AF) recurrence within the first week after AF ablation and its predictive value for late AF recurrences are unclear. TeleCheck-AF is a remote on-demand mobile health (mHealth) infrastructure, which is based on a mobile phone app using photoplethysmography (PPG) technology (Fibricheck) allowing rate and rhythm monitoring through teleconsultations. The feasibility and clinical implications of PPG telemonitoring specifically during the first week after atrial fibrillation ablation is unknown.

Methods

Within the TeleCheck-AF project, the Medical University offered a total of 382 consecutive patients undergoing AF ablation (between June 1st 2020 and December 15th 2021) photoplethysmography (PPG) telemonitoring with "FibriCheck" during the first week after the ablation procedure. Patients received a QR code for activation of the software on their smartphone and were connected to the clinician’s telemedicine portal. They were instructed to perform rhythm monitoring three times per day and in case of symptoms. Clinicians assessed the tracings and contacted the patients if therapeutic steps were indicated.

Results

In total, 119 patients (31%) agreed to perform telemonitoring after ablation. Patients undergoing telemonitoring were younger compared to those who refused participation (58±10years vs. 62±10years, p<0.001). 34% were female, median CHA2DS2-VASc-Score was 1 (0-6). 62% of patients had paroxysmal AF and 37% had persistent AF. One of four patients (24%) had already undergone previous ablations. Most index ablations were radiofrequency ablations (89%; 7% cryo; 4% pulsed field ablation). Median follow up duration was 281 (16-620) days.

27% of patients had tracings suggestive of AF in the week following the index ablation. Telemonitoring resulted in clinical interventions ins 24% of patients: amiodarone was started in 8%, class I antiarrhythmic drugs were up titrated in 7%, cardioversion was scheduled in 5%, antiarrhythmic drugs were reduced due to symptomatic bradycardia in 3% of patients.

During follow-up, 22% of patients had ECG-documented AF recurrences. PPG recordings suggestive of AF in the week after ablation were predictive of late recurrences (p<0.001).

Conclusion

Rhythm monitoring with a PPG-based mHealth application was feasible and often resulted in clinical interventions. Due to its high availability, PPG-based follow-up actively involving patients after AF ablation may close a diagnostic and prognostic gap and increase active patient-involvement.

Figure 1: Schematic overview of the telemonitoring process. After the ablation, the patient measures PPGs for one week, dashboard view for clinician shows regular rhythm (green, atrial fibrillation (red) and unclear tracings (blue).

Performance of STOP-BANG questionnaire as sleep apnoea screening tool and development of a novel pre-selection model in patients with atrial fibrillation - insights from the Virtual-SAFARI study

Funding Acknowledgements

Type of funding sources: None.

Background

Sleep-disordered breathing (SDB) is highly prevalent in patients with atrial fibrillation (AF) and its screening is recommended in this population. The STOP-BANG questionnaire is widely used as SDB screening tool, but the subjective assessment of some of its parameters might limit its validity to detect SDB in AF patients.

Purpose

We assessed the performance of the STOP-BANG questionnaire to detect SDB with the use of a mobile health-based portable home sleep test given as reference in a cohort of AF patients. Moreover, we explored options to improve pre-selection for SDB screening in this cohort.

Methods

Consecutive AF patients who were referred for AF catheter ablation in two AF outpatient clinics and without previous history of SDB and/or SDB screening, were included prospectively. Patients characteristics together with STOP-BANG questionnaire were assessed at baseline visitation. STOP-BANG scores of 3-4 and 5-8 were interpreted as intermediate and high risk for SDB, respectively. All patients were digitally referred to a virtual SDB management pathway, independent of STOP-BANG score. Patients received a portable home sleep test to detect SDB, which patients used for one night at home after instructions. Sleep recordings were accessed by sleep physicians via a secured cloud and sleep reports were discussed with patients and referring physicians. Apnoea-hypopnoea-indexes (AHI) of >=15 and of >= 30 were interpreted as moderate-to-severe and severe SDB, respectively. Results of the STOP-BANG and the home sleep test were compared and performance of the STOP-BANG questionnaire was assessed. Uni- and multivariable logistic regression analyses based on patient characteristics were used to construct a nomogram to improve pre-selection for SDB screening in this cohort.

Results

A total of 156 patients (median age 65 years, 63.8% male) were included. According to results from the home sleep test, 53% of patients were diagnosed with moderate-to-severe SDB, including 16% with severe SDB. STOP-BANG questionnaire performed poorly with an area under the receiver operating characteristic curve (AUROC) of 0.661 and 0.684 in predicting moderate-to-severe and severe SDB, respectively. On multivariable logistic analysis, independent predictors for moderate-to-severe SDB were body-mass-index (BMI), age and apnoeas. A nomogram was built on this variables (Fig. 1), which performed good with an AUROC of 0.728 in predicting moderate-to-severe SDB.

Conclusion

In a cohort of AF patients scheduled for AF catheter ablation, SDB was highly prevalent. STOP-BANG questionnaire had poor value for the prediction of moderate-to-severe and severe SDB compared to a systematical SDB screening via home sleep test. Using STOP-BANG questionnaire as a pre-selection tool might lead to frequently undetected and untreated SDB. Whether the nomogram based on our analyses improves pre-selection for SDB screening in AF patients will be validated in a future cohort.

Estimates of variance components for feedlot traits of the Simmentaler breed in South Africa

Breeding of beef cattle is changing, with more emphasis on efficiency of production. Feed cost is the highest expense, and reducing it has the potential to increase profitability. Common measures of efficiency are ratio traits such as feed conversion (feed consumed/weight gain) and feed efficiency (weight gain / feed consumed). Feed conversion ratio is commonly used in South Africa in an attempt to improve feed efficiency. These ratio traits are associated with growth rate. Selection for them would result in higher growth as a correlated response and might also increase the mature size of the cows and their maintenance cost. Thus, alternative efficiency traits such as residual feed intake and residual daily gain have been proposed. In this study, variance components, and genetic parameters for feedlot traits for the South African Simmentaler breed were estimated, with emphasis on the efficiency traits. The focus was to evaluate the use of residual feed intake as an alternative trait. The results indicate non-significant correlations between residual feed intake and body weight and growth traits, implying that residual feed intake should have little effect on the other traits. This is in contrast to the moderate to strong correlations of feed conversion ratio with the same traits. The study demonstrates that considerable genetic variation exists for residual feed intake, which can be exploited. Selection for residual feed intake can reduce the carbon footprint of beef due to the associated lower methane emissions.

Self-perceived heart disease risk assessment in patients with hypertension

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): The University of Adelaide supported fieldwork

Introduction

Heart disease is the leading cause of morbidity and mortality worldwide. The risk of heart disease is significantly high among patients with hypertension. However, patients’ poor understanding of their risk even further intensifies the risk of heart disease. Therefore it is crucial to improve patients’ understanding of their lifetime risk and applying a healthy lifestyle, to reduce the risk of heart disease.

Purpose

The aim of this study was to explore self-perceived heart disease risk and knowledge of heart disease risk factors in patients with hypertension.

Methods

A cross-sectional study was conducted in patients with a confirmed diagnosis of hypertension who attended follow up care clinics at two referral hospitals in eastern Ethiopia. Data were collected through face-to-face interviews using two validated instruments (ABCD risk questionnaire for assessment of self-perceived risk and heart disease fact questionnaire for assessment of knowledge of cardiovascular risk factors). Data analysis was conducted using SPSS version 25, and descriptive and correlation analysis were conducted.

Results

A total of 203 patients were included in the study, 60% of them were females, and the mean age was 50 ± 9 years. The majority 143 (70.4%) perceived their future heart disease risk as low, however 60 (29.6%) perceived their future chance of developing heart disease as moderate. The mean heart disease risk factors knowledge score was 72.3 + 13.7, and more than half (57%) had optimal knowledge of heart disease risk factors (scored ≥70%), whereas, the remaining 43% had sub-optimal knowledge. Moreover, there is a statistically significant positive association between self-perceived heart disease risk and knowledge of heart disease risk factors (r = 0.28, p= 0.00).

Conclusion

Despite being at high risk, many patients with hypertension underestimate the chance of developing heart disease in their lifetime. Implementation of interventions to promote healthy lifestyle behaviour is crucial to prevent heart disease risk as well as to improve patient’s understanding of these risks.

The TeleCheck-AF project on remote app-based management of atrial fibrillation during the COVID-19 pandemic: Patient experiences

Funding Acknowledgements

OnBehalf

Aims

Methods

Results

Conclusions

Remote app-based management of atrial fibrillation during the COVID-19: The centre characteristics and experiences of the European TeleCheck-AF project

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

TeleCheck-AF Investigators

Aims

Herein we describe the characteristics, inclusion rates and experiences from participating centres in the European TeleCheck-AF project. TeleCheck-AF is a multicentre international project initiated to maintain care delivery for patients with atrial fibrillation (AF) during COVID-19 through teleconsultations supported by an on-demand photoplethysmography-based heart rate and rhythm monitoring app (FibriCheck®). 

Methods

Two surveys exploring centre characteristics (n = 25) and centre experiences (n = 23) were completed.

Results

Most centres were academic (64%) and specialized public cardiology/district hospitals (36%). Majority of centres had AF outpatient clinics (64%) and only 36% had AF ablation clinics. The time required to start patient inclusion and total number of included patients in the project was comparable for centres experienced (56%) or inexperienced in mHealth use. Within 28 weeks, 1930 AF patients were recruited, mainly for remote AF control (31% of patients) and AF ablation follow-up (42%). Average inclusion rate was highest during the lockdown restrictions and reached a steady state at a lower level after easing the restrictions (188 vs 52 weekly recruited patients). Majority (>80%) of the centres reported no problems during the implementation of the TeleCheck-AF approach. Centres agreed that the on-boarding process of their center in the TeleCheck-AF project was simple and access to the patients measurements via stand-alone cloud infrastructure was trouble-free and possible from the first day on. They also agreed that remote heart rate and rhythm assessment by the FibriCheck® app around teleconsulatation supported their medical decision making; that their patients responded positively to use FibriCheck® for seven days; and that they felt comfortable to interpret PPG recordings. 

Conclusions

Despite different health care settings and mHealth experiences, the TeleCheck-AF approach could be set up within an extremely short time and easily used in different European centres during COVID-19.

P3794MOODS: a novel risk score to identify patients with atrial fibrillation and sleep apnoea

Background

Sleep-disordered breathing (SDB) is an important risk factor for developing atrial fibrillation (AF), and treatment of concomitant SDB can improve AF rhythm outcomes. Diagnosis of SDB requires sleep studies which can pose a significant time and resource burden. We sought to develop a prediction score based on clinical characteristics that can help identify AF patients who require further assessment for SDB.

Methods

Prospectively-collected data for 442 consecutive patients treated for AF from 2009 to 2017 were analysed. All patients were considered candidates for rhythm-control and therefore referred for sleep studies. The diagnosis of SDB was confirmed using in-lab polysomnography and classified using the apnoea-hypopnoea-index (AHI), with cut-offs of ≥15/hr and ≥30/hr indicating moderate-to-severe and severe SDB respectively. Patients treated up to 2015 formed the derivation cohort (n=311) and the remainder (n=113) formed the validation cohort. Multivariate logistic regression analysis was used to identify clinical variables predictive of moderate-to-severe SDB. A risk score model was developed based on regression coefficients and tested using receiver-operating-characteristics analyses on the validation cohort.

Results

Overall, mean age was 60±11 years, mean body mass index (BMI) was 30±5 kg/m2 and 69% were men. The prevalence of moderate-to-severe SDB was 33.7%. There were no significant differences in baseline characteristics between the derivation and validation cohorts. Male gender (score=1), overweight (BMI: 25–29 kg/m2, score=2), obesity (BMI≥30 kg/m2, score=3), diabetes (score=1), and stroke (score=2) were significantly independently predictive of moderate-to-severe SDB and formulated the score. The score performed well to predict moderate-to-severe SDB with a C-statistic of 0.73 (95% CI: 0.67–0.79, P<0.001) in the derivation cohort, and 0.67 (95% CI: 0.57–0.77, P<0.001) in the validation cohort. As a rule-out test, a score of ≤3 had a negative predictive value of 77% for moderate-to-severe SDB (91% for severe SDB). A score of ≥4 had an intermediate positive likelihood ratio (PLR) of 2 for moderate-to-severe SDB (2.2 for severe SDB), while a score of ≥5 had a high PLR of 6.5 and 6.8 for moderate-to-severe SDB and severe SDB respectively.

Sensitivity and specificity table

Conclusion

A novel risk score comprising clinical characteristics can identify patients with AF likely to benefit from further assessment for SDB. Application of this model may aid optimise resource utilisation and facilitate timely patient care.

2199Cardiovascular risk behaviour is an emerging health issue in developing countries

Background

Previously, cardiovascular disease (CVD) was considered the “Disease of the Rich”, however nowadays also populations with low socioeconomic status have been identified at increased risk of developing CVD. The global progress in CVD prevention is scarce particularly in developing countries, which are facing a high burden of CVD whilst there is limited availability of resources and evidence to educate and modify lifestyle behaviours in the population. Moreover, there is a lack of infrastructure and policy making in these countries.

Purpose

The goal of the study was to quantify the prevalence of different cardiovascular risk behaviours among patients with known cardiovascular conditions in a developing countries.

Methods

A hospital based cross-sectional survey was conducted in two referral hospitals in Ethiopia. Outpatient unit patients who had a confirmed diagnosis of CVD were eligible for participation in the study. Data were collected through face-to-face interviews with patients using validated tools; WHO STEPs instrument and international physical activity questionnaire.

Results

A total of 287 CVD patients were recruited, 56% were females and 90% were urban residents. All patients had inadequate consumption of fruit and vegetables, 20% were current khat chewers, 19% were current alcohol drinkers and only 1% were current smokers. The prevalence of low physical activity (defined as less than 600 MET-minutes per week) in the total population was 51.6% for both sexes; more than half of the total population were physically inactive. Moreover, females had a significantly higher prevalence of physical inactivity as compared to males, 58% vs 43.2%, P=0.017. Approximately one-third (30%) of patients had only one of these risk behaviours, more than half (52%) had two, 18% had three or more risk behaviours. The majority (70%) of the patients had multiple risk behaviours (Table 1), the prevalence of these did not significantly vary with sex, residence and educational level (p>0.05).

Conclusion

Patients with CVD maintain unhealthy lifestyles even though attending follow up care with a specific focus on risk management. The findings of this study demonstrate a high prevalence of physical inactivity, alcohol consumption and inadequate fruit and vegetable consumption in developing countries. The emerging increase of CVD and the continuation of unhealthy lifestyle in patients is somewhat comparable with western countries, demonstrating an emerging global problem. Moreover, this study shows the existing follow-up care is ineffective and provides evidence for policy makers that health services reform is required. Implementation of lifestyle support programs should be considered for the disease prevention policy agenda in developing countries.

A genome-wide association study of anorexia nervosa

Anorexia nervosa (AN) is a complex and heritable eating disorder characterized by dangerously low body weight. Neither candidate gene studies nor an initial genome-wide association study (GWAS) have yielded significant and replicated results. We performed a GWAS in 2907 cases with AN from 14 countries (15 sites) and 14 860 ancestrally matched controls as part of the Genetic Consortium for AN (GCAN) and the Wellcome Trust Case Control Consortium 3 (WTCCC3). Individual association analyses were conducted in each stratum and meta-analyzed across all 15 discovery data sets. Seventy-six (72 independent) single nucleotide polymorphisms were taken forward for in silico (two data sets) or de novo (13 data sets) replication genotyping in 2677 independent AN cases and 8629 European ancestry controls along with 458 AN cases and 421 controls from Japan. The final global meta-analysis across discovery and replication data sets comprised 5551 AN cases and 21 080 controls. AN subtype analyses (1606 AN restricting; 1445 AN binge-purge) were performed. No findings reached genome-wide significance. Two intronic variants were suggestively associated: rs9839776 (P=3.01 × 10(-7)) in SOX2OT and rs17030795 (P=5.84 × 10(-6)) in PPP3CA. Two additional signals were specific to Europeans: rs1523921 (P=5.76 × 10(-)(6)) between CUL3 and FAM124B and rs1886797 (P=8.05 × 10(-)(6)) near SPATA13. Comparing discovery with replication results, 76% of the effects were in the same direction, an observation highly unlikely to be due to chance (P=4 × 10(-6)), strongly suggesting that true findings exist but our sample, the largest yet reported, was underpowered for their detection. The accrual of large genotyped AN case-control samples should be an immediate priority for the field.

BRAVISSIMO: 12-month results from a large scale prospective trial

The BRAVISSIMO study is a prospective, non-randomized, multi-center, multi-national, monitored trial, conducted at 12 hospitals in Belgium and 11 hospitals in Italy. This manuscript reports the findings up to the 12-month follow-up time point for both the TASC A&B cohort and the TASC C&D cohort. The primary endpoint of the study is primary patency at 12 months, defined as a target lesion without a hemodynamically significant stenosis on Duplex ultrasound (>50%, systolic velocity ratio no greater than 2.0) and without target lesion revascularization (TLR) within 12 months. Between July 2009 and September 2010, 190 patients with TASC A or TASC B aortoiliac lesions and 135 patients with TASC C or TASC D aortoiliac lesions were included. The demographic data were comparable for the TASC A/B cohort and the TASC C/D cohort. The number of claudicants was significantly higher in the TASC A/B cohort, The TASC C/D cohort contains more CLI patients. The primary patency rate for the total patient population was 93.1%. The primary patency rates at 12 months for the TASC A, B, C and D lesions were 94.0%, 96.5%, 91.3% and 90.2% respectively. No statistical significant difference was shown when comparing these groups. Our findings confirm that endovascular therapy, and more specifically primary stenting, is the preferred treatment for patients with TASC A, B, C and D aortoiliac lesions. We notice similar endovascular results compared to surgery, however without the invasive character of surgery.

On the Configurational and Conformational Changes in Photoactive Yellow Protein that Leads to Signal Generation in Ectothiorhodospira halophila

Photoactive Yellow Protein (PYP), a phototaxis photoreceptor from Ectothiorhodospira halophila, is a small water-soluble protein that iscrystallisable and excellently photo-stable. It can be activated with light(λ(max)= 446 nm), to enter a series of transientintermediates that jointly form the photocycle of this photosensor protein.The most stable of these transient states is the signalling state forphototaxis, pB.The spatial structure of the ground state of PYP, pG and the spectralproperties of the photocycle intermediates have been very well resolved.Owing to its excellent chemical- and photochemical stability, also the spatialstructure of its photocycle intermediates has been characterised with X-raydiffraction and multinuclear NMR spectroscopy. Surprisingly, the resultsobtained showed that their structure is dependent on the molecular contextin which they are formed. Therefore, a large range of diffraction-,scattering- and spectroscopic techniques is now being employed to resolvein detail the dynamical changes of the structure of PYP while it progressesthrough its photocycle. This approach has led to considerable progress,although some techniques still result in mutually inconsistent conclusionsregarding aspects of the structure of particular intermediates.Recently, significant progress has also been made with simulations withmolecular dynamics analyses of the initial events that occur in PYP uponphoto activation. The great challenge in this field is to eventually obtainagreement between predicted dynamical alterations in PYP structure, asobtained with the MD approach and the actually measured dynamicalchanges in its structure as evolving during photocycle progression.

The clinical benefit of blood transfusion: a hypothetical experiment based on a nationwide survey of severe maternal morbidity

BACKGROUND

It is beyond doubt that blood transfusion services have added to the decline in maternal mortality in high-resource countries. To quantify the clinical benefit of red blood cell (RBC) transfusion in obstetric care, we performed a hypothetical experimental study using data from a prospective nationwide cohort of women giving birth in the Netherlands.

STUDY DESIGN AND METHODS

Data were abstracted from a nationwide cohort study on severe maternal morbidity, including obstetric haemorrhage requiring 4 or more units of RBC, to obtain an observed and a hypothetical control group consisting of the same women. In the hypothetical control group, we simulated a situation where RBC transfusion was unavailable and estimated how many of these women would have died in that situation. A questionnaire survey asked experts in major (obstetric) haemorrhage to choose a critical minimal number of RBC transfusions at which a woman with obstetric haemorrhage would have died if RBC transfusion was not available. Maternal mortality rate per 100,000 maternities [maternal mortality ratios (MMR)] and relative risk were calculated for the observed and hypothetical group.

RESULTS

The observed MMR was 13 per 100,000 maternities. According to 47 responding experts, the median number of RBC units without which a woman would have most probably died was nine, resulting in a hypothetical MMR of 87 per 100,000 maternities (relative risk 6·5; 95% confidence interval 4·2-10·0).

CONCLUSIONS

It can be expected that unavailability of RBC transfusion in obstetric care increases the risk of maternal death 6.5-fold. Blood transfusion thus largely contributes to the decline of MMR and would also be an important pillar of improving quality of care in resource-poor settings.

Spontaneous ilio-iliac arteriovenous fistula due to an iliac artery aneurysm: a case-report

A spontaneous arterio-venous ilioiliac fistula (AVF) caused by an iliac artery aneurysm (IAA) is a rare complication. We present the case of a 75-year-old man with previous aortic surgery 11 years before who was admitted at the Emergency Department for acute gluteal pain. He was suspected for a hip problem because of cup loosening on X-ray. A lumbar CT-scan to rule out nerve compression showed an aneurysm of the left common and internal iliac artery that was ruptured into the iliac vein. The AVF was treated endovascularly under local anesthesia by a sandwich technique (covered stent at the venous side and coils at the arterial side) with good results. The case demonstrates that lifelong follow-up of a patient with previous aortic surgery is mandatory.