Principles for management of hip fracture for older adults taking direct oral anticoagulants: an international consensus statement

Hip fracture is a common serious injury among older adults, yet the management of hip fractures for patients taking direct oral anticoagulants remains inconsistent worldwide. Drawing from a synthesis of available evidence and expert opinion, best practice approaches for managing patients with a hip fracture and who are taking direct oral anticoagulants pre-operatively were considered by a working group of the Fragility Fracture Network Hip Fracture Audit Special Interest Group. The literature and related clinical guidelines were reviewed and a two-round modified Delphi study was conducted with a panel of experts from 16 countries and involved seven clinical specialities. Four consensus statements were achieved: peripheral nerve blocks can reasonably be performed on presentation for patients with hip fracture who are receiving direct oral anticoagulants; hip fracture surgery can reasonably be performed for patients taking direct oral anticoagulants < 36 h from last dose; general anaesthesia could reasonably be administered for patients with hip fracture and who are taking direct oral anticoagulants < 36 h from last dose (assuming eGFR > 60 ml.min-1.1.73 m-2); and it is generally reasonable to consider recommencing direct oral anticoagulants (considering blood loss and haemoglobin) < 48 h after hip fracture surgery. No consensus was achieved regarding timing of spinal anaesthesia. The consensus statements were developed to aid clinicians in their decision-making and to reduce practice variations in the management of patients with hip fracture and who are taking direct oral anticoagulants. Each statement will need to be considered specific to each individual patient's treatment.

Triarylphosphine-Coordinated Bipyridyl Ru(II) Complexes Induce Mitochondrial Dysfunction

While cancer cells rely heavily upon glycolysis to meet their energetic needs, reducing the importance of mitochondrial oxidative respiration processes, more recent studies have shown that their mitochondria still play an active role in the bioenergetics of metastases. This feature, in combination with the regulatory role of mitochondria in cell death, has made this organelle an attractive anticancer target. Here, we report the synthesis and biological characterization of triarylphosphine-containing bipyridyl ruthenium (Ru(II)) compounds and found distinct differences as a function of the substituents on the bipyridine and phosphine ligands. 4,4'-Dimethylbipyridyl-substituted compound 3 exhibited especially high depolarizing capabilities, and this depolarization was selective for the mitochondrial membrane and occurred within minutes of treatment in cancer cells. The Ru(II) complex 3 exhibited an 8-fold increase in depolarized mitochondrial membranes, as determined by flow cytometry, which compares favorably to the 2-fold increase observed by carbonyl cyanide chlorophenylhydrazone (CCCP), a proton ionophore that shuttles protons across membranes, depositing them into the mitochondrial matrix. Fluorination of the triphenylphosphine ligand provided a scaffold that maintained potency against a range of cancer cells but avoided inducing toxicity in zebrafish embryos at higher concentrations, displaying the potential of these Ru(II) compounds for anticancer applications. This study provides essential information regarding the role of ancillary ligands for the anticancer activity of Ru(II) coordination compounds that induce mitochondrial dysfunction.

A monoadduct generating Ru(ii) complex induces ribosome biogenesis stress and is a molecular mimic of phenanthriplatin

Ruthenium complexes are often investigated as potential replacements for platinum-based chemotherapeutics in hopes of identifying systems with improved tolerability in vivo and reduced susceptibility to cellular resistance mechanisms. Inspired by phenanthriplatin, a non-traditional platinum agent that contains only one labile ligand, monofunctional ruthenium polypyridyl agents have been developed, but until now, few demonstrated promising anticancer activity. Here we introduce a potent new scaffold, based on [Ru(tpy)(dip)Cl]Cl (tpy = 2,2':6',2''-terpyridine and dip = 4,7-diphenyl-1,10-phenanthroline) in pursuit of effective Ru(ii)-based monofunctional agents. Notably, the extension of the terpyridine at the 4' position with an aromatic ring resulted in a molecule that was cytotoxic in several cancer cell lines with sub-micromolar IC50 values, induced ribosome biogenesis stress, and exhibited minimal zebrafish embryo toxicity. This study demonstrates the successful design of a Ru(ii) agent that mimics many of the biological effects and phenotypes seen with phenanthriplatin, despite numerous differences in both the ligands and metal center structure.

OakEcol: A database of Oak-associated biodiversity within the UK

Globally there is increasing concern about the decline in the health of oak Quercus trees. The impact of a decline in oak trees on associated biodiversity, species that utilize oak trees, is unknown. Here we collate a database of all known birds, bryophytes, fungi, invertebrates, lichens and mammals that use oak (Quercus petraea and Q. robur) in the UK. In total 2300 species are listed in the database. For each species we provide a level of association with oak, ranging from obligate (only found on oak) to cosmopolitan (found on a wide range of other tree species). Data on the ecology of each oak associated species was collated: part of tree used, use made of tree (feeding, roosting, breeding), age of tree, woodland type, tree form (coppice, pollarded, or natural growth form) and season when the tree was used. Data on use or otherwise by each of the 2300 species of 30 other tree species was also collated. A complete list of data sources is provided. For further insights into how this data can be used see Collapsing foundations: The ecology of the British oak, implications of its decline and mitigation options [1]. Data can be found at EIDC https://doi.org/10.5285/22b3d41e-7c35-4c51-9e55-0f47bb845202.

Models of care that avoid or improve transitions to hospital services for residential aged care facility residents: An integrative review

Care transitions for older people moving from residential aged care facilities (RACFs) to hospital services are associated with greater challenges and poorer outcomes. An integrative review was conducted to investigate models of care designed to avoid or improve transitions for older people residing in RACFs to hospital settings. Twenty-one studies were included in the final analysis. Models of care aimed to either improve or avoid transitions of residents through enhanced primary care in RACFs, promoting quality improvement in RACFs, instilling comprehensive hospital care, conducting outreach services, transferring information, or involved a combination of outreach services and comprehensive hospital care. As standalone interventions, standardised communication tools may improve information transfer between RACFs and hospital services. For more complex models, providing quality improvement and outreach to RACFs may prevent some types of hospital admissions.

Productivity and species richness in longleaf pine woodlands: resource-disturbance influences across an edaphic gradient

This study examines the complex feedback mechanisms that regulate a positive relationship between species richness and productivity in a longleaf pine-wiregrass woodland. Across a natural soil moisture gradient spanning wet-mesic to xeric conditions, two large scale manipulations over a 10-yr period were used to determine how limiting resources and fire regulate plant species diversity and productivity at multiple scales. A fully factorial experiment was used to examine productivity and species richness responses to N and water additions. A separate experiment examined standing crop and richness responses to N addition in the presence and absence of fire. Specifically, these manipulations addressed the following questions: (1) How do N and water addition influence annual aboveground net primary productivity of the midstory/overstory and ground cover? (2) How do species richness responses to resource manipulations vary with scale and among functional groups of ground cover species? (3) How does standing crop (including overstory, understory/midstory, and ground cover components) differ between frequently burned and fire excluded plots after a decade without fire? (4) What is the role of fire in regulating species richness responses to N addition? This long-term study across a soil moisture gradient provides empirical evidence that species richness and productivity in longleaf pine woodlands are strongly regulated by soil moisture. After a decade of treatment, there was an overall species richness decline with N addition, an increase in richness of some functional groups with irrigation, and a substantial decline in species richness with fire exclusion. Changes in species richness in response to treatments were scale-dependent, occurring primarily at small scales (≤10 m² ). Further, with fire exclusion, standing crop of ground cover decreased with N addition and non-pine understory/midstory increased in wet-mesic sites. Non-pine understory/midstory standing crop increased in xeric sites with fire exclusion, but there was no influence of N addition. This study highlights the complexity of interactions among multiple limiting resources, frequent fire, and characteristics of dominant functional groups that link species richness and productivity.

Green space and cognitive ageing: A retrospective life course analysis in the Lothian Birth Cohort 1936

International evidence suggests that green space has beneficial effects on general and mental health but little is known about how lifetime exposure to green space influences cognitive ageing. Employing a novel longitudinal life course approach, we examined the association between lifetime availability of public parks and cognitive ageing. Lifetime residential information was gathered from the participants of the Lothian Birth Cohort 1936 using a "life-grid" questionnaire at age 78 years. Parks information from 1949, 1969 and 2009 was used to determine a percentage of parks within a 1500 m buffer zone surrounding residence for childhood, adulthood, and later adulthood periods. Linear regressions were undertaken to test for association with age-standardised, residualised change in cognitive function (Moray House Test score) from age 11 to 70 years, and from age 70 to 76 (n = 281). The most appropriate model was selected using the results of a partial F-test, and then stratified by demographic, genetic and socioeconomic factors. The local provision of park space in childhood and adulthood were both important in explaining the change in cognitive function in later life. The association between childhood and adulthood park availability and change in the Moray House Test Score from age 70 to 76 was strongest for women, those without an APOE e4 allele (a genetic risk factor), and those in the lowest socioeconomic groups. Greater neighbourhood provision of public parks from childhood through to adulthood may help to slow down the rate of cognitive decline in later life, recognising that such environmental associations are always sensitive to individual characteristics.

Enhanced sensitivity and responses to viologens from a whole-cell bacterial bioreporter treated with branched polyethyleneimines

AIMS

Evaluate the use of polyethyleneimines (PEIs) as membrane permeabilizers to improve the responses and sensitivity of a bacterial bioreporter strain to viologens.

METHODS AND RESULTS

The responses from E. coli str. EBS, i.e., E. coli BW25113 carrying plasmid pSDS, when exposed to five different viologens were characterized, as were the toxicities of seven different PEIS, including two linear and five branched species. Based on these results, benzyl viologen led to the greatest responses, and 0·8-kDa branched PEI (BPEI) was the least toxic of the PEIs tested and, therefore, both were selected for the subsequent tests. The bioluminescence and relative responses from E. coli str. EBS exposed to various concentrations of 0·8 kDa BPEI identified 400 mg l^-1 as the optimal concentration. Using this concentration, tests were performed with all five of the viologens.

CONCLUSIONS

The responses from E. coli str. EBS to the viologens were improved, with the maximum relative bioluminescence values increasing between 5·6 and 16·5-fold. The minimum detectable levels for four of the viologens were likewise improved 2- to 4-fold.

SIGNIFICANCE AND IMPACT OF STUDY

Improving bacterial membrane permeability in a controlled manner using BPEIs can improve biosensing of toxic compounds, as well as be used in biofuel and bioenergy applications where membrane permeability to a solute is important.

The relationship between wealth and loneliness among older people across Europe: Is social participation protective?

OBJECTIVE

1. Examine the relationship between household wealth, social participation and loneliness among older people across Europe. 2. Investigate whether relationships vary by type of social participation (charity/volunteer work, sports/social clubs, educational/training course, and political/community organisations) and gender. 3. Examine whether social participation moderates the association between wealth and loneliness.

METHODS

Data (N=29,795) were taken from the fifth wave of the Survey of Health, Ageing and Retirement in Europe (SHARE), which was collected during 2013 from 14 European countries. Loneliness was measured using the short version of the Revised-University of California, Los Angeles (R-UCLA) Loneliness Scale. We used multilevel logistic models stratified by gender to examine the relationships between variables, with individuals nested within countries.

RESULTS

The risk of loneliness was highest in the least wealthy groups and lowest in the wealthiest groups. Frequent social participation was associated with a lower risk of loneliness and moderated the association between household wealth and loneliness, particularly among men. Compared to the wealthiest men who often took part in formal social activities, the least wealthy men who did not participate had greater risk of loneliness (OR=1.91, 95% CI: 1.44 to 2.51). This increased risk was not observed among the least wealthy men who reported frequent participation in formal social activities (OR=1.12, 95% CI: 0.76 to 1.67).

CONCLUSION

Participation in external social activities may help to reduce loneliness among older adults and potentially acts as a buffer against the adverse effects of socioeconomic disadvantage.

Social protection spending and inequalities in depressive symptoms across Europe

PURPOSE

Common mental disorders are an increasing global public health concern. The least advantaged in society experience a greater burden of mental illness, but inequalities in mental health vary by social, political, and economic contexts. This study investigates whether spending on different types of social protection alters the extent of social inequality in depressive symptoms.

METHODS

Data were obtained from the 2006 and 2012 cross-sectional waves of the European Social Survey, which included 48,397 individuals from 18 European countries. Depressive symptoms were measured using the Centre for Epidemiologic Studies-Depression Scale (CES-D 8). Statistical interactions between country-level social protection spending and individuals' education level, employment and family status were explored using multilevel regression models.

RESULTS

Higher spending on active labour market programmes was related to narrower inequality in depressive symptoms by education level. Compared to men with high education, the marginal effect of having low education was 1.67 (95 % CI, 1.46-1.87) among men in countries with lower spending and 0.85 (95 % CI, 0.66-1.03) in higher spending countries. Single parents exhibited fewer depressive symptoms, as spending on family policies increased. Little evidence was found for an overall association between spending on unemployment benefits and employment-related inequalities in depressive symptoms, but in 2012, unemployment spending appeared beneficial to mental health among the unemployed.

CONCLUSIONS

Greater investment in social protection may act to reduce inequalities in depressive symptoms. Reductions in spending levels or increased conditionality may adversely affect the mental health of disadvantaged social groups.

Estimating the human recovery costs of seriously injured road crash casualties

Road crashes result in substantial trauma and costs to societies around the world. Robust costing methods are an important tool to estimate costs associated with road trauma, and are key inputs into policy development and cost-benefit analysis for road safety programmes and infrastructure projects. With an expanding focus on seriously injured road crash casualties, in addition to the long standing focus on fatalities, methods for costing seriously injured casualties are becoming increasingly important. Some road safety agencies are defining a seriously injured casualty as an individual that was admitted to hospital following a road crash, and as a result, hospital separation data provide substantial potential for estimating the costs associated with seriously injured road crash casualties. The aim of this study is to establish techniques for estimating the human recovery costs of (non-fatal) seriously injured road crash casualties directly from hospital separation data. An individuals' road crash-related hospitalisation record and their personal injury insurance claim were linked for road crashes that occurred in New South Wales, Australia. These records provided the means for estimating all of the costs to the casualty directly related to their recovery from their injuries. A total of 10,897 seriously injured road crash casualties were identified and four methods for estimating their recovery costs were examined, using either unit record or aggregated hospital separation data. The methods are shown to provide robust techniques for estimating the human recovery costs of seriously injured road crash casualties, that may prove useful for identifying, implementing and evaluating safety programmes intended to reduce the incidence of road crash-related serious injuries.

Injury risk for matched front and rear seat car passengers by injury severity and crash type: An exploratory study

BACKGROUND

The risk of serious injury or death has been found to be reduced for some front compared to rear seat car passengers in newer vehicles. However, differences in injury severity between car occupants by seating position has not been examined. This study examines the injury severity risk for rear compared to front seat car passengers.

METHOD

A retrospective matched-cohort analysis was conducted of vehicle crashes involving injured rear vs front seat car passengers identified in linked police-reported, hospitalisation and emergency department (ED) presentation records during 2001-2011 in New South Wales (NSW), Australia. Odds ratios were estimated using an ordinal logistic mixed model and logistic mixed models.

RESULTS

There were 5419 front and 4588 rear seat passengers in 3681 vehicles. There was a higher odds of sustaining a higher injury severity as a rear-compared to a front seat car passenger, with a higher odds of rear seat passengers sustaining serious injuries compared to minimal injuries. Where the vehicle occupant was older, travelling in a vehicle manufactured between 1990 and 1996 or after 1997, where the airbag deployed, and where the vehicle was driven where the speed limit was ≥70km/h there was a higher odds of the rear passenger sustaining a higher injury severity then a front seated occupant.

CONCLUSION

Rear seat car passengers are sustaining injuries of a higher severity compared to front seat passengers travelling in the same vehicle, as well as when travelling in newer vehicles and where the front seat occupant is shielded by an airbag deployed in the crash. Rear seat occupant protective mechanisms should be examined. Pre-hospital trauma management policies could influence whether an individual is transported to a hospital ED, thus it would be beneficial to have an objective measure of injury severity routinely available in ED records. Further examination of injury severity between rear and front seat passengers is warranted to examine less severe non-fatal injuries by car seating position and vehicle intrusion.

Comparison of novice and full-licenced driver common crash types in New South Wales, Australia, 2001-2011

OBJECTIVE

To examine the circumstances of passenger vehicle crashes for novice licenced drivers aged 17-25 years and to compare the crash circumstances of the most common crash types for novices to a sample of full-licence drivers aged 40-49 years.

METHOD

A retrospective analysis was conducted of passenger vehicle crashes involving novice and full-licenced drivers during 1 January 2001 to 31 December 2011 in New South Wales (NSW), Australia.

RESULTS

There were 4113 injurious crashes of novice drivers. Almost half the novice driver crashes involved a single vehicle. Vehicle speed (33.2%), fatigue (15.6%) and alcohol (12.6%) were identified risk factors in novice driver crashes. Correspondence analysis for 4 common crash types for novice drivers revealed that the crash characteristics between novice and full-licenced drivers were similar.

CONCLUSIONS

Similarities exist between novice driver and full-licenced driver crash risk for common crash types. Preventive strategies aimed at crash risk reduction for novice drivers may also benefit all drivers.

Neighborhood Environments and Socioeconomic Inequalities in Mental Well-Being

INTRODUCTION

It has been suggested that socioeconomic inequalities in health might be reduced among populations with good access to green space. However, the potential for other neighborhood characteristics to reduce socioeconomic health inequalities, or to confound the effects of green space, has not been well explored. Therefore, this study investigates which, if any, neighborhood characteristics are associated with narrower socioeconomic inequalities in mental well-being in a large, international sample of urban residents.

METHODS

The 2012 European Quality of Life Survey provided data on 21,294 urban residents from 34 European nations. Associations between mental well-being (captured by the WHO-5 scale) and level of financial strain were assessed for interaction with five different neighborhood characteristics, including reported access to recreational/green areas, financial services, transport, and cultural facilities. Multilevel regression models allowed for clustering of individuals within region and country in this cross-sectional, observational study. Data were analyzed in 2014.

RESULTS

Socioeconomic inequality in mental well-being was 40% (8.1 WHO-5 points) narrower among respondents reporting good access to green/recreational areas, compared with those with poorer access. None of the other neighborhood characteristics or services were associated with narrower inequality.

CONCLUSIONS

If societies cannot, or will not, narrow socioeconomic inequality, research should explore the so-called equigenic environments-those that can disrupt the usual conversion of socioeconomic inequality to health inequality. This large, international, observational study suggests that access to recreational/green areas may offer such a disruption.

Difficult Life Events, Selective Migration and Spatial Inequalities in Mental Health in the UK

Objective

Research has indicated that people moving towards neighbourhoods with disadvantaged socio-economic status have poor health, in particular mental health, but the reasons for this are unclear. This study aims to assess why people moving towards more socio-economically deprived areas have poor mental health. It focuses upon the role of difficult life events that may both trigger moves and damage mental health. This study investigates how mental health and socio-spatial patterns of mobility vary between people moving following difficult life events and for other reasons.

Methods

Longitudinal analysis of British Household Panel Survey data describing adults’ moves between annual survey waves, pooled over ten years, 1996-2006 (N=122,892 observations). Respondents were defined as ‘difficult life event movers’ if they had experienced relationship breakdown, housing eviction/repossession, or job loss between waves. Respondents were categorised as moving to more or less deprived quintiles using their Census Area Statistic residential ward Carstairs score. Mental health was indicated by self-reported mental health problems. Binary logistic regression models of weighted data were adjusted for age, sex, education and social class.

Results

The migration rate over one year was 8.5%; 14.1% of movers had experienced a difficult life event during this time period. Adjusted regression model odds of mental health problems among difficult life event movers were 1.67 (95% CI 1.35-2.07) relative to other movers. Odds of difficult life events movers, compared to other movers, moving to a less deprived area, relative to an area with a similar level of deprivation, were 0.70 (95% CI 0.58-0.84). Odds of mental health problems among difficult life event movers relocating to more deprived areas were highly elevated at 2.40 (95% CI 1.63-3.53), relative to stayers.

Conclusion

Difficult life events may influence health selective patterns of migration and socio-spatial trajectories, reducing moves to less deprived neighbourhoods among people with mental illness.

Risk factors associated with the severity of injury outcome for paediatric road trauma

Road trauma is one of the most common causes of injury for children. Yet risk factors associated with different levels of injury severity for childhood road trauma have not been examined in-depth. This study identifies crash and injury risk factors associated with the severity of non-fatal injury outcome for paediatric road trauma. A retrospective analysis was conducted of paediatric road trauma identified in linked police-reported and hospitalisation records during 1 January 2001 to 31 December 2011 in New South Wales (NSW), Australia. The linkage rate was 54%. Injury severity was calculated from diagnosis classifications in hospital records using the International Classification of Disease Injury Severity Score. Univariate and multi-variable logistic regression was conducted. There were 2412 car occupants, 1701 pedestrians and 612 pedal cyclists hospitalised where their hospital record linked to a police report. For car occupants, unauthorised vehicle drivers had twice the odds (OR: 2.21, 95%CI 1.47-3.34) and learner/provisional drivers had one and a half times higher odds (OR: 1.54, 95%CI 1.15-2.07) of a child car occupant sustaining a serious injury compared to a minor injury. For pedal cyclists and pedestrians, there were lower odds of a crash occurring during school commuting time and higher odds of a crash occurring during the weekend or on a dry road for children who sustained a serious versus a minor injury. Injury prevention initiatives, such as restraint and helmet use, that should reduce injury and/or crash severity are advocated.

Safe system approach to reducing serious injury risk in motorcyclist collisions with fixed hazards

Collisions with fixed objects in the roadway environment account for a substantial proportion of motorcyclist fatalities. Many studies have identified individual roadway environment and/or motorcyclist characteristics that are associated with the severity of the injury outcome, including the presence of roadside barriers, helmet use, alcohol use and speeding. However, no studies have reported the cumulative benefit of such characteristics on motorcycling safety. The safe system approach recognises that the system must work as a whole to reduce the net injury risk to road users to an acceptable level, including the four system cornerstone areas of roadways, speeds, vehicles and people. The aim of the present paper is to consider these cornerstone areas concomitantly, and quantitatively assess the serious injury risk of motorcyclists in fixed object collisions using this holistic approach. A total of 1006 Australian and 15,727 (weighted) United States motorcyclist-fixed object collisions were collected retrospectively, and the serious injury risks associated with roadside barriers, helmet use, alcohol use and speeding were assessed both individually and concomitantly. The results indicate that if safety efforts are made in each of the safe system cornerstone areas, the combined effect is to substantially reduce the serious injury risk of fixed hazards to motorcyclists. The holistic approach is shown to reduce the serious injury risk considerably more than each of the safety efforts considered individually. These results promote the use of a safe system approach to motorcycling safety.

Residential mobility and the association between physical environment disadvantage and general and mental health

BACKGROUND

Selective migration may influence the association between physical environments and health. This analysis assessed whether residential mobility concentrates people with poor health in neighbourhoods of the UK with disadvantaged physical environments.

METHODS

Data were from the British Household Panel Survey. Moves were over 1 year between adjacent survey waves, pooled over 10 pairs of waves, 1996-2006. Health outcomes were self-reported poor general health and mental health problems. Neighbourhood physical environment was defined using the Multiple Environmental Deprivation Index (MEDIx) for wards. Logistic regression analysis compared risk of poor health in MEDIx categories before and after moves. Analyses were stratified by age groups 18-29, 30-44, 45-59 and 60+ years and adjusted for age, sex, marital status, household type, housing tenure, education and social class.

RESULTS

The pooled data contained 122 570 observations. 8.5% moved between survey waves but just 3.0% changed their MEDIx category. In all age groups odds ratios for poor general and mental health were not significantly increased in the most environmentally deprived neighbourhoods following moves.

CONCLUSIONS

Over a 1-year time period residential moves between environments with different levels of multiple physical deprivation were rare and did not significantly raise rates of poor health in the most deprived areas.

A review of the use of human factors classification frameworks that identify causal factors for adverse events in the hospital setting

Various human factors classification frameworks have been used to identified causal factors for clinical adverse events. A systematic review was conducted to identify human factors classification frameworks that identified the causal factors (including human error) of adverse events in a hospital setting. Six electronic databases were searched, identifying 1997 articles and 38 of these met inclusion criteria. Most studies included causal contributing factors as well as error and error type, but the nature of coding varied considerably between studies. The ability of human factors classification frameworks to provide information on specific causal factors for an adverse event enables the focus of preventive attention on areas where improvements are most needed. This review highlighted some areas needing considerable improvement in order to meet this need, including better definition of terms, more emphasis on assessing reliability of coding and greater sophistication in analysis of results of the classification. Practitioner Summary: Human factors classification frameworks can be used to identify causal factors of clinical adverse events. However, this review suggests that existing frameworks are diverse, limited in their identification of the context of human error and have poor reliability when used by different individuals.

The rising burden of serious thoracic trauma sustained by motorcyclists in road traffic crashes

In many countries increased on-road motorcycling participation has contributed to increased motorcyclist morbidity and mortality over recent decades. Improved helmet technologies and increased helmet wearing rates have contributed to reductions in serious head injuries, to the point where in many regions thoracic injury is now the most frequently occurring serious injury. However, few advances have been made in reducing the severity of motorcyclist thoracic injury. The aim of the present study is to provide needed information regarding serious motorcyclist thoracic trauma, to assist motorcycling groups, road safety advocates and road authorities develop and prioritise counter-measures and ultimately reduce the rising trauma burden. For this purpose, a data collection of linked police-reported and hospital data was established, and considerable attention was given to establishing a weighting procedure to estimate hospital cases not reported to police and fatal cases not admitted to hospital. The resulting data collection of an estimated 19,979 hospitalised motorcyclists is used to provide detailed information on the nature, incidence and risk factors for thoracic trauma. Over the last decade the incidence of motorcyclist serious thoracic injury has more than doubled in the population considered, and by 2011 while motorcycles comprised 3.2% of the registered vehicle fleet, one quarter of road traffic-related serious thoracic trauma cases treated in hospitals were motorcyclists. Motor-vehicle collisions, fixed object collisions and non-collision crashes were fairly evenly represented amongst these cases, while older motorcyclists were over-represented. Several prevention strategies are identified and discussed.

The effectiveness of helmets in bicycle collisions with motor vehicles: a case-control study

There has been an ongoing debate in Australia and internationally regarding the effectiveness of bicycle helmets in preventing head injury. This study aims to examine the effectiveness of bicycle helmets in preventing head injury amongst cyclists in crashes involving motor vehicles, and to assess the impact of 'risky cycling behaviour' among helmeted and unhelmeted cyclists. This analysis involved a retrospective, case-control study using linked police-reported road crash, hospital admission and mortality data in New South Wales (NSW), Australia during 2001-2009. The study population was cyclist casualties who were involved in a collision with a motor vehicle. Cases were those that sustained a head injury and were admitted to hospital. Controls were those admitted to hospital who did not sustain a head injury, or those not admitted to hospital. Standard multiple variable logistic regression modelling was conducted, with multinomial outcomes of injury severity. There were 6745 cyclist collisions with motor vehicles where helmet use was known. Helmet use was associated with reduced risk of head injury in bicycle collisions with motor vehicles of up to 74%, and the more severe the injury considered, the greater the reduction. This was also found to be true for particular head injuries such as skull fractures, intracranial injury and open head wounds. Around one half of children and adolescents less than 19 years were not wearing a helmet, an issue that needs to be addressed in light of the demonstrated effectiveness of helmets. Non-helmeted cyclists were more likely to display risky riding behaviour, however, were less likely to cycle in risky areas; the net result of which was that they were more likely to be involved in more severe crashes.

Measured and modelled leaf and stand-scale productivity across a soil moisture gradient and a severe drought

Environmental controls on carbon dynamics operate at a range of interacting scales from the leaf to landscape. The key questions of this study addressed the influence of water and nitrogen (N) availability on Pinus palustris (Mill.) physiology and primary productivity across leaf and canopy scales, linking the soil-plant-atmosphere (SPA) model to leaf and stand-scale flux and leaf trait/canopy data. We present previously unreported ecophysiological parameters (e.g. V(cmax) and J(max)) for P. palustris and the first modelled estimates of its annual gross primary productivity (GPP) across xeric and mesic sites and under extreme drought. Annual mesic site P. palustris GPP was ∼23% greater than at the xeric site. However, at the leaf level, xeric trees had higher net photosynthetic rates, and water and light use efficiency. At the canopy scale, GPP was limited by light interception (canopy level), but co-limited by nitrogen and water at the leaf level. Contrary to expectations, the impacts of an intense growing season drought were greater at the mesic site. Modelling indicated a 10% greater decrease in mesic GPP compared with the xeric site. Xeric P. palustris trees exhibited drought-tolerant behaviour that contrasted with mesic trees' drought-avoidance behaviour.

The protective effect of roadside barriers for motorcyclists

OBJECTIVE

Roadside barriers are often deployed between road users and fixed hazards to protect users from injury. However, the United States and Australian Roadside Design Guides do not consider motorcyclists in the risk-based decision process for the deployment of a barrier, because the severity indices for barriers and fixed hazards were developed for passenger vehicles. The aim of the present article is to quantify the protective effect of barriers with regards to motorcyclist injury and to thereby inform the Roadside Design Guides as to the relative severity of roadside hazards and infrastructure for motorcyclists.

METHOD

A retrospective case series study, using linked police-reported road crash and hospital admission data in New South Wales, Australia, from 2001 to 2009 was performed. Crude and adjusted relative risks of motorcyclist serious injury were determined for various fixed objects compared to barriers, using serious injury rates and multiple variable logistic regression. Calculated relative risks compared with guardrail for motorcyclists were compared with those determined from the United States and Australian Roadside Design Guides for passenger vehicle occupants.

RESULTS

The study identified 1364 motorcyclists injured as a result of single-vehicle collisions with roadside barriers, trees, utility poles, and other fixed roadside infrastructure. Trees, posts, and utility poles were shown to provide significantly higher risks of serious injury to motorcyclists compared to barriers. This was also found to be true for serious injuries to particular body regions, such as the head, spine, and torso. The results for motorcyclists were in reasonable agreement with those derived from severity indices in the United States and Australian Roadside Design Guides for passenger vehicle occupants.

CONCLUSIONS

Roadside barriers provide a significant reduction in the risk of serious injury to motorcyclists compared to various roadside hazards. The provisions in the United States and Australian Roadside Design Guides for passenger vehicle occupants are generally applicable to motorcyclists and support the prior and ongoing use of such guides for designing roadsides that reduce the risk of injury to motorcyclists. However, a more realistic estimation might be derived by increasing the severity indices for barriers by around 25 percent for motorcyclists.

Environmental justice and health: a study of multiple environmental deprivation and geographical inequalities in health in New Zealand

There is an increasing interest in the unequal socio-spatial distribution of environmental 'goods' and 'bads' and the associated implications for geographical inequalities in health. Until recently, research in this area has focused on solitary environmental characteristics and has been hindered by the absence of geographically-specific measures that recognise the multifactorial nature of the physical environment. However, recent work in the United Kingdom has developed an area-level multivariate index of health-related physical environmental deprivation that captures both pathogenic and salutogenic environmental characteristics. Applications of this index have demonstrated that, at the national level, multiple environmental deprivation increased as the degree of income deprivation rose. Further, after adjusting for key confounders, there was a significant association between multiple environmental deprivation and the health outcomes of local residents. In the current study we tested the methods developed in the UK to create the New Zealand Multiple Environmental Deprivation Index (NZ-MEDIx) for small areas across the country (n = 1860). We considered whether socially disadvantaged places in New Zealand had higher levels of multiple environmental deprivation, and if environmental disadvantage exerted an influence on health after adjustment for key confounders such as socioeconomic status. We found that although neighbourhoods with higher levels of multiple environmental deprivation tended to have greater social disadvantage, this association was not linear. Further, multiple environmental deprivation tended to exert a modest effect on health that was independent of the age, sex and socioeconomic structure of the population. These findings demonstrate that it is possible to develop an index of multiple environmental deprivation in an alternative national context which has utility in epidemiological investigations.

The essential work of fracture of thermoplastic orthodontic retainer materials

OBJECTIVE

To investigate whether oral cleansing agents affect the essential work of fracture (EWF) and plastic work of fracture (PWF) for two types of orthodontic thermoplastic retainer materials.

MATERIALS AND METHODS

Polyethylene-terephthalate-glycol (PETG; Tru-Tain Splint) and polypropylene/ethylene-propylene rubber (PP-EPR) blend (Essix-C+) sheets were compared. For each material, six sets of 25 sheets were thermoformed into double-edge-notched-tension specimens; subsets of five specimens were formed with internotch distances (L) equal to 6, 8, 10, 12, or 14 mm, respectively. Sets were stored (160 hours, 25 degrees C) in air (DRY), distilled water (DW), Original Listerine (LIS), mint Crest ProHealth (CPH), 3% hydrogen peroxide (HP), or Polident solution (POL). Specimens were fractured in tension at 2.54 mm/min. Areas under load-elongation curves were measured to determine total work of fracture (W(f)). Linear regressions (W(f) vs L [n = 25]) yielded intercepts (EWF) and slopes (PWF). Ninety-five percent confidence intervals were used to evaluate differences in EWF and PWF estimates.

RESULTS

PP-EPR blends showed higher EWFs after storage in HP vs storage in DW. PP-EPR blend showed higher EWFs after storage in CPH vs PETG. After HP storage, PP-EPR exhibited lower PWFs than with any other storage conditions. PP-EPR exhibited higher PWFs than PETG after storage in DRY, DW, and LIS.

CONCLUSIONS

Compared with DW, none of the cleansers decreased the energy to initiate fracture. With one exception, no cleanser decreased the energy to continue plastic fracture extension. In PP-EPR blend, increased resistance to fracture initiation was observed with CPH and HP, yet, surprisingly, HP decreased resistance to plastic fracture growth.

Effect of body mass index and alcohol consumption on liver disease: analysis of data from two prospective cohort studies

OBJECTIVE

To investigate whether alcohol consumption and raised body mass index (BMI) act together to increase risk of liver disease.

DESIGN

Analysis of data from prospective cohort studies.

SETTING

Scotland.

PARTICIPANTS

Data were from two of the Midspan prospective cohort studies (9559 men): "Main" study 1965-8, participants from workplaces across central belt of Scotland, population of island of Tiree, and mainland relatives, and "Collaborative" study, 1970-3, participants from 27 workplaces in Glasgow, Clydebank, and Grangemouth. Follow-up was to 31 December 2007 (median 29 years, range 0.13-42). We divided participants into nine groups based on measures of body mass index (BMI) (underweight/normal weight <25, overweight 25 to <30, and obese >or=30) and alcohol consumption (none, 1-14, and >or=15 units per week).

MAIN OUTCOME MEASURES

Liver disease morbidity and mortality.

RESULTS

80 (0.8%) men died with liver disease as the main cause and 146 (1.5%) with liver disease as any cause. In the Collaborative study, 196 men (3.3%) had liver disease defined by a death, admission, or cancer registration. BMI and alcohol consumption were strongly associated with liver disease mortality in analyses adjusted for other confounders (P=0.001 and P<0.0001 respectively). Drinkers of 15 or more units per week in any BMI category and obese drinkers had raised relative rates for all definitions of liver disease, compared with underweight/normal weight non-drinkers. Drinkers of 15 or more units per week had adjusted relative rates for liver disease mortality of 3.16 (95% confidence interval 1.28 to 7.8) for underweight/normal weight men, 7.01 (3.02 to 16.3) for overweight, and 18.9 (6.84 to 52.4) for obese men. The relative rate for obese men who consumed 1-14 units per week was 5.3 (1.36 to 20.7). The relative excess risk due to interaction between BMI and alcohol consumption was 5.58 (1.09 to 10.1); synergy index=2.89 (1.29 to 6.47).

CONCLUSIONS

Raised BMI and alcohol consumption are both related to liver disease, with evidence of a supra-additive interaction between the two. The occurrence of both factors in the same populations should inform health promotion and public health policies.

Evidence-based selection of environmental factors and datasets for measuring multiple environmental deprivation in epidemiological research

This Environment and Human Health project aims to develop a health-based summary measure of multiple physical environmental deprivation for the UK, akin to the measures of multiple socioeconomic deprivation that are widely used in epidemiology. Here we describe the first stage of the project, in which we aimed to identify health-relevant dimensions of physical environmental deprivation and acquire suitable environmental datasets to represent population exposure to these dimensions at the small-area level. We present the results of this process: an evidence-based list of environmental dimensions with population health relevance for the UK, and the spatial datasets we obtained and processed to represent these dimensions. This stage laid the foundations for the rest of the project, which will be reported elsewhere.

The influence of nitrogen in stemflow and precipitation on epiphytic bryophytes, Isothecium myosuroides Brid., Dicranum scoparium Hewd. and Thuidium tamariscinum (Hewd.) Schimp of Atlantic oakwoods

The spatial relationship between the concentration and deposition of the major ions in precipitation and stemflow and their influence on the tissue nitrogen concentration of three epiphytic bryophytes on Quercus petraea (Matt) Liebl. and Q. robur L. was investigated at seven UK Atlantic oak woodland sites with a range of total N deposition of 55-250 mmol m(-2). The main driver of change in tissue N concentrations of three epiphytic bryophytes (Isothecium myosuroides Brid. (Eurhynchium myosuroides (Brid.) Schp.), Dicranum scoparium Hewd. and Thuidium tamariscinum (Hewd.) Schimp.) was total N deposition in stemflow, dominated by ammonium deposition. The three epiphytic species also showed strong relationships between tissue N concentration and total N deposition in rainfall but a poor correlation with total N ion concentration in rainfall. This study shows that epiphytic bryophytes utilise stemflow N and thus increase their risk from inputs of total N deposition compared to terricolous species at the same site.

Posterior amalgam restorations--usage, regulation, and longevity

The use of dental amalgam has declined, but in most of the world, amalgam is the most widely used and widely taught direct restorative material for load-bearing posterior restorations. There are few national regulations on the use of amalgam; however, there are several nations where few amalgam restorations are placed. Long-term studies have shown that under optimum conditions, posterior restorations of amalgam and resin composite last longer than reported previously and that amalgam restorations outlast composite restorations. In general practice settings, posterior amalgam and composite restorations both have lower longevities.

Removal time of fiber posts versus titanium posts

PURPOSE

To evaluate the time needed to remove a glass reinforced fiber post versus a titanium post.

METHODS

40 extracted anterior teeth were mounted in acrylic blocks then treated endodontically. They were randomly assigned to three groups. The teeth were sectioned horizontally, with the coronal portion removed. The fiber posts were cemented with resin cement and the titanium posts were cemented with glass ionomer or resin cement. The fiber posts were removed by coring them out internally. The titanium posts were removed by creating a trough around the post then vibrating with ultrasonic energy. The teeth were examined visually and radiographically to ensure complete removal of the post and cement. Removal time included the time to make radiographs necessary to ensure complete removal.

RESULTS

Post-cement combination significantly affected the median rank of the removal time (Kruskal-Wallis test; H = 12.709; P = 0.002). The mean rank removal time of titanium posts cemented with resin cement were significantly higher than the mean rank of the other two post-cement combinations (Dunn's multiple comparison test; P < 0.05). There was no significant difference between the other two combinations.

Cascade genetic testing for mismatch repair gene mutations

Mismatch repair gene mutation carriers have a high risk of developing colorectal cancer, and can benefit from appropriate surveillance. A combined population based ascertainment cascade genetic testing approach provides a systematic and potentially effective strategy for identifying such carriers. We have developed a Markov Chain computer model system which simulates various factors influencing cascade genetic testing; including demographics, uptake, genetic epidemiology and family size. This was used to evaluate cascade genetic testing for mismatch repair gene mutations in theory and practice. Simulations focussed on the population of Scotland by way of illustration, and were based on a 20-year programme in which index cases were ascertained from colorectal cancer cases aged<55 years at onset. Results indicated that without practical barriers to cascade genetic testing, 545 (95% CI=522, 568) carriers could be identified; 42% of the population total. This comprised approximately 140 index cases, 302 asymptomatic relatives and 104 previously affected relatives. However, when realistic ascertainment and acceptance rates were used to inform simulations, only 257 (95% CI=246, 268) carriers, about 20% of the carrier population, were identifiable. Of these approximately 112 were index cases, 108 were asymptomatic relatives, and 37 were previously affected relatives. This contrast emphasises the importance of ascertainment and acceptance rates. Likewise the low number of index cases shows that case identification is a limiting factor. In the absence of robust data from epidemiological studies, these findings can inform decisions about the use of cascade genetic testing for mismatch repair gene mutations.

Locked nucleic acids in PCR primers increase sensitivity and performance

The incorporation of locked nucleic acids (LNAs) into oligonucleotide primers has been shown to increase template binding strength and specificity for DNA amplification. Real-time PCR and DNA sequencing have been shown to be significantly enhanced by the use of LNAs. Theoretically, increasing primers' binding strength may also increase the sensitivity of conventional PCR, reducing minimum template requirements. We compared LNA-modified PCR primers with their standard DNA counterparts for amplification sensitivity with template amounts as low as 5 pg. Although the results are highly dependent on the design of the LNA primers, large increases in peak height can be achieved from as little as 75 pg, as well as clearer and more complete profiles. Increased amplification success with lower template amounts may also be seen. Additionally, the use of LNAs can enhance multiplexing. Thus, incorporating LNAs into PCR primers can increase amplification success, sensitivity, and performance under a wide range of conditions.

An investigation of sequence deletions of amelogenin (AMELY), a Y-chromosome locus commonly used for gender determination

BACKGROUND

Accurate gender determination is crucial in many scientific disciplines, but especially so in prenatal diagnosis of X-linked diseases and forensic investigations. Today, molecular techniques, especially typing for a length variation in the X-Y homologous amelogenin gene (AMELX and AMELY), are used for gender assignation. This amelogenin test is an integral part of most PCR multiplex kits that are used for DNA profiling, but in 1998 there was a report of two normal males being typed as female with this test. Subsequently, a small number of amelogenin negative (or AMELY null) males have been reported in various populations but little data are available characterising these deletions.

AIMS

The study aims to determine the size of the deletion in five AMELY null males by typing DNA samples for markers surrounding this gender-determining locus. The possible relationships among the AMELY null samples are examined through analysis of their deletion size and associated Y-chromosome microsatellite haplotypes. We also attempt to determine the frequency of AMELY negative males in Australia.

SUBJECTS AND METHODS

DNA samples from five AMELY null males, from different geographical regions, were made available for this study. The samples were typed for eight sites, all located on the short arm of the Y chromosome, using PCR and gel electrophoresis. Eleven Y-chromosome specific microsatellites were also typed on each sample in order to generate haplotypes for phylogenetic analysis. A questionnaire was sent to all Australian forensic centres requesting information on the frequency of AMELY negative males observed in their laboratories.

RESULTS

Two different sized deletions were seen in the five AMELY null samples. One deletion (in two samples) has a size of between 304 and 731 kbp, whereas the other (in three samples) ranges between 712 and 1001 kbp. Y-microsatellite haplotypes indicate that the smaller deletion is probably identical in the two samples, but this is not the case with the larger deletion. The frequency of AMELY negative is rare in Australia, with an overall frequency of 0.02%.

CONCLUSION

Comparisons of both deletion size and haplotypes with published data suggest that most AMELY nulls are the result of independent evolutionary events, even in those populations where the frequency is relatively high. Although AMELY null males are extremely rare in most populations, typing an additional gender-determining locus should be considered in forensic investigations where the reference sample is of unknown gender.

Effects of elevated atmospheric carbon dioxide on biomass and carbon accumulation in a model regenerating longleaf pine community

Plant species vary in response to atmospheric CO2 concentration due to differences in physiology, morphology, phenology, and symbiotic relationships. These differences make it very difficult to predict how plant communities will respond to elevated CO2. Such information is critical to furthering our understanding of community and ecosystem responses to global climate change. To determine how a simple plant community might respond to elevated CO2, a model regenerating longleaf pine community composed of five species was exposed to two CO2 regimes (ambient, 365 micromol mol(-1) and elevated, 720 micromol mol(-1)) for 3 yr. Total above- and belowground biomass was 70 and 49% greater, respectively, in CO2-enriched plots. Carbon (C) content followed a response pattern similar to biomass, resulting in a significant increase of 13.8 Mg C ha(-1) under elevated CO2. Responses of individual species, however, varied. Longleaf pine (Pinus palustris Mill.) was primarily responsible for the positive response to CO2 enrichment. Wiregrass (Aristida stricta Michx.), rattlebox (Crotalaria rotundifolia Walt. Ex Gmel.), and butterfly weed (Asclepias tuberosa L.) exhibited negative above- and belowground biomass responses to elevated CO2, while sand post oak (Quercus margaretta Ashe) did not differ significantly between CO2 treatments. As with pine, C content followed patterns similar to biomass. Elevated CO2 resulted in alterations in community structure. Longleaf pine comprised 88% of total biomass in CO2-enriched plots, but only 76% in ambient plots. In contrast, wiregrass, rattlebox, and butterfly weed comprised 19% in ambient CO2 plots, but only 8% under high CO2. Therefore, while longleaf pine may perform well in a high CO2 world, other members of this community may not compete as well, which could alter community function. Effects of elevated CO2 on plant communities are complex, dynamic, and difficult to predict, clearly demonstrating the need for more research in this important area of global change science.

Adjustments in hydraulic architecture of Pinus palustris maintain similar stomatal conductance in xeric and mesic habitats

We investigated relationships between whole-tree hydraulic architecture and stomatal conductance in Pinus palustris Mill. (longleaf pine) across habitats that differed in soil properties and habitat structure. Trees occupying a xeric habitat (characterized by sandy, well-drained soils, higher nitrogen availability and lower overstory tree density) were shorter in stature and had lower sapwood-to-leaf area ratio (A(S):A(L)) than trees in a mesic habitat. The soil-leaf water potential gradient (psiS - psiL) and leaf-specific hydraulic conductance (kL) were similar between sites, as was tissue-specific hydraulic conductivity (Ks) of roots. Leaf and canopy stomatal conductance (gs and Gs, respectively) were also similar between sites, and they tended to be somewhat higher at the xeric site during morning hours when vapour pressure deficit (D) was low. A hydraulic model incorporating tree height, A(S):A(L) and psiS-psiL accurately described the observed variation in individual tree G(Sref) (G(S) at D = 1 kPa) across sites and indicated that tree height was an important determinant of G(Sref) across sites. This, combined with a 42% higher root-to-leaf area ratio (A(R):A(L)) at the xeric site, suggests that xeric site trees are hydraulically well equipped to realize equal--and sometimes higher potential for conductance compared with trees on mesic sites. However, a slightly more sensitive stomatal closure response to increasing D observed in xeric site trees suggests that this potential for higher conductance may only be reached when D is low and when the capacity of the hydraulic system to supply water to foliage is not greatly challenged.

Dental amalgam restorations: daily mercury dose and biocompatibility

Over the past 150 years, silver-tin-copper amalgam has been the most frequently used dental restorative material. Amalgam may be the single most frequently used implant material. In the early 1980s, researchers discovered that amalgam restorations release mercury vapor during chewing. This review describes the research that has led to an estimate of the daily dose of mercury that will be absorbed by a subject with a large number of amalgam restorations. Along the way, the history and chemistry of dental amalgam are outlined. The routes of absorption of liquid mercury, ionic mercury, organic mercury, and mercury vapor are also briefly described. The daily dose is found to be 14% of the threshold above which observable adverse neurological symptoms are expected. The review concludes with a summary of the research on the adverse effects of dental amalgam. As expected from the low daily dose, few adverse neurological symptoms have been reported. There is also little evidence of an association of amalgam restorations with neurodegenerative diseases, altered renal function, adverse pregnancy outcomes, or autoimmune diseases. There is a lack of data on neurobiological and neurodevelopmental effects on children who may be exposed to mercury from maternal amalgam restorations during gestation. Additional data on the role of amalgam, if any, in Alzheimers disease and multiple sclerosis are needed.

Prevalence of family history of colorectal cancer in the general population

BACKGROUND

Robust estimates of the prevalence of a family history of colorectal cancer in the general population are essential to inform planning of provision for colonoscopic surveillance and for clinical genetics services. However, there is a paucity of high-quality data.

METHODS

Computerized record linkage was used to assess systematically the family history of 160 cancer-free community subjects and thereby provide prevalence data that are independent of participant recall. The data set comprised 2664 first- and second-degree relatives of study subjects, with 148 068 years at risk.

RESULTS

Of people in the 30-70 years age range, 9.4 (95 per cent confidence interval (c.i.) 5.8 to 14.9) per cent had a first-degree relative affected by colorectal cancer, and 28.8 (95 per cent c.i. 22.3 to 36.2) per cent had an affected first- or second-degree relative. Between 0 and 3.1 per cent of study subjects merited colonic surveillance, depending on the stringency of the guidelines used.

CONCLUSION

An appreciable proportion of the general population has a relative affected by colorectal cancer, sufficient to merit screening under certain criteria. In the absence of good-quality evidence supporting colonoscopic surveillance in groups at moderate risk, these data directly inform the planning of services for people with a family history of colorectal cancer. However, the clinical risk and financial implications of screening should be taken into account.

FMR1 alleles in Tasmania: a screening study of the special educational needs population

The distribution of fragile X mental retardation-1 (FMR1) allele categories, classified by the number of CGG repeats, in the population of Tasmania was investigated in 1253 males with special educational needs (SEN). The frequencies of these FMR1 categories were compared with those seen in controls as represented by 578 consecutive male births. The initial screening was based on polymerase chain reaction analysis of dried blood spots. Inconclusive results were verified by Southern analysis of a venous blood sample. The frequencies of common FMR1 alleles in both samples, and of grey zone alleles in the controls, were similar to those in other Caucasian populations. Consistent with earlier reports, we found some (although insignificant) increase of grey zone alleles in SEN subjects compared with controls. The frequencies of predisposing flanking haplotypes among grey zone males FMR1 alleles were similar to those seen in other Caucasian SEN samples. Contrary to expectation, given the normal frequency of grey zone alleles, no premutation (PM) or full mutation (FM) allele was detected in either sample, with only 15 fragile X families diagnosed through routine clinical admissions registered in Tasmania up to 2002. An explanation of this discrepancy could be that the C19th founders of Tasmania carried few PM or FM alleles. The eight to ten generations since white settlement of Tasmania has been insufficient time for susceptible grey zone alleles to evolve into the larger expansions.