Quantifying the effectiveness of ultraviolet-C light at inactivating airborne Mycobacterium abscessus

BACKGROUND

Mycobacterium abscessus (MABS) group are environmental organisms that can cause infection in people with cystic fibrosis (CF) and other suppurative lung diseases. There is potential for person-to-person airborne transmission of MABS among people with CF attending the same care centre. Ultraviolet light (band C, UV-C) is used for Mycobacterium tuberculosis control indoors; however, no studies have assessed UV-C for airborne MABS.

AIM

To determine whether a range of UV-C doses increased the inactivation of airborne MABS, compared with no-UVC conditions.

METHODS

MABS was generated by a vibrating mesh nebulizer located within a 400 L rotating drum sampler, and then exposed to an array of 265 nm UV-C light-emitting diodes (LED). A six-stage Andersen Cascade Impactor was used to collect aerosols. Standard microbiological protocols were used for enumerating MABS, and these quantified the effectiveness of UV-C doses (in triplicate). UV-C effectiveness was estimated using the difference between inactivation with and without UV-C.

FINDINGS

Sixteen tests were performed, with UV-C doses ranging from 276 to 1104 μW s/cm². Mean (±SD) UV-C effectiveness ranged from 47.1% (±13.4) to 83.6% (±3.3). UV-C led to significantly greater inactivation of MABS (all P-values ≤0.045) than natural decay at all doses assessed. Using an indoor model of the hospital environment, it was estimated that UV-C doses in the range studied here could be safely delivered in clinical settings where patients and staff are present.

CONCLUSION

This study provides empirical in-vitro evidence that nebulized MABS are susceptible to UV-C inactivation.

Contribution of physical factors to handpump borehole functionality in Africa

Handpumps are the main water supply for rural communities across sub-Saharan Africa. However, studies show that >25 % of handpumps are non-functional at any time. We present results from a systematic field study of handpump borehole functionality. The study was designed to investigate the contribution of physical factors to functionality outcomes, including; hydrogeology, borehole configuration, and handpump components. To achieve this, we deconstructed and examined 145 handpump boreholes in Ethiopia, Uganda and Malawi. Pumping tests showed that 19 % of boreholes were located in aquifers with transmissivity below the minimum required to sustain a handpump. Water levels, measured during the dry season, had a complex relationship with borehole configuration and transmissivity. The handpump cylinder was <10 m below the water table at 38 % of sites, which increases the risk of the handpump running dry during intensive use and/or in areas of low transmissivity. The water column was <20 m at 23 % of sites and screens were <10 m long at 29 % of sites and often sub-optimally positioned in the borehole. Borehole depth had no clear relationship with functionality. Using multinomial regression and four functionality categories (functional; unreliable; low yield; unreliable and low yield) as dependant variables, we found that transmissivity is a significant risk factor for the classification of handpump boreholes as low yield. The configuration of the borehole (e.g. cylinder position, screen/casing configuration and water column) is a statistically significant risk factor for the classification of handpump boreholes as unreliable. Handpump components were in poor overall condition but rising main pipes were a particular problem with 53 % of galvanised pipes corroded and 82 % of uPVC pipes damaged, with implications for handpump performance. Our study highlights the importance of; understanding aquifer properties, investing in borehole siting, construction (including supervision) and commissioning, and improving the quality of components and maintenance of handpumps.

Multi-category classification of left ventricle ejection fraction using a convolutional neural network

Background

Screening for left ventricular (LV) systolic dysfunction (defined as ejection fraction ≤35%) based on data from a standard 12-lead electrocardiogram (ECG) has become well established when standard digital ECGs are available–8 independent leads sampled at least 250 hertz for 10 seconds. As the algorithm has been incorporated into various clinical scenarios and ancillary research projects, a limitation of the binary classification at 35% has become apparent.

Purpose

The objective of this study was to develop and validate a deep learning-based algorithm that would classify LVEF into three categories based on only the digital ECG input.

Methods

After IRB approval, native digital resting ECGs acquired between 1/1/2010 and 12/31/2021 on patients seen in Mayo Clinic in Jacksonville were extracted from the institutional electronic ECG database management system (MUSE, GE Healthcare). These ECGs were matched with transthoracic echocardiograms obtained up to four days prior or 30 days after the ECGs acquisition. A convolutional neural network consisting of 8 layers of convolutions, batch normalization and pooling was trained using Keras and Tensorflow with hyper-parameter optimization for L1 and L2 regularization, learning rate adjustments, and class weights to predict three classes of LVEF: ≤35%, 36–51%, and ≥52% based on clinical relevance. The primary measure of overall performance was the detection of LVEF ≤35%; however, the triad of model predictions was also considered in translating the model output to human interpretable findings.

Results

A total of 30,153 patients (60,169 ECG pairings; mean age 63 years; 48% male) were randomly split at the patient level into training (24,172 patients), validation (2,973 patients) and testing (3,008 patients). The trained model provided robust discrimination in the withheld testing data – AUROC of 0.941 (95% CI: 0.931 to 0.950). Using the optimal model threshold based on Youden's index from the validation data (0.186), sensitivity and specificity were estimated to be 87.9% (95% CI: 83.8% to 91.2%) and 86.3% (95% CI: 85.4% to 87.2%) in the testing data. In instances where discordant predictions were observed, the posterior distribution of model probabilities provide additional insights into the possible underlying value of LVEF (Figure 1).

Conclusions

The utilization of a multi-category deep learning classification model for the detection of reduced ejection fraction adds new dimensions to the use of AI technologies on digital ECGs. This work shows high discrimination can still be obtained when using three classes of LVEF.

Funding Acknowledgement

Type of funding sources: None.

Screening for cardiac allograft rejection among heart transplant recipients using an electrocardiogram-based deep learning model

Background

Current approaches utilizing non-invasive methods to screen for cardiac allograft rejection (gene expression profiling and cell free DNA) have yet to be broadly integrated into heart transplant management and have shown limited discrimination (AUCs of 0.68 and 0.77, respectively). Changes in the electrocardiogram (ECG) have been reported at the time of severe cardiac rejection, including low voltages and conduction abnormalities. It remains unknown if subtle ECG changes correlating with cardiac allograft rejection can be detected earlier using machine learning methods.

Purpose

We sought to develop an artificial intelligence (AI) model to detect cardiac allograft rejection based on the 12 lead ECG.

Methods

We identified all patients who underwent a heart transplant at 3 hospital sites within a single health system from Jan 1998 through Apr 2021 and extracted digital 12-lead ECG data as well as endomyocardial biopsy pathology results from the electronic medical record. We partitioned our data into a training (80%), validation (10%), and test set (10%) based on a group stratification sampling. Each patient was present in only one set and each set had a positivity rate of 2.6% with 6,074/758/758 ECGs belonging to 1,146/140/141 unique patients in each set respectively. Cardiac allograft rejection was defined as moderate or severe acute cellular rejection based on International Society for Heart and Lung Transplantation (ISHLT) guidelines. A convolutional neural network, using the 12-lead ECG data as input, was trained with hyperparameter optimization for regularization, learning rate adjustments, and class weights. Model performance metrics were based on the test data and estimated using the final model architecture.

Results

1,587 heart transplant recipients who had at least one endomyocardial biopsy were evaluated for inclusion. We limited our sample to ECGs performed within 30 days of the biopsy date (7,590 ECGs, representing 1,425 unique patients). Our study population had a median age of 55.8 years and 28.7% were female. The median number of ECG-biopsy pairs per patient was 5. The majority of endomyocardial biopsy results were classified as none or mild rejection (97.1%), and 2.9% had moderate/severe rejection. The ECG-based AI model detected cardiac allograft rejection with an area under the receiver operative curve (AUC) of 0.84 in the test set. The sensitivity, specificity, positive and negative predictive values were 95%, 52.6%. 5.2% and 99.7% respectively.

Conclusions

An AI-ECG model appears to outperform novel non-invasive laboratory tests (gene expression profiling and cell free DNA) for detecting cardiac allograft rejection and does not require a blood draw or the additional complexities surrounding sample processing. This model relies on a readily available and relatively inexpensive test, the ECG. In addition, AI predictions can be made available within a few minutes following ECG acquisition.

Funding Acknowledgement

Type of funding sources: Private hospital(s). Main funding source(s): Mayo Clinic

Relationship between cardiovascular symptoms, health status assessment and cardiomyopathy in the obstetric population

Background

Pregnancy related cardiomyopathy is a significant cause of maternal morbidity and mortality globally. A presumed overlap between normal pregnancy-associated symptoms and clinical symptoms of cardiomyopathy contributes to delays in diagnosis and increased risk of maternal mortality.

Purpose

We sought to evaluate the association between patient-reported cardiovascular symptoms and the presence of cardiomyopathy among pregnant and postpartum patients. We hypothesize that individual cardiovascular symptoms are unrelated to the presence of cardiomyopathy. We also evaluated the use of a novel adaptation of a validated health status questionnaire in relation to cardiomyopathy.

Methods

We enrolled 48 pregnant (&gt;13 weeks) and postpartum (up to 12 months) participants in a prospective study between October 2021 and February 2022. All study participants completed a baseline questionnaire, which included current cardiovascular symptoms, an assessment of health status using an adapted version of the Kansas City Cardiomyopathy Questionnaire (KCCQ-12), followed by a resting transthoracic echocardiogram on the same day. We defined cardiomyopathy as a left ventricular ejection fraction (LVEF) &lt;50% based on 2-D echocardiography. Fisher's exact and Wilcoxon rank-sum tests were employed to evaluate the association between reported cardiovascular symptoms, the adapted KCCQ-12 (KCC-A) score, and cardiomyopathy.

Results

At the time of enrollment, 67% were pregnant and 33% postpartum. Forty-eight percent identified as White, 31% as Black, 10% as Asian, and 10% as other race. The median age was 31 years (Q1: 28, Q3: 35) and 6% had an LVEF &lt;50%. We found no statistically significant association between four reported cardiovascular symptoms (shortness of breath, orthopnea, fast breathing, and episodes of “asthma” that did not improve with inhalers or other treatment) and cardiomyopathy or medial E/e' ratio. KCC-A scores were low in the study population overall (median 52; Q1:40, Q3: 61). We demonstrated a significantly lower KCC-A score among women with LVEF &lt;50% (median 24; Q1: 15, Q3: 44) compared to women with LVEF ≥50% (median 54; Q1: 44, Q3: 61) p=0.02.

Conclusions

We showed no significant association between individual cardiovascular symptoms and cardiomyopathy in an obstetric population. However, we demonstrate for the first time that an adapted KCCQ-12 questionnaire for health status assessment could potentially identify women with a high-likelihood of cardiomyopathy during the peripartum period who may benefit from additional evaluation including echocardiography. Larger studies are needed to validate this finding.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): This study was funded by a research grant from the Miami Heart Research Institute, Florida Heart Foundation. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health

A Systematic Review Of Primary Ankle Arthrodesis In The Treatment Of Pilon Fractures

BACKGROUND

Pilon fractures are severe, intra-articular and comminuted fractures to the distal tibia. They are uncommon injuries and are often associated with fibular fractures. The optimal management of these fractures is widely debated. Open reduction and internal fixation (ORIF) and external fixation have been used to treat these fractures. Ankle arthrodesis is often used in the latter stages of management for end-stage ankle arthritis. The aim of this systematic review was to identify the outcomes associated with using primary ankle arthrodesis in pilon fractures.

METHODS

Ovid Medline and PubMed were searched from the inception of their databases until October 2018. Eligible literature for use in our review included patient cohorts that had been operated in the form of primary ankle arthrodesis. All relevant data was included that met the inclusion criteria. The demographic of the patients with pilon fractures and this operative management were identified. The outcomes of interest were fusion rate, infection rate, length of follow-up and patient reported outcomes. 8 papers were deemed eligible for review.

RESULTS

Of the 8 papers that were eligible, 6 were retrospective studies, 1 was a case report and 1 was an abstract. There were a total of 109 patients included. Fusion rate was 100% in 5 of the studies. 6 of the 7 studies that reported on infection rate had no post-operative infections. Outcome assessment scores were used in 5 of the studies. The SF-36 score, the FOAS and the AOFAS were used.

CONCLUSIONS

This review shows that primary ankle arthrodesis yields reasonable results in the management of pilon fractures. However, the quantity and quality of current literature is not sufficient and further studies with larger cohorts and longer follow-up times are warranted.

Measurement of airborne particle exposure during simulated tracheal intubation using various proposed aerosol containment devices during the COVID-19 pandemic

The COVID‐19 pandemic has led to the production of novel devices intended to protect airway managers during the aerosol‐generating procedure of tracheal intubation. Using an in‐situ simulation model, we evaluated laryngoscopist exposure of airborne particles sized 0.3 ‐ 5.0 microns using five aerosol containment devices (aerosol box; sealed box with and without suction; vertical drape; and horizontal drape) compared with no aerosol containment device. Nebulised saline was used as the aerosol‐generating model for 300 s, at which point, the devices were removed to assess particle spread. Primary outcome was the quantity and size of airborne particles measured at the level of the laryngoscopist’s head at 30, 60, 120 and 300 s, as well as 360 s (60 s after device removal). Airborne particles sizes of 0.3, 0.5, 1.0, 2.5 and 5.0 microns were quantified using an electronic airborne particle counter. Compared with no device use, the sealed intubation box with suction resulted in a decrease in 0.3, 0.5, 1.0 and 2.5 micron, but not 5.0 micron, particle exposure over all time‐periods (p = 0.003 for all time periods). Compared with no device use, the aerosol box showed an increase in 1.0, 2.5 and 5.0 micron airborne particle exposure at 300 s (p = 0.002, 0.008, 0.002, respectively). Compared with no device use, neither horizontal nor vertical drapes showed any difference in any particle size exposure at any time. Finally, when the patient coughed, use of the aerosol box resulted in a marked increase in airborne particle exposure compared with other devices or no device use. In conclusion, novel devices intended to protect the laryngoscopist require objective testing to ensure they are fit for purpose and do not result in increased airborne particle exposure.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

A real-time electronic symptom monitoring system for patients after discharge following surgery: a pilot study in cancer-related surgery

Background

Advances in peri-operative care of surgical oncology patients result in shorter hospital stays. Earlier discharge may bring benefits, but complications can occur while patients are recovering at home. Electronic patient-reported outcome (ePRO) systems may enhance remote, real-time symptom monitoring and detection of complications after hospital discharge, thereby improving patient safety and outcomes. Evidence of the effectiveness of ePRO systems in surgical oncology is lacking. This pilot study evaluated the feasibility of a real-time electronic symptom monitoring system for patients after discharge following cancer-related upper gastrointestinal surgery.

Methods

A pilot study in two UK hospitals included patients who had undergone cancer-related upper gastrointestinal surgery. Participants completed the ePRO symptom-report at discharge, twice in the first week and weekly post-discharge. Symptom-report completeness, system actions, barriers to using the ePRO system and technical performance were examined. The ePRO surgery system is an online symptom-report that allows clinicians to view patient symptom-reports within hospital electronic health records and was developed as part of the eRAPID project. Clinically derived algorithms provide patients with tailored self-management advice, prompts to contact a clinician or automated clinician alerts depending on symptom severity. Interviews with participants and clinicians determined the acceptability of the ePRO system to support patients and their clinical management during recovery.

Results

Ninety-one patients were approached, of which 40 consented to participate (27 male, mean age 64 years). Symptom-report response rates were high (range 63–100%). Of 197 ePRO completions analysed, 76 (39%) triggered self-management advice, 72 (36%) trigged advice to contact a clinician, 9 (5%) triggered a clinician alert and 40 (20%) did not require advice. Participants found the ePRO system reassuring, providing timely information and advice relevant to supporting their recovery. Clinicians regarded the system as a useful adjunct to usual care, by signposting patients to seek appropriate help and enhancing their understanding of patients’ experiences during recovery.

Conclusion

Use of the ePRO system for the real-time, remote monitoring of symptoms in patients recovering from cancer-related upper gastrointestinal surgery is feasible and acceptable. A definitive randomised controlled trial is needed to evaluate the impact of the system on patients’ wellbeing after hospital discharge.

Identification and characterization of a Masculinizer homologue in the diamondback moth, Plutella xylostella

Recently, a novel sex-determination system was identified in the silkworm (Bombyx mori) in which a piwi-interacting RNA (piRNA) encoded on the female-specific W chromosome silences a Z-linked gene (Masculinizer) that would otherwise initiate male sex-determination and dosage compensation. Masculinizer provides various opportunities for developing improved genetic pest management tools. A pest lepidopteran in which a genetic pest management system has been developed, but which would benefit greatly from such improved designs, is the diamondback moth, Plutella xylostella. However, Masculinizer has not yet been identified in this species. Here, focusing on the previously described 'masculinizing' domain of B. mori Masculinizer, we identify P. xylostella Masculinizer (PxyMasc). We show that PxyMasc is Z-linked, regulates sex-specific alternative splicing of doublesex and is necessary for male survival. Similar results in B. mori suggest this survival effect is possibly through failure to initiate male dosage compensation. The highly conserved function and location of this gene between these two distantly related lepidopterans suggests a deep role for Masculinizer in the sex-determination systems of the Lepidoptera.

Change management reduces antibiotic use on pig farms

A clostridial 'syndrome' in suckling and weaner pigs, with risk factors of high injectable ceftiofur use and poor hygiene, presented an opportunity to engage in management change to improve pig health and reduce ceftiofur use on four farms. Management changes included all-in-all-out pig flow, batch disinfection with biofilm control, reduced protein starter diets, appropriate stocking density and the use of an anti-clostridial probiotic. Assessment of the program was obtained from a questionnaire. The health and production changes were positive across all farms and were associated with reduced use of antibiotics, together with cost and labour savings. Provided there is a good relationship between a committed, competent veterinarian, and a committed, competent manager, change management programs can be successfully implemented over 6-12 months.

Drug-resistant tuberculosis diagnosis since Xpert® MTB/RIF introduction in Papua New Guinea, 2012-2017

SETTING

Xpert® MTB/RIF was introduced in Papua New Guinea in 2012 for the diagnosis of tuberculosis (TB) and of rifampicin-resistant TB (RR-TB), a marker of multi-drug-resistant TB (MDR-TB).

OBJECTIVE

To assess the concordance of Xpert with phenotypic drug susceptibility testing (DST) performed at the supranational reference laboratory and to describe the patterns of drug-resistant TB observed.

DESIGN

This was a retrospective descriptive study of laboratory data collected from April 2012 to December 2017.

RESULTS

In 69 months, 1408 specimens with Xpert results were sent for mycobacterial culture and DST; Mycobacterium tuberculosis was cultured from 63% (884/1408) and DST was completed in 99.4%. The concordance between Xpert and culture for M. tuberculosis detection was 98.6%. Of 760 RR-TB cases, 98.7% were detected using Xpert; 98.5% of 620 MDR-TB cases were identified using phenotypic DST. Phenotypic resistance to second-line drugs was detected in 59.4% (522/879) of specimens tested, including 29 with fluoroquinolone resistance; the majority were from the National Capital District and Daru Island.

CONCLUSION

The high concordance between phenotypic DST and Xpert in identifying RR-TB cases supports the scale-up of initial Xpert testing in settings with high rates of drug resistance. However, rapid DST in addition to the detection of RR-TB is required.

Identification of Cystic Lesions by Secondary Screening of Familial Pancreatic Cancer (FPC) Kindreds Is Not Associated with the Stratified Risk of Cancer

OBJECTIVES

Intraductal papillary mucinous neoplasms (IPMNs) are associated with risk of pancreatic ductal adenocarcinoma (PDAC). It is unclear if an IPMN in individuals at high risk of PDAC should be considered as a positive screening result or as an incidental finding. Stratified familial pancreatic cancer (FPC) populations were used to determine if IPMN risk is linked to familial risk of PDAC.

METHODS

This is a cohort study of 321 individuals from 258 kindreds suspected of being FPC and undergoing secondary screening for PDAC through the European Registry of Hereditary Pancreatitis and Familial Pancreatic Cancer (EUROPAC). Computerised tomography, endoscopic ultrasound of the pancreas and magnetic resonance imaging were used. The risk of being a carrier of a dominant mutation predisposing to pancreatic cancer was stratified into three even categories (low, medium and high) based on: Mendelian probability, the number of PDAC cases and the number of people at risk in a kindred.

RESULTS

There was a median (interquartile range (IQR)) follow-up of 2 (0-5) years and a median (IQR) number of investigations per participant of 4 (2-6). One PDAC, two low-grade neuroendocrine tumours and 41 cystic lesions were identified, including 23 IPMN (22 branch-duct (BD)). The PDAC case occurred in the top 10% of risk, and the BD-IPMN cases were evenly distributed amongst risk categories: low (6/107), medium (10/107) and high (6/107) (P = 0.63).

CONCLUSIONS

The risk of finding BD-IPMN was independent of genetic predisposition and so they should be managed according to guidelines for incidental finding of IPMN.

Costs Related to Skin Cancer Prevention in Victoria and Australia

Background: The aim of this presentation is to provide an update on the economic evaluation of the Australian SunSmart program as well as outline the cost of skin cancer treatment to the Victorian public hospital system. This follows the publication of two recently released published economic evaluations that discusses the potential effects of skin cancer prevention inventions. Aim: 1. To highlight the cost effectiveness of skin cancer prevention in Australia 2. To highlight the costs of skin cancer treatment in the Victorian public hospital system 3. To provide strong evidence to inform governments of the value of skin cancer prevention to reduce the costs of treatment in future years. Methods: Program cost was compared with cost savings to determine the investment return of the program. In a separate study, a prevalence-based cost approach was undertaken in public hospitals in Victoria. Costs were estimated for inpatient admissions, using state service statistics, and outpatient services based on attendance at three hospitals in 2012-13. Cost-effectiveness for prevention was estimated from 'observed vs expected' analysis, together with program expenditure data. Results: With additional $AUD 0.16 ($USD 0.12) per capita investment into skin cancer prevention across Australia from 2011 to 2030, an upgraded SunSmart Program would prevent 45,000 melanoma and 95,000 NMSC cases. Potential savings in future healthcare costs were estimated at $200 million, while productivity gains were significant. A future upgraded SunSmart Program was predicted to be cost-saving from the funder perspective, with an investment return of $3.20 for every additional dollar the Australian governments/funding bodies invested into the program. In relation to the costs to the Victorian public hospital system, total annual costs were $48 million to $56 million. Skin cancer treatment in public hospitals ($9.20∼$10.39 per head/year) was 30-times current public funding in skin cancer prevention ($0.37 per head/year). Conclusion: The study demonstrates the strong economic credentials of the SunSmart Program, with a strong economic rationale for increased investment. Increased funding for skin cancer prevention must be kept high on the public health agenda. This would also have the dual benefit of enabling hospitals to redirect resources to nonpreventable conditions.

Oxidative Stress and Cardiovascular Risk in Type 1 Diabetes Mellitus: Insights From the DCCT/EDIC Study

Background

Hyperglycemia leading to increased oxidative stress is implicated in the increased risk for the development of macrovascular and microvascular complications in patients with type 1 diabetes mellitus.

Methods and Results

A random subcohort of 349 participants was selected from the DCCT / EDIC (Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications) cohort. This included 320 controls and 29 cardiovascular disease cases that were augmented with 98 additional known cases to yield a case cohort of 447 participants (320 controls, 127 cases). Biosamples from DCCT baseline, year 1, and closeout of DCCT , and 1 to 2 years post‐ DCCT ( EDIC years 1 and 2) were measured for markers of oxidative stress, including plasma myeloperoxidase, paraoxonase activity, urinary F 2α isoprostanes, and its metabolite, 2,3 dinor‐8 iso prostaglandin F 2α . Following adjustment for glycated hemoblobin and weighting the observations inversely proportional to the sampling selection probabilities, higher paraoxonase activity, reflective of antioxidant activity, and 2,3 dinor‐8 iso prostaglandin F 2α , an oxidative marker, were significantly associated with lower risk of cardiovascular disease (−4.5% risk for 10% higher paraoxonase, P <0.003; −5.3% risk for 10% higher 2,3 dinor‐8 iso prostaglandin F 2α , P =0.0092). In contrast, the oxidative markers myeloperoxidase and F 2α isoprostanes were not significantly associated with cardiovascular disease after adjustment for glycated hemoblobin. There were no significant differences between DCCT intensive and conventional treatment groups in the change in all biomarkers across time segments.

Conclusions

Heightened antioxidant activity (rather than diminished oxidative stress markers) is associated with lower cardiovascular disease risk in type 1 diabetes mellitus, but these biomarkers did not change over time with intensification of glycemic control.

Clinical Trial Registration

URL : https://www.clinicaltrials.gov . Unique identifiers: NCT 00360815 and NCT 00360893.

Translational study identifies XPF and MUS81 as predictive biomarkers for oxaliplatin-based peri-operative chemotherapy in patients with esophageal adenocarcinoma

Oxaliplatin-based chemotherapy is used to treat patients with esophageal adenocarcinoma (EAC), but no biomarkers are currently available for patient selection. We performed a prospective, clinical trial to identify potential biomarkers associated with clinical outcomes. Tumor tissue was obtained from 38 patients with resectable EAC before and after 2 cycles of oxaliplatin-fluorouracil chemotherapy. Pre-treatment mRNA expression of 280 DNA repair (DNAR) genes was tested for association with histopathological regression at surgery, disease-free survival (DFS) and overall survival (OS). High expression of 13 DNA damage repair genes was associated with DFS less than one year (P < 0.05); expression of 11 DNAR genes were associated with worse OS (P < 0.05). From clinical associations with outcomes, two genes, ERCC1 and EME1, were identified as candidate biomarkers. In cell lines in vitro, we showed the mechanism of action related to repair of oxaliplatin-induced DNA damage by depletion and knockout of protein binding partners of the candidate biomarkers, XPF and MUS81 respectively. In clinical samples from the clinical trial, pre-treatment XPF protein levels were associated with pathological response, and MUS81 protein was associated with 1-year DFS. XPF and MUS81 merit further validation in prospective clinical trials as biomarkers that may predict clinical response of EAC to oxaliplatin-based chemotherapy.

Trial protocol: a clustered, randomised, longitudinal, type 2 translational trial of alcohol consumption and alcohol-related harm among adolescents in Australia

Background

This cluster randomised control trial is designed to evaluate whether the Communities That Care intervention (CTC) is effective in reducing the proportion of secondary school age adolescents who use alcohol before the Australian legal purchasing age of 18 years. Secondary outcomes are other substance use and antisocial behaviours. Long term economic benefits of reduced alcohol use by adolescents for the community will also be assessed.

Methods

Fourteen communities and 14 other non-contiguous communities will be matched on socioeconomic status (SES), location, and size. One of each pair will be randomly allocated to the intervention in three Australian states (Victoria, Queensland and Western Australia). A longitudinal survey will recruit grade 8 and 10 students (M = 15 years old, N = 3500) in 2017 and conduct follow-up surveys in 2019 and 2021 (M = 19 years old). Municipal youth populations will also be monitored for trends in alcohol-harms using hospital and police administrative data.

Discussion

Community-led interventions that systematically and strategically implement evidence-based programs have been shown to be effective in producing population-level behaviour change, including reduced alcohol and drug use. We expect that the study will be associated with significant effects on alcohol use amongst adolescents because interventions adopted within communities will be based on evidence-based practices and target specific problems identified from surveys conducted within each community.

Trial registration

The trial was retrospectively registered in September, 2017 (ACTRN12616001276448), as communities were selected prior to trial registration; however, participants were recruited after registration. Findings will be disseminated in peer-review journals and community fora.

Intratumoural expression of deoxycytidylate deaminase or ribonuceotide reductase subunit M1 expression are not related to survival in patients with resected pancreatic cancer given adjuvant chemotherapy

BACKGROUND

Deoxycytidylate deaminase (DCTD) and ribonucleotide reductase subunit M1 (RRM1) are potential prognostic and predictive biomarkers for pyrimidine-based chemotherapy in pancreatic adenocarcinoma.

METHODS

Immunohistochemical staining of DCTD and RRM1 was performed on tissue microarrays representing tumour samples from 303 patients in European Study Group for Pancreatic Cancer (ESPAC)-randomised adjuvant trials following pancreatic resection, 272 of whom had received gemcitabine or 5-fluorouracil with folinic acid in ESPAC-3(v2), and 31 patients from the combined ESPAC-3(v1) and ESPAC-1 post-operative pure observational groups.

RESULTS

Neither log-rank testing on dichotomised strata or Cox proportional hazard regression showed any relationship of DCTD or RRM1 expression levels to survival overall or by treatment group.

CONCLUSIONS

Expression of either DCTD or RRM1 was not prognostic or predictive in patients with pancreatic adenocarcinoma who had had post-operative chemotherapy with either gemcitabine or 5-fluorouracil with folinic acid.

Expression of dihydropyrimidine dehydrogenase (DPD) and hENT1 predicts survival in pancreatic cancer

BACKGROUND

Dihydropyrimidine dehydrogenase (DPD) tumour expression may provide added value to human equilibrative nucleoside transporter-1 (hENT1) tumour expression in predicting survival following pyrimidine-based adjuvant chemotherapy.

METHODS

DPD and hENT1 immunohistochemistry and scoring was completed on tumour cores from 238 patients with pancreatic cancer in the ESPAC-3(v2) trial, randomised to either postoperative gemcitabine or 5-fluorouracil/folinic acid (5FU/FA).

RESULTS

DPD tumour expression was associated with reduced overall survival (hazard ratio, HR = 1.73 [95% confidence interval, CI = 1.21-2.49], p = 0.003). This was significant in the 5FU/FA arm (HR = 2.07 [95% CI = 1.22-3.53], p = 0.007), but not in the gemcitabine arm (HR = 1.47 [0.91-3.37], p = 0.119). High hENT1 tumour expression was associated with increased survival in gemcitabine treated (HR = 0.56 [0.38-0.82], p = 0.003) but not in 5FU/FA treated patients (HR = 1.19 [0.80-1.78], p = 0.390). In patients with low hENT1 tumour expression, high DPD tumour expression was associated with a worse median [95% CI] survival in the 5FU/FA arm (9.7 [5.3-30.4] vs 29.2 [19.5-41.9] months, p = 0.002) but not in the gemcitabine arm (14.0 [9.1-15.7] vs. 18.0 [7.6-15.3] months, p = 1.000). The interaction of treatment arm and DPD expression was not significant (p = 0.303), but the interaction of treatment arm and hENT1 expression was (p = 0.009).

CONCLUSION

DPD tumour expression was a negative prognostic biomarker. Together with tumour expression of hENT1, DPD tumour expression defined patient subgroups that might benefit from either postoperative 5FU/FA or gemcitabine.

Masked priming with graphemically related forms: Repetition or partial activation?

Form-priming occurs when a prime that is graphemically similar to the target word facilitates processing of the target. In an activation model (such as Morton's logogen model), such an effect can be interpreted as a partial-activation effect. A prime that shares letters with the target must inevitably produce activation in the detectors for both the prime and the target. Alternatively, form-priming could be seen as a special case of repetition-priming, in which the prime actually accesses the entry for the target. It is shown that masked-priming effects in the lexical decision task can be obtained for graphemically related pairs such as bontrast-CONTRAST, but not for four-letter pairs such as bamp-CAMP. It is suggested that the priming effect is controlled by neighbourhood density, short words usually having many neighbours, long words having very few. This hypothesis is supported by the finding that form-priming does occur for four-letter words if the prime and target are drawn from low-density neighbourhoods. For a partial-activation theory, an inhibitory mechanism that is sensitive to the number of prime-neighbours is required to explain the results. Of the several versions of a repetition account considered, the “best match” hypothesis appears to be the most promising: this assumes that priming is limited to the stimulus that best matches the prime. It is also shown that prime-target pairs that are related in form and meaning (e.g. made-MAKE) produce the same priming effect as identical pairs, as predicted by a repetition account that assumes a common entry underlying both forms.

Active transport and obesity prevention - A transportation sector obesity impact scoping review and assessment for Melbourne, Australia

Given the alarming prevalence of obesity worldwide and the need for interventions to halt the growing epidemic, more evidence on the role and impact of transport interventions for obesity prevention is required. This study conducts a scoping review of the current evidence of association between modes of transport (motor vehicle, walking, cycling and public transport) and obesity-related outcomes. Eleven reviews and thirty-three primary studies exploring associations between transport behaviours and obesity were identified. Cohort simulation Markov modelling was used to estimate the effects of body mass index (BMI) change on health outcomes and health care costs of diseases causally related to obesity in the Melbourne, Australia population. Results suggest that evidence for an obesity effect of transport behaviours is inconclusive (29% of published studies reported expected associations, 33% mixed associations), and any potential BMI effect is likely to be relatively small. Hypothetical scenario analyses suggest that active transport interventions may contribute small but significant obesity-related health benefits across populations (approximately 65 health adjusted life years gained per year). Therefore active transport interventions that are low cost and targeted to those most amenable to modal switch are the most likely to be effective and cost-effective from an obesity prevention perspective. The uncertain but potentially significant opportunity for health benefits warrants the collection of more and better quality evidence to fully understand the potential relationships between transport behaviours and obesity. Such evidence would contribute to the obesity prevention dialogue and inform policy across the transportation, health and environmental sectors.

Comparison of genome sequencing and clinical genotyping for pharmacogenes

We compared whole exome sequencing (WES, n = 176 patients) and whole genome sequencing (WGS, n = 68) and clinical genotyping (DMET array-based approach) for interrogating 13 genes with Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines. We focused on 127 CPIC important variants: 103 single nucleotide variations (SNV), 21 insertion/deletions (Indel), HLA-B alleles, and two CYP2D6 structural variations. WES and WGS provided interrogation of nonoverlapping sets of 115 SNV/Indels with call rate >98%. Among 68 loci interrogated by both WES and DMET, 64 loci (94.1%, confidence interval [CI]: 85.6-98.4%) showed no discrepant genotyping calls. Among 66 loci interrogated by both WGS and DMET, 63 loci (95.5%, CI: 87.2-99.0%) showed no discrepant genotyping calls. In conclusion, even without optimization to interrogate pharmacogenetic variants, WES and WGS displayed potential to provide reliable interrogation of most pharmacogenes and further validation of genome sequencing in a clinical lab setting is warranted.

Decreased Npas4 and Arc mRNA Levels in the Hippocampus of Aged Memory-Impaired Wild-Type But Not Memory Preserved 11β-HSD1 Deficient Mice

Mice deficient in the glucocorticoid-regenerating enzyme 11β-HSD1 resist age-related spatial memory impairment. To investigate the mechanisms and pathways involved, we used microarrays to identify differentially expressed hippocampal genes that associate with cognitive ageing and 11β-HSD1. Aged wild-type mice were separated into memory-impaired and unimpaired relative to young controls according to their performance in the Y-maze. All individual aged 11β-HSD1-deficient mice showed intact spatial memory. The majority of differentially expressed hippocampal genes were increased with ageing (e.g. immune/inflammatory response genes) with no genotype differences. However, the neuronal-specific transcription factor, Npas4, and immediate early gene, Arc, were reduced (relative to young) in the hippocampus of memory-impaired but not unimpaired aged wild-type or aged 11β-HSD1-deficient mice. A quantitative reverse transcriptase-polymerase chain reaction and in situ hybridisation confirmed reduced Npas4 and Arc mRNA expression in memory-impaired aged wild-type mice. These findings suggest that 11β-HSD1 may contribute to the decline in Npas4 and Arc mRNA levels associated with memory impairment during ageing, and that decreased activity of synaptic plasticity pathways involving Npas4 and Arc may, in part, underlie the memory deficits seen in cognitively-impaired aged wild-type mice.

Elevated presence of myeloid dendritic cells in nasal polyps of patients with chronic rhinosinusitis

BACKGROUND

Although chronic rhinosinusitis with nasal polyps (CRSwNP) is characterized by Th2 inflammation, the mechanism underlying the onset and amplification of this inflammation has not been fully elucidated. Dendritic cells (DCs) are major antigen-presenting cells, central inducers of adaptive immunity and critical regulators of many inflammatory diseases. However, the presence of DCs in CRS, especially in nasal polyps (NPs), has not been extensively studied.

OBJECTIVE

The objective of this study was to characterize DC subsets in CRS.

METHODS

We used real-time PCR to assess the expression of mRNA for markers of myeloid DCs (mDCs; CD1c), plasmacytoid DCs (pDCs; CD303) and Langerhans cells (LCs; CD1a, CD207) in uncinate tissue (UT) from controls and patients with CRS as well as in NP. We assayed the presence of DCs by immunohistochemistry and flow cytometry.

RESULTS

Compared to UT from control subjects (n = 15) and patients with CRS without NP (CRSsNP) (n = 16) and CRSwNP (n = 17), mRNAs for CD1a and CD1c were significantly elevated in NPs (n = 29). In contrast, CD207 mRNA was not elevated in NPs. Immunohistochemistry showed that CD1c(+) cells but not CD303(+) cells were significantly elevated in NPs compared to control subjects or patients with CRSsNP. Flow cytometric analysis showed that CD1a(+) cells in NPs might be a subset of mDC1s and that CD45(+) CD19(-) CD1c(+) CD11c(+) CD141(-) CD303(-) HLA-DR(+) mDC1s and CD45(+) CD19(-) CD11c(+) CD1c(-) CD141(high) HLA-DR(+) mDC2s were significantly elevated in NPs compared to UT from controls and CRSsNP, but CD45(+) CD11c(-) CD303(+) HLA-DR(+) pDCs were only elevated in NPs compared to control UT.

CONCLUSION AND CLINICAL RELEVANCE

Myeloid DCs are elevated in CRSwNP, especially in NPs. Myeloid DCs thus may indirectly contribute to the inflammation observed in CRSwNP.

Maternal obesity programs offspring non-alcoholic fatty liver disease through disruption of 24-h rhythms in mice

BACKGROUND

Maternal obesity increases offspring propensity to metabolic dysfunctions and to non-alcoholic fatty liver disease (NAFLD), which may lead to cirrhosis or liver cancer. The circadian clock is a transcriptional/epigenetic molecular machinery synchronising physiological processes to coordinate energy utilisation within a 24-h light/dark period. Alterations in rhythmicity have profound effects on metabolic pathways, which we sought to investigate in offspring with programmed NAFLD.

METHODS

Mice were fed a standard or an obesogenic diet (OD), before and throughout pregnancy, and during lactation. Offspring were weaned onto standard or an OD at 3 weeks postpartum and housed in 12:12 light/dark conditions. Biochemical and histological indicators of NAFLD and fibrosis, analysis of canonical clock genes with methylation status and locomotor activity were investigated at 6 months.

RESULTS

We show that maternal obesity interacts with an obesogenic post-weaning diet to promote the development of NAFLD with disruption of canonical metabolic rhythmicity gene expression in the liver. We demonstrate hypermethylation of BMAL-1 (brain and muscle Arnt like-1) and Per2 promoter regions and altered 24-h rhythmicity of hepatic pro-inflammatory and fibrogenic mediators.

CONCLUSIONS

These data implicate disordered circadian rhythms in NAFLD and suggest that disruption of this system during critical developmental periods may be responsible for the onset of chronic liver disease in adulthood.

Chlamydia screening for pregnant women aged 16-25 years attending an antenatal service: a cost-effectiveness study

OBJECTIVE

Determine the cost-effectiveness of screening all pregnant women aged 16-25 years for chlamydia compared with selective screening or no screening.

DESIGN

Cost effectiveness based on a decision model.

SETTING

Antenatal clinics in Australia.

SAMPLE

Pregnant women, aged 16-25 years.

METHODS

Using clinical data from a previous study, and outcomes data from the literature, we modelled the short-term perinatal (12-month time horizon) incremental direct costs and outcomes from a government (as the primary third-party funder) perspective for chlamydia screening. Costs were derived from the Medicare Benefits Schedule, Pharmaceutical Benefits Scheme, and average cost-weights reported for hospitalisations classified according to the Australian refined diagnosis-related groups.

MAIN OUTCOME MEASURES

Direct costs of screening and managing chlamydia complications, number of chlamydia cases detected and treated, and the incremental cost-effectiveness ratios were estimated and subjected to sensitivity analyses.

RESULTS

Assuming a chlamydia prevalence rate of 3%, screening all antenatal women aged 16-25 years at their first antenatal visit compared with no screening was $34,931 per quality-adjusted life-years gained. Screening all women could result in cost savings when chlamydia prevalence was higher than 11%. The incremental cost-effectiveness ratios were most sensitive to the assumed prevalence of chlamydia, the probability of pelvic inflammatory disease, the utility weight of a positive chlamydia test and the cost of the chlamydia test and doctor's appointment.

CONCLUSION

From an Australian government perspective, chlamydia screening of all women aged 16-25 years old during one antenatal visit was likely to be cost-effective compared with no screening or selective screening, especially with increasing chlamydia prevalence.

TWEETABLE ABSTRACT

Chlamydia screening for all pregnant women aged 16-25 years during an antenatal visit is cost effective.

Ovarian hyperstimulation syndrome on the acute medical unit: a problem-based review

Ovarian Hyperstimulation Syndrome (OHSS) is a spectrum of clinical features typically resulting from assisted conception techniques. With 2.35% of all live births in the UK resulting from in-vitro fertilisation (IVF), OHSS is on the rise. Moreover, there has been an increase in the presentation of its complications to GP surgeries and unscheduled acute care services nationwide. This review will discuss signs and symptoms of the increasingly common and potentially fatal complications of OHSS, namely pleural effusion, ascites and thromboembolic events. With such propensity toward critical, life-threatening events it is not only prudent to recognise the population at risk, but also to be aware of the signs, symptoms and complications to expedite treatment and ensure optimum outcome.

Computer-aided diagnosis improves detection of small intracranial aneurysms on MRA in a clinical setting

BACKGROUND AND PURPOSE

MRA is widely accepted as a noninvasive diagnostic tool for the detection of intracranial aneurysms, but detection is still a challenging task with rather low detection rates. Our aim was to examine the performance of a computer-aided diagnosis algorithm for detecting intracranial aneurysms on MRA in a clinical setting.

MATERIALS AND METHODS

Aneurysm detectability was evaluated retrospectively in 48 subjects with and without computer-aided diagnosis by 6 readers using a clinical 3D viewing system. Aneurysms ranged from 1.1 to 6.0 mm (mean = 3.12 mm, median = 2.50 mm). We conducted a multireader, multicase, double-crossover design, free-response, observer-performance study on sets of images from different MRA scanners by using DSA as the reference standard. Jackknife alternative free-response operating characteristic curve analysis with the figure of merit was used.

RESULTS

For all readers combined, the mean figure of merit improved from 0.655 to 0.759, indicating a change in the figure of merit attributable to computer-aided diagnosis of 0.10 (95% CI, 0.03-0.18), which was statistically significant (F(1,47) = 7.00, P = .011). Five of the 6 radiologists had improved performance with computer-aided diagnosis, primarily due to increased sensitivity.

CONCLUSIONS

In conditions similar to clinical practice, using computer-aided diagnosis significantly improved radiologists' detection of intracranial DSA-confirmed aneurysms of ≤6 mm.

How is cyber threat evolving and what do organisations need to consider?

Organisations and members of the public are becoming accustomed to the increasing velocity, frequency and variety of cyber-attacks that they have been facing over the last few years. In response to this challenge, it is important to explore what can be done to offer commercial and private users a reliable and functioning environment. This paper discusses how cyber threats might evolve in the future and seeks to explore these threats more fully. Attention is paid to the changing nature of cyber-attackers and their motivations and what this means for organisations. Finally, useful and actionable steps are provided, which practitioners can use to understand how they can start to address the future challenges of cyber security.

High field structural MRI reveals specific episodic memory correlates in the subfields of the hippocampus

The involvement of the hippocampus (HC) in episodic memory is well accepted; however it is unclear how each subfield within the HC contributes to memory function. Recent magnetic resonance imaging (MRI) studies suggest differential involvement of hippocampal subfields and subregions in episodic memory. However, most structural MRI studies have examined the HC subfields within a single subregion of the HC and used specialised experimental memory paradigms. The purpose of the present study was to determine the association between volumes of HC subfields throughout the entire HC structure and performance on standard neuropsychological memory tests in a young, healthy population. We recruited 34 healthy participants under the age of 50. MRI data was acquired with a fast spin echo (FSE) sequence yielding a 0.52×0.68×1.0 mm(3) native resolution. The HC subfields - the cornu ammonis 1-3 (CA), dentate gyrus (DG), and subiculum (SUB) - were segmented manually within three hippocampal subregions using a previously defined protocol. Participants were administered the Wechsler Memory Scale, 4th edition (WMS-IV) to assess performance in episodic memory using verbal (Logical Memory, LM) and visual (Designs, DE; visual-spatial memory, DE-Spatial; visual-content memory, DE-Content) memory subtests. Working memory subtests (Spatial Addition, SA; and Symbol Span, SSP) were included as well. Working memory was not associated with any HC volumes. Volumes of the DG were correlated with verbal memory (LM) and visual-spatial memory (DE-Spatial). Posterior CA volumes correlated with both visual-spatial and visual-object memory (DE-Spatial, DE-Content). In general, anterior subregion volumes (HC head) correlated with verbal memory, while some anterior and many posterior HC subregion volumes (body and tail) correlated with visual memory scores (DE-Spatial, DE-Content). In addition, while verbal memory showed left-lateralized associations with HC volumes, visual memory was associated with HC volumes bilaterally. This the first study to examine the associations between hippocampal subfield volumes across the entire hippocampal formation with performance in a set of standard memory tasks.

Pre-operative cardiopulmonary exercise testing predicts adverse post-operative events and non-progression to adjuvant therapy after major pancreatic surgery

BACKGROUND

Surgery followed by chemotherapy is the primary modality of cure for patients with resectable pancreatic cancer but is associated with significant morbidity. The aim of the present study was to evaluate the role of cardiopulmonary exercise testing (CPET) in predicting post-operative adverse events and fitness for chemotherapy after major pancreatic surgery.

METHODS

Patients who underwent a pancreaticoduodenectomy or total pancreatectomy for pancreatic head lesions and had undergone pre-operative CPET were included in this retrospective study. Data on patient demographics, comorbidity and results of pre-operative evaluation were collected. Post-operative adverse events, hospital stay and receipt of adjuvant therapy were outcome measures.

RESULTS

One hundred patients were included. Patients with an anaerobic threshold less than 10 ml/kg/min had a significantly greater incidence of a post-operative pancreatic fistula [International Study Group for Pancreatic Surgery (ISGPS) Grades A-C, 35.4% versus 16%, P = 0.028] and major intra-abdominal abscesses [Clavien-Dindo (CD) Grades III-V, 22.4% versus 7.8%, P = 0.042] and were less likely to receive adjuvant therapy [hazard ratio (HR) 6.30, 95% confidence interval (CI) 1.25-31.75, P = 0.026]. A low anaerobic threshold was also associated with a prolonged hospital stay (median 20 versus 14 days, P = 0.005) but not with other adverse events.

DISCUSSION

CPET predicts a post-operative pancreatic fistula, major intra-abdominal abscesses as well as length of hospital stay after major pancreatic surgery. Patients with a low anaerobic threshold are less likely to receive adjuvant therapy.

Offering fragile X syndrome carrier screening: a prospective mixed-methods observational study comparing carrier screening of pregnant and non-pregnant women in the general population

INTRODUCTION

Fragile X syndrome (FXS) is the leading cause of inherited intellectual and developmental disability. Policy development relating to carrier screening programmes for FXS requires input from large studies examining not only test uptake but also psychosocial aspects. This study will compare carrier screening in pregnant and non-pregnant populations, examining informed decision-making, psychosocial issues and health economics.

METHODS AND ANALYSIS

Pregnant and non-pregnant women are being recruited from general practices and obstetric services. Women receive study information either in person or through clinic mail outs. Women are provided pretest counselling by a genetic counsellor and make a decision about testing in their own time. Data are being collected from two questionnaires: one completed at the time of making the decision about testing and the second 1 month later. Additional data are gathered through qualitative interviews conducted at several time points with a subset of participating women, including all women with a positive test result, and with staff from recruiting clinics. A minimum sample size of 500 women/group has been calculated to give us 88% power to detect a 10% difference in test uptake and 87% power to detect a 10% difference in informed choice between the pregnant and non-pregnant groups. Questionnaire data will be analysed using descriptive statistics and multivariate logistic regression models. Interview data will be thematically analysed. Willingness-to-pay and cost effectiveness analyses will also be performed. Recruitment started in July 2009 and data collection will be completed by December 2013.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the Universities of Melbourne and Western Australia and by recruiting clinics, where required. Results will be reported in peer-reviewed publications, conference presentations and through a website http://www.fragilexscreening.net.au. The results of this study will make a significant contribution to discussions about the wider introduction of population carrier screening for FXS.