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Although we are unaware of the existence of a recognized fetal MRI qualification, individuals who perform fetal MRI should have undergone specialized training in collaboration with a teaching center, enabling them to perform a state-of-the-art fetal MRI examination after exposure to a sufficient number of cases. Introduction Fetal magnetic resonance imaging (MRI) is an important diagnostic imaging adjunct to ultrasonography[1], especially for evaluation of the fetal brain, lungs and bowel[2] and the placenta[3]. Factors influencing the decision to perform fetal MRI include, but are not limited to: experience/equipment of the ultrasound and MRI facilities, accessibility to MRI, maternal conditions such as obesity, abdominal scarring and oligohydramnios, gestational age, safety concerns, legal considerations regarding termination of pregnancy (TOP) and parental wishes after appropriate counseling[8]. [Extracted from the article]

For our purposes, DAW refers to the common clinical scenario in which, because of degraded image quality, and despite efforts (described below) to optimize fetal cardiac imaging, an examination cannot demonstrate sufficiently the recommended components of the fetal heart. Formal guidelines for fetal cardiac imaging1-5 delineate parameters felt to represent the most important components of the sonographic assessment of the fetal heart. Part of the problem is that current guidelines for fetal cardiac imaging provide minimal guidance for cases in which, because of persistently and significantly degraded acoustic windows (DAW), some of the recommended components of the fetal heart cannot be visualized sufficiently. [Extracted from the article]

Objective: The Nuchal Translucency Quality Review (NTQR) program has provided standardized education, credentialing and epidemiological monitoring of nuchal translucency (NT) measurements since 2005. Our aim was to review the effect on NT measurement of provider characteristics since the program's inception.Methods: We evaluated the distribution of NT measurements performed between January 2005 and December 2019, for each of the three primary performance indicators of NT measurement (NT median multiples of the median (MoM), SD of log10 NT MoM and slope of NT with respect to crown-rump length (CRL)) for all providers within the NTQR program with more than 30 paired NT/CRL results. Provider characteristics explored as potential sources of variability included: number of NT ultrasound examinations performed annually (annual scan volume of the provider), duration of participation in the NTQR program, initial credentialing by an alternative pathway, provider type (physician vs sonographer) and number of NT-credentialed providers within the practice (size of practice). Each of these provider characteristics was evaluated for its effect on NT median MoM and geometric mean of the NT median MoM weighted for the number of ultrasound scans, and multiple regression was performed across all variables to control for potential confounders.Results: Of 5 216 663 NT measurements from 9340 providers at 3319 sites, the majority (75%) of providers had an NT median MoM within the acceptable range of 0.9-1.1 and 85.5% had NT median MoM not statistically significantly outside this range. Provider characteristics associated with measurement within the expected range of performance included higher volume of NT scans performed annually, practice at a site with larger numbers of other NT-credentialed providers, longer duration of participation in the NTQR program and alternative initial credentialing pathway.Conclusions: Annual scan volume, duration of participation in the NTQR program, alternative initial credentialing pathway and number of other NT-credentialed providers within the practice are all associated with outcome metrics indicating quality of performance. It is critical that providers participate in ongoing quality assessment of NT measurement to maintain consistency and precision. Ongoing assessment programs with continuous feedback and education are necessary to maintain quality care. © 2021 International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the accuracy of an automated three-dimensional (3D) ultrasound technique for fetal intracranial measurements compared with manual acquisition.Methods: This was a prospective observational study of patients presenting for routine anatomical survey between 18 + 0 and 22 + 6 weeks' gestation. After providing informed consent, each patient underwent two consecutive ultrasound examinations of the fetal head, one by a sonographer and one by a physician. Each operator obtained manual measurements of the biparietal diameter (BPD), head circumference (HC), transcerebellar diameter (TCD), cisterna magna (CM) and posterior horn of the lateral ventricle (Vp), followed by automated measurements of these structures using an artificial intelligence-based tool, SonoCNS® Fetal Brain. Both operators repeated the automated approach until all five measurements were obtained in a single sweep, up to a maximum of three attempts. The accuracy of automated measurements was compared with that of manual measurements using intraclass correlation coefficients (ICC) by operator type, accounting for patient and ultrasound characteristics.Results: One hundred and forty-three women were enrolled in the study. Median body mass index was 24.0 kg/m2 (interquartile range (IQR), 22.5-26.8 kg/m2 ) and median subcutaneous thickness was 1.6 cm (IQR, 1.3-2.0 cm). Fifteen (10%) patients had at least one prior Cesarean delivery, 17 (12%) had other abdominal surgery and 78 (55%) had an anterior placenta. Successful acquisition of the automated measurements was achieved on the first, second and third attempts in 70%, 22% and 3% of patients, respectively, by sonographers and in 76%, 16% and 3% of cases, respectively, by physicians. The automated algorithm was not able to identify and measure all five structures correctly in six (4%) and seven (5%) patients scanned by the sonographers and physicians, respectively. The ICCs reflected good reliability (0.80-0.88) of the automated compared with the manual approach for BPD and HC and poor to moderate reliability (0.23-0.50) for TCD, CM and Vp. Fetal lie, head position, placental location, maternal subcutaneous thickness and prior Cesarean section were not associated with the success or accuracy of the automated technique.Conclusions: Automated 3D ultrasound imaging of the fetal head using SonoCNS reliably identified and measured BPD and HC but was less consistent in accurately identifying and measuring TCD, CM and Vp. While these results are encouraging, further optimization of the automated technology is necessary prior to incorporation of the technique into routine sonographic protocols. © 2020 International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

Objective: Screening via noninvasive prenatal testing (NIPT) involving the analysis of cell-free DNA (cfDNA) from plasma has become readily available to screen for chromosomal and DNA aberrations through maternal blood. This report reviews a laboratory's experience with follow-up of positive NIPT screens for microdeletions.Methods: Patients that were screened positive by NIPT for a microdeletion involving 1p, 4p, 5p, 15q, or 22q who underwent diagnostic studies by either chorionic villus sampling or amniocentesis were evaluated.Results: The overall positive predictive value for 349 patients was 9.2%. When a microdeletion was confirmed, 39.3% of the cases had additional abnormal microarray findings. Unrelated abnormal microarray findings were detected in 11.8% of the patients in whom the screen positive microdeletion was not confirmed. Stretches of homozygosity in the microdeletion were frequently associated with a false positive cfDNA microdeletion result.Conclusions: Overall, this report reveals that while cfDNA analysis will screen for microdeletions, the positive predictive value is low; in our series it is 9.2%. Therefore, the patient should be counseled accordingly. Confirmatory diagnostic microarray studies are imperative because of the high percentage of false positives and the frequent additional abnormalities not delineated by cfDNA analysis. [ABSTRACT FROM AUTHOR]

An editorial is presented in which the author discusses three-dimensional imaging of bony structures of the fetal head and face. Topics discussed include conduction of imaging for fetal development by using methods including, three-dimensional-ultrasound (3D-US) multiplanar imaging, and tomographic imaging.

The article focuses on fetal magnetic resonance imaging (MRI) practice guidelines developed by the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) following a survey in 2014. Topics include fetal MRI as an imaging adjunct to ultrasonography for fetal brain development assessment, factors influencing performance such as gestational age and termination of pregnancy (TOP) and improvement in management of complicated pregnancies from standardized criteria MRI.

Objectives: To describe our experience with non-invasive prenatal testing (NIPT) in twin pregnancy.Methods: Two sets of maternal blood samples from twin pregnancies were analyzed at our laboratory using NIPT: 115 stored samples from pregnancies with known outcome (Clinical Study A) and 487 prospectively collected samples for which outcomes were requested from providers (Clinical Study B). NIPT was used to screen for the presence of fetal aneuploidy on chromosomes 13, 18, 21, X and Y in all cases, and results were compared with outcomes when known.Results: In Clinical Study A, all 115 samples were classified correctly by NIPT: three cases of trisomy 21 (one fetus affected), one of monochorionic trisomy 18 (both fetuses affected) and 111 euploid. In Clinical Study B, a NIPT result was reported for 479 (98.4%) of the 487 samples. Aneuploidy was detected or suspected in nine (1.9%) cases: seven cases of trisomy 21 detected, one case of trisomy 21 suspected and one case with trisomy 21 detected and trisomy 18 suspected. Information on aneuploidy outcome was available for 171 (35.7%) cases in Clinical Study B. Of the nine cases with aneuploidy detected or suspected, six were confirmed to be a true positive in at least one twin based on karyotype or birth outcome and two were suspected to be concordant based on ultrasound findings; the one known discordant result was for the aneuploidy suspected case. No false negatives were reported.Conclusion: NIPT performed well in the detection of trisomy 21 in twin pregnancy, with a combined false-positive frequency for trisomies 13, 18 and 21 of 0% for Clinical Study A and 0.2% for Clinical Study B. © 2016 Illumina. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

ABSTRACT Objective To evaluate the performance of first-trimester nuchal translucency ( NT) measurement by providers (physician-sonologists and sonographers) within the Nuchal Translucency Quality Review ( NTQR) program. Methods After training and credentialing providers, the NTQR monitored performance of NT measurement by the extent to which an individual's median multiple of the normal median ( MoM) for crown-rump length ( CRL) was within the range 0.9-1.1 MoM of a published normal median curve. The SD of log10 MoM and regression slope of NT on CRL were also evaluated. We report the distribution between providers of these performance indicators and evaluate potential sources of variation. Results Among the first 1.5 million scans in the NTQR program, performed between 2005 and 2011, there were 1 485 944 with CRL in the range 41-84 mm, from 4710 providers at 2150 ultrasound units. Among the 3463 providers with at least 30 scans in total, the median of the providers' median NT-MoMs was 0.913. Only 1901 (55%) had a median NT-MoM within the expected range; there were 89 above 1.1 MoM, 1046 at 0.8-0.9 MoM, 344 at 0.7-0.8 MoM and 83 below 0.7 MoM. There was a small increase in the median NT-MoM according to providers' length of time in the NTQR program and number of scans entered annually. On average, physician-sonologists had a higher median NT-MoM than did sonographers, as did those already credentialed before joining the program. The median provider SD was 0.093 and the median slope was 13.5%. SD correlated negatively with the median NT-MoM ( r = −0.34) and positively with the slope ( r = 0.22). Conclusion Even with extensive training, credentialing and monitoring, there remains considerable variability between NT providers. There was a general tendency towards under-measurement of NT compared with expected values, although more experienced providers had performance closer to that expected. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd. [ABSTRACT FROM AUTHOR]

Transition from design to adoption of innovations must be evidence-based and inform product development, regulatory approval and adoption. [ABSTRACT FROM AUTHOR]

Background and Objective: The prenatal detection of congenital heart defects remains one of the most difficult challenges for the sonologist/sonographer when performing the second- or third-trimester screening examination. The four-chamber view has been used for a number of years as the primary screening image for detection of heart defects, but the inclusion of the right and left outflow tracts increases the detection of cardiac malformations. One of the difficulties, however, is obtaining and interpreting two-dimensional images of the outflow tracts. This paper reviews a new technique using three-dimensional (3D) multiplanar imaging that allows the examiner to identify the outflow tracts within a few minutes of acquiring the 3D volume dataset by rotating the volume dataset around the x- and y-axes. Methods: 3D multiplanar imaging of the fetal heart using static 3D or spatio-temporal image correlation (STIC) imaging allows the examiner to obtain a volume of data that can be manipulated along the x- and y-axes using reference points from the four-chamber view, five-chamber view, three-vessel view at the level of the bifurcation of the pulmonary arteries, and three-vessel view at the level of the transverse aortic arch and trachea. Results: The full length of the main pulmonary artery, ductus arteriosus, aortic arch and superior vena cava could be identified easily in the normal fetus by rotating the volume dataset along the x- and y-axes. The vessels were identified using the four-chamber view, the five-chamber view, and the two three-vessel views. The technique was useful in identification of d-transposition of the great vessels and evaluation of the outflow tracts in hypoplastic left heart syndrome. Conclusion: 3D multiplanar evaluation of the fetal heart allows the examiner to identify the outflow tracts using a simple technique that requires only rotation around x- and y-axes from reference images obtained in a transverse sweep through the fetal chest. [ABSTRACT FROM AUTHOR]

ABSTRACT Objective To describe the process of training for measuring nuchal translucency at five clinical centers in North America and to evaluate methods of quality assurance and feedback. Design Throughout a period of 18 months, the performance of sonographers in measuring fetal nuchal translucency was monitored using qualitative and quantitative methods of review. After 12 months, different approaches (written and personal feedback) were used to inform sonographers of technical aspects that needed to or could be improved. Results On initial qualitative review, discrepancies in judgment from different reviewers coincided with suboptimal magnification, failure to visualize the amniotic membrane and/or use of cross-shaped calipers. At subsequent global review, 13 (29%) images of nuchal translucency measurements were considered unacceptable. Quantitative assessment revealed that, during the first part of the study, the means from four sonographers were significantly smaller and the mean from the fifth sonographer was significantly larger than expected on the basis of findings from The Fetal Medicine Foundation (P < 0.0001). Following feedback, sonographers who underestimated nuchal translucency and who received a written report only did not change measurements overall (P = 0.9759). In contrast, those who received additional intervention showed a marked difference (P < 0.0001). Conclusions Global qualitative review of images from one sonographer may be preferable to assessment of individual aspects of images. Results from global qualitative review correspond well with findings from quantitative analysis, indicating that the latter can be applied for ongoing audit. Observation of divergent results should prompt extensive personal feedback, rather than a written report, to prevent sonographers from settling in their own, inappropriate technique. [ABSTRACT FROM AUTHOR]

Editorial. Highlights developments in three-dimensional (3D) ultrasound as of September 2000. Application of obstetric and gynecologic imaging in breast and ovarian pathology; Sources of artifacts observed in 3D sonography; Monitoring of follicular response during ovarian stimulation; Techniques used in the evaluation of needle position during breast biopsy.

This study assesses two methods used to define relatively short femur in screening for trisomy 21 and examines changes in performance of screening with gestational age. Retrospective analysis of data on menstrual age, femur length (FL) and biparietal diameter (BPD) in 49 trisomy 21 pregnancies and 6069 normal controls. Reference ranges were derived for BPD/FL versus menstrual age and for FL versus BPD. Two methods of defining short femur (BPD/FL and observed-to-expected FL ratio) were examined for false-positive rates and detection rates for trisomy 21 at different gestational ages. In the control group the BPD/FL ratio and its standard deviation decreased with menstrual age. Trisomy 21 was associated with a significantly higher BPD/FL ratio (P < 0.001) and the deviation increased significantly with menstrual age (P < 0.05). Eleven percent of 28 fetuses examined at 15–17 weeks had a BPD/FL above the 95th centile compared with 24% of 21 fetuses examined at 18–20 weeks (P = 0.40). The median observed-to-expected FL ratio in the control group was 1.0 throughout the gestational age range but the standard deviation decreased significantly with menstrual age (P < 0.01). Trisomy 21 was associated with a significantly reduced observed-to-expected FL ratio (P < 0.001) and the deviation increased significantly with menstrual age (P < 0.05). A fixed cut-off of 0.91 for observed-to-expected FL ratio provided a false-positive rate of 12% at 15–17 weeks compared with 6% at 18–20 weeks of gestation (P < 0.001) with detection rates of 29 and 38%, respectively (P = 0.73). Irrespective of the definition used to define the condition, relatively short femur is a poor marker for trisomy 21 particularly when the assessment takes place before 18 weeks of gestation. [ABSTRACT FROM AUTHOR]

The Maternal PKU Study began in 1984 and during the intervening years, 572 pregnancies in women with hyperphenylalaninemia (HPA) and 99 controls and their outcomes have been evaluated. Among Women with HPA who delivered a live infant, only 15.9% were treated and in metabolic control preconceptionally; however, another 18.4% were in control by 10 weeks. Compared to the results reported by Lenke and Levy in 1980, there is a marked improvement in outcome with treatment. Microcephaly was unusual in preconceptionally treated pregnancies with well-controlled phenylalanine-restricted diets. Even in pregnancies that established control after conception but before the 8th week, congenital heart disease did not occur in the offspring; however, it did occur in 12% of pregnancies not achieving control until after 10 weeks of pregnancy. The recommended level of blood phenylalanine during pregnancy is 120–360 μmol/L. Best results were obtained by close cooperation between the attending obstetrician and a metabolic team experienced in the care of persons with phenylketonuria. MRDD Research Reviews 1999;5:117–121. © 1999 Wiley-Liss, Inc. [ABSTRACT FROM AUTHOR]

Subglottic stenosis was corrected surgically in three young children. The key surgical maneuver is the anterior and posterior division of the cricoid cartilage. Endoscopic, xerographic and speech assessments have been done at intervals since decannulation. The anterior commissure is widened and the endolarynx deformed in two children examined. Radiographic studies indicated that increased airway diameters have been maintained to date. Speech has been adversely affected to some degree in all three patients. [ABSTRACT FROM AUTHOR]

- Thirty-two female patients with clinical and urodynamic findings of genuine stress urinary incontinence were evaluated before and 6 months after surgery for stress urinary incontinence. Twenty-nine control patients had identical evaluations before and 6 months after surgery which did not involve the urethrovesical junction. Twenty-four patients with primary bladder instability had similar evaluations and served as a second control group. Anatomical landmarks indicating support to the urethrovesical junction were evaluated by the position of the urethra at the most dependent point in the bladder on straining and the urethral descent on straining to beneath the posterior ramus of the symphysis pubis on bead chain cystography. The urethrovesical junction drop on straining was evaluated by transrectal ultrasonography. Cystographic and ultrasonographic tests for the position of the urethrovesical junction at the most dependent position in the bladder during straining were very sensitive in women with stress urinary incontinence (94 and 87% respectively) but much less specific (45 and 48% respectively). When evaluating anatomical support to the urethrovesical junction and its descent on straining, these tests were both highly sensitive (97 and 94% respectively) and specific (76 and 96% respectively) in women with genuine stress urinary incontinence. Simple clinical tests for support of the urethrovesical junction, such as the Q tip test, are nonspecific in patients with stress urinary incontinence. Transrectal ultrasonography is a simple and quick out-patient procedure. The availability of ultrasound equipment in most clinics and the high sensitivity and specificity of the test make it an attractive and cost-effective alternative to X-ray cystography in the pre-operative evaluation of anatomical support to the urethrovesical junction. [ABSTRACT FROM AUTHOR]

An abstract of the conference paper "Visualization of the fetal three vessel view, aortic arch, and ductal arch views: A comparison of 2-D and 3-D rapid acquisition at 18-22 weeks gestation," by L. Cohen and colleagues is presented.

An abstract of the research paper "Satisfactory Visualization Rates of Standard Cardiac Views at 18-22 Weeks Gestation: A Comparison of Static 2-D and Spatial Temporal Image Correlation (STIC 4-D)," by L. Cohen and colleagues is presented.

The author reflects on the growth of the International Society of Ultrasound in Obstetrics and Gynecology, the publisher of the journal "Ultrasound in Obstetrics and Gynecology." He said that while the organization's journal has been in its 13th anniversary, it has served its purpose which is to provide information related to the field since in its first issue. Meanwhile, the author believes that the society have realized all its goals and have continued serving people as it promised.

Deals with the challenge faced by the editors of `Ultrasound in Obstetrics and Gynecology' journal in the publication of papers on the use of color and pulsed Doppler ultrasound in the first trimester of pregnancy. Information on the theoretical risks of Doppler examination for the fetus in the early first trimester of pregnancy; Policy adopted by the journal on Doppler studies in the first trimester.

An abstract of the article "Cost-effectiveness of testing amniotic fluid for alpha-fetoprotein and acetocholinesterase versus detailed ultrasound," by A. A. Flick, D. Krakow and L. D. Platt is presented.

An abstract of the article "Potential role and clinical impact of noninvasive prenatal testing by massively parallel DNA sequencing of maternal blood," by A. J. Sehnert is presented.

An abstract of the article "The impact of fetal renal pelvic diameter on postnatal outcome," by A. A. Shamshirsaz and colleagues is presented.

An abstract of the article "Intra- and inter-observer variability of crown-rump length and other fetal biometry at the nuchal translucency scan," by R. Gutkin and colleagues is presented.

An abstract of the article "Nuchal Translucency Education and Quality Review (NTQR) program: first one million results," by H. Cuckle and colleagues is presented.

An abstract of the article "Accuracy and precision of crown-rump length and other fetal biometry in nuchal translucency screening interpretation," by R. Gutkin and colleagues is presented.

An abstract of the article "Assisted reproductive technologies and fetal anomalies in multiple gestations," by R. Gutkin and colleagues is presented.

An abstract of the conference paper "Expanded singleton first trimester fetal biometry," by L. D. Platt, E. Bruckner and D. Kahn is presented.

An abstract of the conference paper "Safety of ultrasonography in pregnancy: WHO systematic review of the literature and meta-analysis," by M. R. Torloni, and colleagues is presented.

An abstract of the conference paper "Change in hCG in twin gestations during sequential independent screening," byD. A. Kahn and colleagues is presented.

An abstract of the article "Basic as well as detailed neurosonogram can be performed by an off-line analysis of 3D fetal brain volumes," by E. Bornstein and colleagues, is presented.

An abstract of the article "Integrated second trimester risk assessment in twin gestations previously screened in the first trimester," by D. A. Kahn and colleagues, is presented.

An abstract of the article "Median view obtained by an off-line analysis of 3D fetal brain volume can provide easy and reliable measurements of the cerebellar vermis, cisterna magna and nuchal fold," by E. Bornstein and colleagues, is presented.

Three large multi-center studies have identified the clinical utility of intravenous immunoglobulin (IVIg) in the treatment of Down syndrome regression disorder (DSRD). Yet the tolerability of infusions in individuals with DS and the safety of IVIg remains unknown in this population. This study sought to evaluate the safety and tolerability of IVIg in individuals with DSRD compared to a real-world cohort of individuals with pediatric onset neuroimmunologic disorders. A single-center, retrospective chart review evaluating clinically documented infusion reactions was performed for individuals meeting international consensus criteria for DSRD and having IVIg infusions between 2019 and 2023. Infusion reactions were evaluated for severity and need for alterations in infusion plan. This cohort was compared against an age and sex matched cohort of children with neuroimmunologic conditions who had also received IVIg infusions. In total, 127 individuals with DSRD and 186 individuals with other neuroimmunologic disorders were enrolled. There was no difference in the overall rate of adverse reactions (AEs) between the DSRD and general neuroimmunology cohorts (p = 0.31, 95% CI: 0.80-2.00), but cardiac-related AEs specifically were more common among the DSRD group (p = 0.02, 95% CI: 1.23-17.54). When AEs did occur, there was no difference in frequency of pharmacologic intervention (p = 0.12, 95% CI: 0.34-1.13) or discontinuation of therapy (p = 0.74, 95% CI: 0.06-7.44). There was a higher incidence of lab abnormalities on IVIG among the general neuroimmunology cohort (p = 0.03, 95% CI: 0.24-0.94) compared to the DSRD cohort. Transaminitis was the most common laboratory abnormality in the DSRD group. In a large cohort of individuals with DSRD, there were no significant differences in the safety and tolerability of IVIg compared to a cohort of children and young adults with neuroimmunologic conditions., (© 2024 Wiley Periodicals LLC.)

Aim: To evaluate the cost-effectiveness of needle and syringe programmes (NSPs) compared with no NSPs on hepatitis C virus (HCV) transmission in the United Kingdom., Design: Cost-effectiveness analysis from a National Health Service (NHS)/health-provider perspective, utilizing a dynamic transmission model of HCV infection and disease progression, calibrated using city-specific surveillance and survey data, and primary data collection on NSP costs. The effectiveness of NSPs preventing HCV acquisition was based on empirical evidence., Setting and Participants: UK settings with different chronic HCV prevalence among people who inject drugs (PWID): Dundee (26%), Walsall (18%) and Bristol (45%) INTERVENTIONS: Current NSP provision is compared with a counterfactual scenario where NSPs are removed for 10 years and then returned to existing levels with effects collected for 40 years., Measurements: HCV infections and cost per quality-adjusted life year (QALY) gained through NSPs over 50 years., Findings: Compared with a willingness-to-pay threshold of £20 000 per QALY gained, NSPs were highly cost-effective over a time-horizon of 50 years and decreased the number of HCV incident infections. The mean incremental cost-effectiveness ratio was cost-saving in Dundee and Bristol, and £596 per QALY gained in Walsall, with 78, 46 and 40% of simulations being cost-saving in each city, respectively, with differences driven by coverage of NSP and HCV prevalence (lowest in Walsall). More than 90% of simulations were cost-effective at the willingness-to-pay threshold. Results were robust to sensitivity analyses, including varying the time-horizon, HCV treatment cost and numbers of HCV treatments per year., Conclusions: Needle and syringe programmes are a highly effective low-cost intervention to reduce hepatitis C virus transmission, and in some settings they are cost-saving. Needle and syringe programmes are likely to remain cost-effective irrespective of changes in hepatitis C virus treatment cost and scale-up., (© 2019 Society for the Study of Addiction.)

Aims: To estimate the impact of existing high-coverage needle and syringe provision (HCNSP, defined as obtaining more than one sterile needle and syringe per injection reported) and opioid substitution therapy (OST) on hepatitis C virus (HCV) transmission among people who inject drugs (PWID) in three UK settings and to determine required scale-up of interventions, including HCV treatment, needed to reach the World Health Organization (WHO) target of reducing HCV incidence by 90% by 2030., Design: HCV transmission modelling using UK empirical estimates for effect of OST and/or HCNSP on individual risk of HCV acquisition., Setting and Participants: Three UK cities with varying chronic HCV prevalence (Bristol 45%, Dundee 26%, Walsall 19%), OST (72-81%) and HCNSP coverage (28-56%)., Measurements: Relative change in new HCV infections throughout 2016-30 if current interventions were stopped. Scale-up of HCNSP, OST and HCV treatment required to achieve the WHO elimination target., Findings: Removing HCNSP or OST would increase the number of new HCV infections throughout 2016 to 2030 by 23-64 and 92-483%, respectively. Conversely, scaling-up these interventions to 80% coverage could achieve a 29 or 49% reduction in Bristol and Walsall, respectively, whereas Dundee may achieve a 90% decrease in incidence with current levels of intervention because of existing high levels of HCV treatment (47-58 treatments per 1000 PWID). If OST and HCNSP are scaled-up, Walsall and Bristol can achieve the same impact by treating 14 or 40 per 1000 PWID annually, respectively (currently two and nine treatments per 1000 PWID), while 18 and 43 treatments per 1000 PWID would be required if OST and HCNSP are not scaled-up., Conclusions: Current opioid substitution therapy and high-coverage needle and syringe provision coverage is averting substantial hepatitis C transmission in the United Kingdom. Maintaining this coverage while getting current drug injectors onto treatment can reduce incidence by 90% by 2030., (© 2018 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction.)

Aims: To estimate the effects of needle and syringe programmes (NSP) and opioid substitution therapy (OST), alone or in combination, for preventing acquisition of hepatitis C virus (HCV) in people who inject drugs (PWID)., Methods: Systematic review and meta-analysis. Bibliographic databases were searched for studies measuring concurrent exposure to current OST (within the last 6 months) and/or NSP and HCV incidence among PWID. High NSP coverage was defined as regular NSP attendance or ≥ 100% coverage (receiving sufficient or greater number of needles and syringes per reported injecting frequency). Studies were assessed using the Cochrane risk of bias in non-randomized studies tool. Random-effects models were used in meta-analysis., Results: We identified 28 studies (n = 6279) in North America (13), United Kingdom (five), Europe (four), Australia (five) and China (one). Studies were at moderate (two), serious (17) critical (seven) and non-assessable risk of bias (two). Current OST is associated with 50% [risk ratio (RR) =0.50, 95% confidence interval (CI) = 0.40-0.63] reduction in HCV acquisition risk, consistent across region and with low heterogeneity (I 2  = 0, P = 0.889). Weaker evidence was found for high NSP coverage (RR = 0.79, 95% CI = 0.39-1.61) with high heterogeneity (I 2  = 77%, P = 0.002). After stratifying by region, high NSP coverage in Europe was associated with a 56% reduction in HCV acquisition risk (RR = 0.44, 95% CI = 0.24-0.80) with low heterogeneity (I 2  = 12.3%, P = 0.337), but not in North America (RR = 1.58, I 2  = 89.5%, P = < 0.001). Combined OST/NSP is associated with a 74% reduction in HCV acquisition risk (RR = 0.26, 95% CI = 0.07-0.89, I 2  = 80% P = 0.007). According to Grades of Recommendation Assessment, Development and Evaluation (GRADE) criteria, the evidence on OST and combined OST/NSP is low quality, while NSP is very low., Conclusions: Opioid substitution therapy reduces risk of hepatitis C acquisition and is strengthened in combination with needle and syringe programmes (NSP). There is weaker evidence for the impact of needle syringe programmes alone, although stronger evidence that high coverage is associated with reduced risk in Europe., (© 2017 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction.)