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Background: cystic fibrosis (CF) is a life-threatening genetic disease, affecting around 10 500 people in the UK. Precision medicines have been developed to treat specific CF-gene mutations. The newest, elexacaftor/tezacaftor/ivacaftor (ELEX/TEZ/IVA), has been found to be highly effective in randomised controlled trials (RCTs) and became available to a large proportion of UK CF patients in 2020. Understanding the potential health economic impacts of ELEX/TEZ/IVA is vital to planning service provision.Methods: we combined observational UK CF Registry data with RCT results to project the impact of ELEX/TEZ/IVA on total days of intravenous (IV) antibiotic treatment at a population level. Registry data from 2015 to 2017 were used to develop prediction models for IV days over a 1-year period using several predictors, and to estimate 1-year population total IV days based on standards of care pre-ELEX/TEZ/IVA. We considered two approaches to imposing the impact of ELEX/TEZ/IVA on projected outcomes using effect estimates from RCTs: approach 1 based on effect estimates on FEV1% and approach 2 based on effect estimates on exacerbation rate.Results: ELEX/TEZ/IVA is expected to result in significant reductions in population-level requirements for IV antibiotics of 16.1% (~17 800 days) using approach 1 and 43.6% (~39 500 days) using approach 2. The two approaches require different assumptions. Increased understanding of the mechanisms through which ELEX/TEZ/IVA acts on these outcomes would enable further refinements to our projections.Conclusions: this work contributes to increased understanding of the changing healthcare needs of people with CF and illustrates how Registry data can be used in combination with RCT evidence to estimate population-level treatment impacts.

Background It has been hypothesised that greater maternal adiposity before or during pregnancy causes greater offspring adiposity in childhood and adulthood, via causal intrauterine or periconceptional mechanisms. Previous Mendelian randomization (MR) estimates were imprecise, with wide confidence intervals that included potentially important protective or adverse effects, and may have been biased by collider effects or imperfect adjustment for genetic inheritance. Here we use an improved MR approach to investigate whether associations between maternal pre-/early pregnancy body mass index (BMI) and offspring adiposity from birth to adolescence are causal, or are instead due to confounding. Methods and findings We undertook confounder adjusted multivariable (MV) regression and Mendelian randomization (MR) using mother-offspring pairs from two UK cohorts: Avon Longitudinal Study of Parents and Children (ALSPAC) and Born in Bradford (BiB). In ALSPAC and BiB the outcomes were birthweight (BW; N = 9339) and BMI at age 1 (N = 8659) and 4 years (N = 7575), and in ALSPAC only we investigated BMI at 10 (N = 4476) and 15 years (N = 4112) and dual-energy X-ray absorptiometry (DXA) determined fat mass index (FMI) from age 10– 18 years (N = 2659 to 3855). We compared MR results from several polygenic risk scores (PRS), calculated from maternal non-transmitted alleles at between 29 and 80,939 single nucleotide polymorphisms (SNPs). MV and MR showed a consistent positive association of maternal BMI with BW, but for adiposity at most older ages MR estimates were weaker than MV estimates. In MV regression a one standard deviation (SD) higher maternal BMI was associated with a 0.13 (95% confidence interval [CI]: 0.10, 0.16) SD increase in offspring BW. The corresponding MR estimate from the strongest PRS (including up to 80,939 SNPs) was 0.14 (95% CI: 0.05, 0.23), with no difference between the two estimates (Pdifference = 0.84). For 15 year BMI the MV and MR estimates (80,939 SNPs) were 0.32 (95% CI: 0.29, 0.36) and 0.13 (95% CI: 0.01, 0.24) respectively (Pdifference = 1.0e-3). Results for FMI were similar to those for adolescent BMI. As the number of SNPs included in the PRS increased, the MR confidence intervals narrowed and the effect estimates for adolescent adiposity became closer to the MV estimates. Sensitivity analyses suggested the stronger effects with more SNPs were explained by horizontal pleiotropic bias away from zero. Consequently, the unbiased difference between the MV and MR estimates is probably greater than shown in our main analyses. Furthermore, MR estimates from IVs with fewer SNPs provided no strong evidence for a causal effect on adolescent adiposity. Conclusions Our results suggest that higher maternal pre-/early-pregnancy BMI is not a key driver of higher adiposity in the next generation. Thus, they support interventions that target the whole population for reducing overweight and obesity, rather than a specific focus on women of reproductive age.

BACKGROUND: Psychological stress is commonly cited as a risk factor for melanoma, but clinical evidence is limited. OBJECTIVES: This study aimed to evaluate the association between partner bereavement and (i) first-time melanoma diagnosis and (ii) mortality in patients with melanoma. METHODS: We conducted two cohort studies using data from the U.K. Clinical Practice Research Datalink (1997-2017) and Danish nationwide registries (1997-2016). In study 1, we compared the risk of first melanoma diagnosis in bereaved vs. matched nonbereaved people using stratified Cox regression. In study 2 we estimated hazard ratios (HRs) for death from melanoma in bereaved compared with nonbereaved individuals with melanoma using Cox regression. We estimated HRs separately for the U.K. and for Denmark, and then pooled the data to perform a random-effects meta-analysis. RESULTS: In study 1, the pooled adjusted HR for the association between partner bereavement and melanoma diagnosis was 0·88 [95% confidence interval (CI) 0·84-0·92] across the entire follow-up period. In study 2, we observed increased melanoma-specific mortality in people experiencing partner bereavement across the entire follow-up period (HR 1·17, 95% CI 1·06-1·30), with the peak occurring during the first year of follow-up (HR 1·31, 95% CI 1·07-1·60). CONCLUSIONS: We found decreased risk of melanoma diagnosis, but increased mortality associated with partner bereavement. These findings may be partly explained by delayed detection resulting from the loss of a partner who could notice skin changes. Stress may play a role in melanoma progression. Our findings indicate the need for a low threshold for skin examination in individuals whose partners have died. What is already known about this topic? Psychological stress has been proposed as a risk factor for the development and progression of cancer, including melanoma, but evidence is conflicting. Clinical evidence is limited by small sample sizes, potential recall bias associated with self-report, and heterogeneous stress definitions. What does this study add? We found a decreased risk of melanoma diagnosis, but increased mortality associated with partner bereavement. While stress might play a role in the progression of melanoma, an alternative explanation is that bereaved people no longer have a close person to help notice skin changes, leading to delayed melanoma detection. Linked Comment: Talaganis et al. Br J Dermatol 2020; 183:607-608.

This project received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 633595

Introduction Young children commonly wheeze but only some have asthma later in life. Asthma prediction tools have poor predictive performance and few have been validated. We aimed to develop a robust tool for the prediction of asthma at age 10–14 years using readily available information. Methods we studied 5 UK birth cohorts (the STELAR consortium) and considered two groups: 1. all children recruited at birth and 2. high-risk children on the basis of reported wheezing at 2/3 or 5 years. Two comparable cohorts (Ashford and ALSPAC) were used to select predictors (training sample) and the SEATON, MAAS and Isle of Wight studies to assess predictive performance (validation sample). We included 16 187 and 814 children from groups 1 and 2 respectively in the training sample and validated the developed predictive tools in 5320 and 285 children from the validation sample. We considered 40 potential predictors collected at recruitment and at 1, 2/3 and 5 years of age: demographic and perinatal information, eczema, hay-fever, respiratory symptoms, environmental and family-related factors. We defined asthma at 10–14 years by the presence of both current wheeze and asthma treatment. We compared 5 statistical methods to select variables and estimate coefficients: stepwise regression, classical (LASSO and Elastic-Net, EN), empirical Bayes (EB) and Bayesian (BM) regularisation Methods Predictive performance was assessed using calibration and discrimination measures including area under the ROC curve (AUC). Results Asthma prevalence at age 10–14 ranged from 7%–18% in group 1 and from 32%–52% in group 2. Frequency of early wheezing, eczema, and paternal asthma were important predictors in all models and both groups. Other selected predictors included birth order, maternal asthma and domestic pets. Specificity and negative predictive value (NPV) were higher in the general population, while sensitivity and positive predictive value (PPV) were higher in high-risk group. BM (AUC 0.77, specificity 0.84 and NPV 0.93) and EN (AUC 0.74, sensitivity 0.71 and PPV 0.65) provided the highest accuracy and discriminative ability predictive ability in the 2 groups, respectively. Conclusion The use of sophisticated statistical methods in a large, multicentre population demonstrated promising Results in developing an asthma predictive tool.

Previous studies have raised concerns about possible excess risks of bladder, brain and hepatobiliary cancers and leukaemias near landfill sites. Several cancers have been implicated, but no consistent pattern has emerged. We present a large nationwide analysis of selected cancers near landfill sites in Great Britain. The base population comprised people living within 2 km of 9565 (from a total of 19 196) landfill sites that were operational at some time from 1982 to 1997, with populations living more than 2 km from a landfill as reference. Risks of cancers at the above sites were computed with adjustment for age, sex, year of diagnosis, region and deprivation. National post-coded registers provided a total of 341 856 640 person–years for the adult cancer analyses and 113 631 443 person–years for childhood leukaemia. There were 89 786 cases of bladder cancer, 36 802 cases of brain cancer, 21 773 cases of hepatobiliary cancer, 37 812 cases of adult leukaemia and 3973 cases of childhood leukaemia. In spite of the very large scale of this national study, we found no excess risks of cancers of the bladder and brain, hepatobiliary cancer or leukaemia, in populations living within 2 km of landfill sites. The results were similar if the analysis were restricted to landfill sites licensed to carry special (hazardous) waste. Our results do not support suggestions of excess risks of cancer associated with landfill sites reported in other studies. British Journal of Cancer (2002) 86, 1732–1736. doi:10.1038/sj.bjc.6600311 www.bjcancer.com © 2002 Cancer Research UK

Background: A major cause of disability in secondary progressive multiple sclerosis (SPMS) is progressive brain atrophy, whose pathogenesis is not fully understood. The objective of this study was to identify protein biomarkers of brain atrophy in SPMS. Methods: We used surface-enhanced laser desorption-ionization time-of-flight mass spectrometry to carry out an unbiased search for serum proteins whose concentration correlated with the rate of brain atrophy, measured by serial MRI scans over a 2-year period in a well-characterized cohort of 140 patients with SPMS. Protein species were identified by liquid chromatography-electrospray ionization tandem mass spectrometry. Results: There was a significant (p-12) in patients with secondary progressive multiple sclerosis. Conclusions: The results are consistent with the following hypothesis. In progressive multiple sclerosis, low-grade chronic intravascular haemolysis releases haemoglobin into the serum; the haemoglobin is subsequently translocated into the central nervous system (CNS) across the damaged blood-brain barrier. In the CNS, the haemoglobin and its breakdown products, including haem and iron, contribute to the neurodegeneration and consequent brain atrophy seen in progressive disease. We postulate that haemoglobin is a source of the iron whose deposition along blood vessels in multiple sclerosis plaques is associated with neurodegeneration. If so, then chelators of haemoglobin, rather than chelators of free serum iron, may be effective in preventing this neurodegeneration.