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Abstract Background Front-of-pack (FOP) warning labels have demonstrated effectiveness for reducing sugar-sweetened beverage (SSB) consumption and switching to water. However, an unintended consequence is that they may also increase switching to non-sugar-sweetened beverages (NSSBs). A non-hypothetical experimental study examined the effectiveness of combining sugar and sweetener FOP warning labels to reduce sugary drink consumption and prevent NSSB substitution. The study also examined potential integration with Australia and New Zealand’s existing Health Star Rating (HSR) system to determine suitability for local context and other jurisdictions with interpretive labelling schemes already in place. Methods Participants (N = 414) accessed an online convenience store app via an on-campus laptop to select one drink from an array of 10 beverages, on three occasions. Drink options included a variety of SSBs, 100% fruit juice, NSSBs, and water. Following an escalating exposure procedure, drinks were presented (1) without any additional labelling, (2) with warning labels added to sugary drinks or to both sugary drinks and NSSBs (according to allocated condition), then (3) with HSR icons added to all drinks. Participants were informed they would receive a complementary drink, based on their selections, following the completion of a brief questionnaire. Results Baseline results indicated that SSBs and water were the most and least popular drink choices, respectively. Placing FOP warning labels on sugary drinks decreased selection of SSBs and increased NSSB and water choices. Water became the most popular individual drink choice in response to warnings on sugary drinks. Placing FOP warning labels on both sugary drinks and NSSBs successfully avoided an increase in NSSB choices, whilst also increasing water selections, but did not significantly decrease selection of SSBs until HSR ratings were added. The incorporation of HSR icons consolidated warning label effects on NSSB and water selection across both conditions. Conclusions Results demonstrate the potential of FOP sugar warning labels for addressing beverage consumption behaviours. The incorporation of sweetener warning labels may successfully avoid substitution towards NSSBs, whilst still promoting water choices, but may also dilute the impact of the sugary drinks warning labels. Warning labels were complementary to existing interpretive FOP labels.

Abstract Background Alcohol is a discretionary, energy dense, dietary component. Compared to non-drinkers, people who consume alcohol report higher total energy intake and may be at increased risk of weight gain, overweight, and obesity, which are key preventable risk factors for illness. However, accurate consumer knowledge of the energy content in alcohol is low. To inform future behaviour change interventions among drinkers, this study investigated individual characteristics associated with changing alcohol consumption due to energy-related concerns. Methods An online survey was undertaken with 801 Australian adult drinkers (18–59 years, 50.2% female), i.e. who consumed alcohol at least monthly. In addition to demographic and health-related characteristics, participants reported past-year alcohol consumption, past-year reductions in alcohol consumption, frequency of harm minimisation strategy use (when consuming alcohol), and frequency of changing alcohol consumption behaviours because of energy-related concerns. Results When prompted, 62.5% of participants reported changing alcohol consumption for energy-related reasons at least ‘sometimes’. Women, those aged 30–44 years, metropolitan residents, those with household income $80,001–120,000, and risky/more frequent drinkers had increased odds of changing consumption because of energy-related concerns, and unemployed respondents had reduced odds. Conclusions Results indicate that some sociodemographic groups are changing alcohol consumption for energy-related reasons, but others are not, representing an underutilised opportunity for health promotion communication. Further research should investigate whether messaging to increase awareness of alcohol energy content, including through systems-based policy actions such as nutritional/energy product labelling, would motivate reduced consumption across a broader range of drinkers.

Abstract Nance–Horan syndrome (NHS) is a rare X-linked dominant disorder caused by mutation in the NHS gene on chromosome Xp22.13. (OMIM 302350). Classic NHS manifested in males is characterized by congenital cataracts, dental anomalies, dysmorphic facial features and occasionally intellectual disability. Females typically have a milder presentation. The majority of reported cases of NHS are the result of nonsense mutations and small deletions. Isolated X-linked congenital cataract is caused by non-recurrent rearrangement-associated aberrant NHS transcription. Classic NHS in females associated with gene disruption by balanced X-autosome translocation has been infrequently reported. We present a familial NHS associated with translocation t(X;19) (Xp22.13;q13.1). The proband, a 28-year-old female, presented with intellectual disability, dysmorphic features, short stature, primary amenorrhea, cleft palate, and horseshoe kidney, but no NHS phenotype. A karyotype and chromosome microarray analysis (CMA) revealed partial monosomy Xp/partial trisomy 19q with the breakpoint at Xp22.13 disrupting the NHS gene. Family history revealed congenital cataracts and glaucoma in the patient’s mother, and congenital cataracts in maternal half-sister and maternal grandmother. The same balanced translocation t(X;19) was subsequently identified in both the mother and maternal half-sister, and further clinical evaluation of the maternal half-sister made a diagnosis of NHS. This study describes the clinical implication of NHS gene disruption due to balanced X-autosome translocations as a unique mechanism causing Nance–Horan syndrome, refines dose effects of NHS on disease presentation and phenotype expressivity, and justifies consideration of karyotype and fluorescence in situ hybridization (FISH) analysis for female patients with familial NHS if single-gene analysis of NHS is negative.

Abstract Background SARS-CoV-2 poses a considerable threat to those living in residential aged care facilities (RACF). RACF COVID-19 outbreaks have been characterised by the rapid spread of infection and high rates of severe disease and associated mortality. Despite a growing body of evidence supporting airborne transmission of SARS-CoV-2, current infection control measures in RACF including hand hygiene, social distancing, and sterilisation of surfaces, focus on contact and droplet transmission. Germicidal ultraviolet (GUV) light has been used widely to prevent airborne pathogen transmission. Our aim is to investigate the efficacy of GUV technology in reducing the risk of SARS-CoV-2 infection in RACF. Methods A multicentre, two-arm double-crossover, randomised controlled trial will be conducted to determine the efficacy of GUV devices to reduce respiratory viral transmission in RACF, as an adjunct to existing infection control measures. The study will be conducted in partnership with three aged care providers in metropolitan and regional South Australia. RACF will be separated into paired within-site zones, then randomised to intervention order (GUV or control). The initial 6-week period will be followed by a 2-week washout before crossover to the second 6-week period. After accounting for estimated within-zone and within-facility correlations of infection, and baseline infection rates (10 per 100 person-days), a sample size of n = 8 zones (n = 40 residents/zone) will provide 89% power to detect a 50% reduction in symptomatic infection rate. The primary outcome will be the incidence rate ratio of combined symptomatic respiratory infections for intervention versus control. Secondary outcomes include incidence rates of hospitalisation for complications associated with respiratory infection; respiratory virus detection in facility air and fomite samples; rates of laboratory confirmed respiratory illnesses and genomic characteristics. Discussion Measures that can be deployed rapidly into RACF, that avoid the requirement for changes in resident and staff behaviour, and that are effective in reducing the risk of airborne SARS-CoV-2 transmission, would provide considerable benefit in safeguarding a highly vulnerable population. In addition, such measures might substantially reduce rates of other respiratory viruses, which contribute considerably to resident morbidity and mortality. Trial registration Australian and New Zealand Clinical Trials Registry ACTRN12621000567820 (registered on 14th May, 2021).

Purpose The Registry of Senior Australians (ROSA) was established to evaluate aged care experiences in Australia. In this manuscript, we describe the ROSA framework, the two ROSA cohorts, highlights from research findings, and future plans.Participants The South Australian ROSA Prospective Cohort (August 2018–June 2020) enrolled 26 605 participants, of which 59.2% (N=15 745) are women, with a median age of 83 (interquartile range (IQR) 77–88). The National ROSA Historical Cohort (January 2002–June 2020) includes 1 694 206 participants with an aged care eligibility assessment, of which 59.1% (N=1 001 705) are women and the median age is 78 (IQR 72–83).Findings to date Most research using the ROSA has focused on dementia, service accessibility, quality and safety of care, falls and injuries and quality use of medicines. The ROSA has also examined the experience of individuals with highly prevalent and understudied conditions in aged care settings (eg, eye and mental health) and aspects of services (eg, built environment) and innovation (eg, mobile radiological services) that can affect older people’s health. Important learnings from the ROSA’s development include the significant resources and multidisciplinary expertise required for establishing this platform. Between 2018 and 2022, 43 academic publications, eight reports of the Australian Government Royal Commission into Aged Care Quality and Safety, and several reports to state health authorities and professional societies have used the ROSA.Future plans Our plans include to: (1) continue delivering high-quality evidence to support the improvement of ageing and aged care services; (2) influence and improve the quality of research in and for the aged care sector; (3) expand scope to facilitate examining aims in more depth; (4) include future aged care sector data collections within the ROSA; (5) inform best practices and innovate how consumer engagement occurs in research; (6) monitor and evaluate the impact of the 2021 Australian Aged Care Reforms.

Objectives To: (1) outline the research produced using linked data from the Registry of Senior Australians (ROSA) which informed the recommendations from Australia’s Royal Commission into Aged Care Quality and Safety (delivered February 2021); (2) describe the Australian Government Aged Care Roadmap Reforms (announced May 2021) resulting from the recommendations. Approach ROSA was established in 2017 and is led by a partnership of scientists, clinicians, aged care providers and consumer advocates from nine organisations seeking to improve the lives of Australians in aged care. ROSA is a Clinical Quality Registry comprised of linked national and cross-jurisdictional aged and health care data and includes a national historical de-identified cohort (3.5 million individuals, 2002-2020) and a prospectively enrolled cohort in the state of South Australia (26,600 individuals, 2018-current). This is a summary of ROSA’s high-quality evidence used by the Royal Commission and translation of this evidence into policy by leveraging existing data infrastructure. Results Between 2019-2020 the ROSA team led the delivery of four in-depth reports for the Royal Commission, contributed data and expertise to an additional four published Commission reports. Examples of ROSA outputs informing the Commissions’ recommendations included: evidence of national increased psychotropic medication use following entry to residential aged care, evidence of higher risk of mortality and entry to permanent care while waiting for home care packages, development of quality indicators to monitor quality and safety of care nationally, and to facilitate international comparisons and benchmarking. Examples of recommendations included in the Australian Government Aged Care Roadmap: release of substantial funding to increase the availability of home care packages, public reporting system for quality and safety monitoring and several changes to medication management. Conclusion Registries are key resources for high quality real-world evidence generation needed to inform national investigations, ultimately leading to significant sector reform. The ROSA experience highlights that cross-sectoral data linkages, together with technical expertise, informed by clinicians and consumers, are invaluable resources for system reform and policy generation.

Abstract Objective: There is limited knowledge of what influences sugary drink purchasing decisions in the Australian population. This study aimed to identify the most common locations and reasons across different demographic groups for purchasing sugary drinks in Australia. Methods: A total of 891 respondents (who purchased sugary drinks for personal consumption at least occasionally) from a broader national population telephone survey of Australian adults conducted in 2017 (n=3,430) were included in the analysis. Results: ‘Taste’ was a ubiquitous reason for purchase (94%) and the majority also agreed with ‘easily available’ (76%). Males, younger people and people of lower socioeconomic status (SES) were significantly more likely to agree that sugary drinks were ‘cheap’ and ‘better value than water’. Furthermore, males and younger people were more likely to report buying sugary drinks because they were ‘part of a meal deal’. The most common purchase locations were supermarkets (56%), followed by convenience stores (19%) and food or entertainment venues (17%). Conclusion: Taste is paramount in decisions to purchase sugary drinks, and widespread availability and value for money support consumption. Implications for public health: Policies and interventions targeting point‐of‐sale sugary drink purchasing decisions among the most ‘at risk’ consumers are warranted.

Summary: Background: Encouraging and assisting smokers to quit remains a key public health goal. Government and commercial initiatives have nudged smokers towards supported cessation. We tracked long-term trends in Australian smokers’ quit attempt methods across 20 years. Methods: Data from 11,917 smokers were collected from an annual, cross-sectional, face-to-face, random and representative population survey. The survey measured demographic characteristics, tobacco use, recent quit attempts, nicotine dependence, quit intentions, and recent methods used when attempting to quit. Quit attempt preferences were analysed over time and by smoker characteristics. Findings: Each year, more smokers attempted to quit than remained quit, with a stable trend over time. Socioeconomic disadvantage and mental health conditions are more likely among smokers, but there was no difference in quit attempts by these characteristics. Quit attempts have risen among those aged 60 years and over whereas other age groups have remained stable. Although trending downwards, unassisted quitting remained the most common method: 1998: 61% and 2017: 40%. Asking a doctor for help/advice (34%) was the most common assisted method in 2017, increasing from 18% in 1998. Methods of quitting varied by smoker characteristics, with supported methods used more often by older, more dependent, socio-economically disadvantaged smokers and those with a mental health condition. Interpretation: The relative stability of recent quit attempts, persistence in unassisted quitting, and fluctuating preferences for supported cessation methods indicate that it is important for clinicians and policy makers to continue to support quit attempts through a variety of options, tailored to smoker's needs. Funding: This study was supported by Drug and Alcohol Services SA (Government of South Australia), via funding of the Tobacco Control Research and Evaluation Program within Cancer Council SA (1998-2013) and the Health Policy center, SAHMRI (2013-2021). The funder had no involvement in any aspect of the study.

Abstract Background Little is known about whether a more comprehensive health assessment, performed by a general practitioner (GP) during a clinical encounter, could influence patients’ lifestyle. We aimed to investigate whether health assessments, performed by GPs, are more important than the presence of cardiovascular disease (CVD) or cardiometabolic risk factors (obesity, diabetes, hypertension, dyslipidaemia) for engagement in lifestyle change. Methods Cross-sectional, population-based survey conducted in South Australia (September–December 2017) using face-to-face interviews and self-reported data of 2977 individuals aged 15+ years. The main outcome was engagement in four lifestyle changes: 1) increasing fruit/vegetable intake, 2) increasing physical activity level, 3) reducing alcohol consumption, and 4) attempts to stop smoking. Health assessments performed by a GP in the last 12 months included clinical/laboratory investigations (weight/waist circumference, blood pressure, glucose levels, lipid levels) and questions about lifestyle/wellbeing (current diet, physical activity, smoking status, alcohol intake, mental health, sleeping problems). Results were restricted to individuals aged 35+ years because of the low prevalence of CVD or their risk factors among younger participants. Logistic regression was used in all associations, adjusted for sociodemographic, lifestyle, mental health, and clinical variables. Results Of the 2384 investigated adults (mean age 57.3 ± 13.9 years; 51.9% females), 10.2% had CVD and 49.1% at least one cardiometabolic risk factor. Clinical/laboratory assessments performed by the GP were 2–3 times more frequent than assessments of lifestyle, mental health status, or sleeping problems, especially among those with CVD. Individuals with CVD or a cardiometabolic risk factor were no more likely to be increasing their fruit/vegetable consumption (33.6%), physical activity level (40.9%), reducing alcohol consumption (31.1%), or trying to quit smoking (34.0%) than ‘healthy’ participants. However, lifestyle changes were between 30 and 100% more likely when GPs performed three or more health assessments (either clinical/laboratory or questions about lifestyle/wellbeing) than when individuals did not visit the GP or when GPs performed no any assessment during these clinical encounters (p

Objective To identify what outcomes have been assessed in traumatic brachial plexus injury (TBPI) research to inform the development of a core outcome set for TBPI.Design Systematic review.Method Medline (OVID), EMBASE, CINAHL and AMED were systematically searched for studies evaluating the clinical effectiveness of interventions in adult TBPIs from January 2013 to September 2018 updated in May 2021. Two authors independently screened papers. Outcome reporting bias was assessed. All outcomes were extracted verbatim from studies. Patient-reported outcomes or performance outcome measures were extracted directly from the instrument. Variation in outcome reporting was determined by assessing the number of unique outcomes reported across all included studies. Outcomes were categorised into domains using a prespecified taxonomy.Results Verbatim outcomes (n=1491) were extracted from 138 studies including 32 questionnaires. Unique outcomes (n=157) were structured into 4 core areas and 11 domains. Outcomes within the musculoskeletal domain were measured in 86% of studies, physical functioning in 25%, emotional functioning in 25% and adverse events in 33%. We identified 63 different methods for measuring muscle strength, 16 studies for range of movement and 63 studies did not define how they measured movement. More than two-thirds of the outcomes were incompletely reported in prospective studies.Conclusion This review of outcome reporting in TBPI research demonstrated an impairment focus and heterogeneity. A core outcome set would ensure standardised and relevant outcomes are reported to facilitate future systematic review and meta-analysis.PROSPERO registration number CRD42018109843.

Objectives: Despite significant evidence of harms associated with high levels of sugar-sweetened beverage (SSB) consumption, and international moves towards regulation to curb overconsumption of such drinks, Australia has been slow to take policy action. This study provides in-depth insights into consumers’ reactions to different SSB policy options. Methods: Eight focus groups were undertaken with 59 regular SSB consumers and/or household purchasers, stratified by: young adults aged 21–29 years (no children), parents aged 35–50 (with children at home); gender; and socio-economic status. Consumer responses to potential government intervention and policy options were explored using thematic analysis. Results: Three main themes were identified. Theme 1 describes participants’ changing views on regulation of SSBs throughout the focus groups, expressed through shifts in understandings of personal responsibility and the role of government. It was noted that the term ‘regulation’ should be used judiciously, as it was widely misunderstood to infer bans. Theme 2 articulates the participants’ preference for child-focused measures and educative measures such as clearer front-of-pack labelling. Taxation on SSBs was viewed more favourably if paired with investment into education. Theme 3 describes the parallels that participants drew between SSBs and other substances. Conclusions: A comprehensive approach that includes education, child-focused interventions and regulatory approaches may increase acceptability of policy measures to curb overconsumption of SSBs.

Abstract Background To investigate the association between pre-diagnostic colonoscopy and colorectal cancer mortality in South Australia. Methods Colonoscopy histories were obtained for colorectal cancer patients diagnosed in 2003–2013 using linked Medical Benefits Schedule (MBS) claims, hospital-inpatient and cancer-registry data. Colonoscopy histories included the year of colonoscopy, numbers of examinations, and the time from first colonoscopy to diagnosis. Histories of multiple exposures to colonoscopies, and exposures of greater than a year from initial colonoscopy to diagnosis, were regarded as indicators of screening or surveillance activity. Colonoscopies occurring within one year of diagnosis were regarded as more likely to be a response to cancer symptoms than those occurring > 1 year before diagnosis. Associations between colonoscopy history and post-diagnostic survival were analysed using sub-hazard ratios (SHRs) from competing risk regression adjusted for socio-demographic and cancer characteristics. Results Having pre-diagnostic colonoscopy was associated with an unadjusted reduction in risk of colorectal cancer death of 17% (SHR: 0.83, 95% CI 0.78–0.89). After adjusting for time period and sociodemographic characteristics, the risk of colorectal cancer death reduced by 17% for one pre-diagnostic colonoscopy examination; 27% for two pre-diagnostic colonoscopy examinations; and 45% for three or more pre-diagnostic colonoscopy examinations. Those with a time of over one year from first colonoscopy in the study window to diagnosis, when compared with less than one year, had a 17% lower risk of colorectal cancer death in this adjusted analysis. These reductions were substantially reduced or eliminated when also adjusting for less advanced stage. Conclusions Pre-diagnostic colonoscopy, and more so, multiple colonoscopies and first colonoscopy occurring over one year from initial colonoscopy to diagnosis, were associated with longer survival post diagnosis. This was largely explained by less advanced cancer stage at the time of diagnosis.

Summary: Bone morphogenic proteins (BMPs) are members of the transforming growth factor β (TGF-β) cytokine family promoting differentiation, homeostasis, and self-renewal of multiple tissues. We show that signaling through the bone morphogenic protein receptor 1α (BMPR1α) sustains expression of FOXP3 in Treg cells in peripheral lymphoid tissues. BMPR1α signaling promotes molecular circuits supporting acquisition and preservation of Treg cell phenotype and inhibiting differentiation of pro-inflammatory effector Th1/Th17 CD4+ T cell. Mechanistically, increased expression of KDM6B (JMJD3) histone demethylase, an antagonist of the polycomb repressive complex 2, underlies lineage-specific changes of T cell phenotypes associated with abrogation of BMPR1α signaling. These results reveal that BMPs are immunoregulatory cytokines mediating maturation and stability of peripheral FOXP3+ regulatory T cells (Treg cells) and controlling generation of iTreg cells. Thus, we establish that BMPs, a large cytokine family, are an essential link between stromal tissues and the adaptive immune system involved in sustaining tissue homeostasis by promoting immunological tolerance.

BACKGROUND:The Australian National Bowel Cancer Screening Program (NBCSP) provides biennial immunochemical faecal occult blood test (iFOBT) screening for people aged 50-74 years. Previous work has quantified the number of colorectal cancer (CRC) deaths prevented by the NBCSP and has shown that it is cost-effective. With a 40% screening participation rate, the NBCSP is currently underutilised and could be improved by increasing program participation, but the maximum appropriate level of spending on effective interventions to increase adherence has not yet been quantified. OBJECTIVES:To estimate (i) reductions in CRC cases and deaths for 2020-2040 attributable to, and (ii) the threshold for cost-effective investment (TCEI) in, effective future interventions to improve participation in the NBCSP. METHODS:A comprehensive microsimulation model, Policy1-Bowel, was used to simulate CRC natural history and screening in Australia, considering currently reported NBCSP adherence rates, i.e. iFOBT participation (∼40%) and diagnostic colonoscopy assessment rates (∼70%). Australian residents aged 40-74 were modelled. We evaluated three scenarios: (1) diagnostic colonoscopy assessment increasing to 90%; (2) iFOBT screening participation increasing to 60% by 2020, 70% by 2030 with diagnostic assessment rates of 90%; and (3) iFOBT screening increasing to 90% by 2020 with diagnostic assessment rates of 90%. In each scenario, we estimated CRC incidence and mortality, colonoscopies, costs, and TCEI given indicative willingness-to-pay thresholds of AUD$10,000-$30,000/LYS. RESULTS:By 2040, age-standardised CRC incidence and mortality rates could be reduced from 46.2 and 13.5 per 100,000 persons, respectively, if current participation rates continued, to (1) 44.0 and 12.7, (2) 36.8 and 8.8, and (3) 31.9 and 6.5. In Scenario 2, 23,000 lives would be saved from 2020-2040 vs current participation rates. The estimated scenario-specific TCEI (Australian dollars or AUD$/year) to invest in interventions to increase participation, given a conservative willingness-to-pay threshold of AUD$10,000/LYS, was (1) AUD$14.9M, (2) AUD$72.0M, and (3) AUD$76.5M. CONCLUSION:Significant investment in evidence-based interventions could be used to improve NBCSP adherence and help realise the program's potential. Such interventions might include mass media campaigns to increase program participation, educational or awareness interventions for practitioners, and/or interventions resulting in improvements in referral pathways. Any set of interventions which achieves at least 70% iFOBT screening participation and a 90% diagnostic assessment rate while costing under AUD$72 million annually would be highly cost-effective (

Small intestinal neuroendocrine tumors (SINT) are rare with incidence increasing over the past 40 years. The purpose of this work is to examine the role of environmental exposures in the rise of SINT incidence using the Utah Population Database, a resource of linked records including life events, cancer diagnoses and residential histories. SINT cases born in Utah were identified through the Utah Cancer Registry with: diagnosis years of 1948 to 2014 and age at diagnosis of 23 to 88 years. Controls were matched to cases 10:1 based on sex, birth year and residence time in Utah. Cases and controls were geocoded to their birth locale. An isotonic spatial scan statistic was used to test for the occurrence and location(s) of SINT clusters. Potential environmental exposures and economic conditions in the birth locales at the time of the birth (1883-1982) were generated using historical references. Conditional logistic regression was used to estimate odd ratios. We report a spatial cluster central to historic coal mining communities, associated with a 2.86 relative risk (p = 0.016) of SINT. Aspatial analyses of industry and mining exposures further suggest elevated risk for early life exposure near areas involved in the construction industry (OR 1.98 p = 0.024). Other exposures approached significance including coal, uranium and hard rock mining during the earliest period (1883-1929) when safety from exposures was not considered. We do observe a lower risk (OR 0.58 p = 0.033) associated with individuals born in rural areas in the most recent period (1945-1982). Environmental exposures early in life, especially those from industries such as mining, may confer an elevated risk of SINT.

Abstract Background The value of hospital registries for describing treatment and survival outcomes for vulval cancer was investigated. Hospital registry data from four major public hospitals in 1984–2016 were used because population-based data lacked required treatment and outcomes data. Unlike population registries, the hospital registries had recorded FIGO stage, grade and treatment. Methods Unadjusted and adjusted disease-specific survival and multiple logistic regression were used. Disease-specific survivals were explored using Kaplan-Meier product-limit estimates. Hazards ratios (HRs) were obtained from proportional hazards regression for 1984–1999 and 2000–2016. Repeat analyses were undertaken using competing risk regression. Results Five-year disease-specific survival was 70%, broadly equivalent to the five-year relative survivals reported for Australia overall (70%), the United Kingdom (70%), USA (72%), Holland (70%), and Germany (Munich) (68%). Unadjusted five-year survival tended to be lower for cancers diagnosed in 2000–2016 than 1984–1999, consistent with survival trends reported for the USA and Canada, but higher for 2000–2016 than 1984–1999 after adjusting for stage and other covariates, although differences were small and did not approach statistical significance (p ≥ 0.40). Surgery was provided as part of the primary course of treatment for 94% of patients and radiotherapy for 26%, whereas chemotherapy was provided for only 6%. Less extensive surgical procedures applied in 2000–2016 than 1984–1999 and the use of chemotherapy increased over these periods. Surgery was more common for early FIGO stages, and radiotherapy for later stages with a peak for stage III. Differences in treatment by surgery and radiotherapy were not found by geographic measures of remoteness and socioeconomic status in adjusted analyses, suggesting equity in service delivery. Conclusions The data illustrate the complementary value of hospital-registry data to population-registry data for informing local providers and health administrations of trends in management and outcomes, in this instance for a comparatively rare cancer that is under-represented in trials and under-reported in national statistics. Hospital registries can fill an evidence gap when clinical data are lacking in population-based registries.

Abstract Objective: To examine the barriers and facilitators among health professionals to providing referrals to Quitline for Aboriginal and Torres Strait Islander clients who smoke. Methods: A brief online survey, based on the Theoretical Domains Framework, was completed by 34 health professionals who work with Aboriginal and Torres Strait Islander people in South Australia and the Northern Territory. Results: Respondents who frequently made referrals had higher domain scores than less frequent referrers for ‘Skills and knowledge’ (M=4.44 SD=0.39 vs. M=4.09 SD=0.47, p

Abstract Background This study examined how front-of-pack labels and product healthfulness affect choice and willingness to pay across a range of foods. It was hypothesized that: (i) product choice and (ii) willingness to pay would be more aligned with product healthfulness when healthfulness was expressed through the Health Star Rating, followed by the Multiple Traffic Light, then the Daily Intake Guide, and (iii) the Nutrition Facts Panel would be viewed infrequently. Methods Adults and children aged 10+ years (n = 2069) completed an online discrete choice task involving mock food packages. A 4 food type (cookies, corn flakes, pizza, yoghurt) × 2 front-of-pack label presence (present, absent) × 3 front-of-pack label type (Daily Intake Guide, Multiple Traffic Light, Health Star Rating) × 3 price (cheap, moderate, expensive) × 3 healthfulness (less healthy, moderately healthy, healthier) design was used. A 30 s time limit was imposed for each choice. Results Of the three front-of-pack labels tested, the Health Star Rating produced the largest differences in choices, with 40% (95% CIs: 38%-42%) of respondents selecting the healthier variant, 33% selecting the moderately healthy variant (95% CIs: 31%-35%), and 23% (95% CIs: 21%-24%) selecting the less healthy variant of the four products included in the study. The Multiple Traffic Light led to significant differences in choices between healthier (35%, 95% CIs: 33%-37%) and less healthy products (29%, 95% CIs: 27%-31%), but not moderately healthy products (32%, 95% CIs: 30%-34%). No significant differences in choices were observed by product healthfulness when the Daily Intake Guide was present. Only the Health Star Rating resulted in a significantly greater willingness to pay for healthier versus less healthy products. The Nutrition Facts Panel was viewed for only 7% of all mock packages. Conclusions Front-of-pack labels that are more interpretive, such as the Health Star Rating, can be more effective at directing consumers towards healthier choices than reductive front-of-pack labels such as the Daily Intake Guide. The study results provide policy makers with clear guidance on the types of front-of-pack labels that are most likely to achieve positive health outcomes at a population level.

The National Institutes of Health (NIH) supports 24 IDeA Networks of Biomedical Research Excellence (INBRE) Programs that help develop university-based biomedical research capacity in states that historically receive low levels of extramural grant support. To assess the effectiveness of the Arkansas INBRE in meeting its biomedical research capacity-building goals, we evaluated how the context (i.e., local and institutional settings) at two undergraduate institutions impacted variability in science faculty use of program resources. Data were collected by in-depth interviews with faculty and administrators (N = 9), focused observations, a review of Arkansas INBRE databases, and internet searches. Content analysis was used to code interview transcripts and field notes, and then qualitative data were integrated with data from databases and internet searches to construct two institutional case summaries. Constant comparison was used to identify similarities and differences between the institutions that helped to explain variability in how frequently faculty used Arkansas INBRE resources, including an enrollment crisis at undergraduate institutions in the United States and the presence or absence of a robust research culture at each institution. These findings were used to suggest program improvements (e.g., classroom-based research) that could further strengthen biomedical research capacity in Arkansas. As some barriers to program effectiveness are likely found in other IDeA-eligible states, improvements suggested for the Arkansas INBRE could apply to INBRE programs elsewhere.

IntroductionTraumatic brachial plexus injury (TBPI) involves major trauma to the large nerves of the arm which control the movement and sensation. Fifty per cent of injuries result in complete paralysis of the arm with many other individuals having little movement, sensation loss and unremitting pain. The injury often causes severe and permanent disability affecting work and social life, with an estimated cost to the National Health Service and the economy of £35 million per annum. Advances in microsurgery have resulted in an increase in interventions aimed at reconstructing these injuries. However, data to guide evidence-based decisions is lacking. Different outcomes are used across studies to assess the effectiveness of treatments. This has impeded our ability to synthesise results to determine which treatments work best. Studies frequently report short-term clinical outcomes but rarely report longer term outcomes and those focused on quality of life. This project aims to produce a core outcome set (COS) for surgical and conservative management of TBPI. The TBPI COS will contain a minimum set of outcomes to be reported and measured in effectiveness studies and collected through routine clinical care.Methods and analysisThis mixed-methods project will be conducted in two phases. In phase 1 a long list of patient-reported and clinical outcomes will be identified through a systematic review. Interviews will then explore outcomes important to patients. In phase 2, the outcomes identified across the systematic review, and the interviews will be included in a three-round online Delphi exercise aiming to reach consensus on the COS. The Delphi process will include patient and healthcare participants. A consensus meeting will be held to achieve the final COS.Ethics and disseminationThe use of a COS in TBPI will increase the relevance of research and clinical care to all stakeholders, facilitate evidence synthesis and evidence-based decision making. The study has ethical approval.Trial registration numbersCRD42018109843.

Abstract Background Common disease risk clusters in families due to shared genetics, exposure to environmental risk factors, and because many health behaviours are established and maintained in family environments. This randomised controlled trial will test whether the provision of a family health history (FHH) risk assessment tool increases intentions and engagement in health behaviors. Message distribution and collective behavior change within family networks will be mapped using social network analysis. The relative intervention impact will be compared between families from different ethnic backgrounds. Methods One hundred and fifty mothers (50 Anglo-Australian, 50 Italian-Australian, 50 Vietnamese-Australian) will be recruited, with four or more other family members across three generations, including a child (aged 10–18 years). Each family is randomly assigned to intervention or control. At baseline and 6-month follow-up, all participants complete surveys to assess dietary and physical activity intentions and behaviors, attitudes towards food, and perceived disease risk. Intervention families receive a visual pedigree detailing their FHH of diabetes, heart disease, breast and bowel cancer, a health education workbook to ascertain members’ disease risk (i.e. average or above average risk), and screening and primary prevention recommendations. After completion of follow-up assessments, controls will receive their pedigree and workbook. The primary hypothesis is that attitudes and lifestyle behaviors will improve more within families exposed to FHH feedback, although the extent of this improvement may vary between families from different ethnic backgrounds. Additionally, the extent of improvement in the treatment group will be moderated by the level of family disease risk, with above-average risk leading to greater improvement. A secondary aim will explore different family members’ roles in message distribution and collective responses to risk using social network approaches and to compare network functioning between families with different ethnic backgrounds. Discussion Results will guide future health promotion programs aimed at improving lifestyle factors. This research will assess whether FHH can motivate families to adopt family-level strategies to support health promoting behaviors. Secondary analyses aim to identify change agents within the family who are particularly effective in shifting normative behaviors. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12613001033730 . Retrospectively registered: 17 September, 2013.

Background Wastewater analysis is a method of routinely sampling the wastewater within a city to detect drug metabolites. Smoking by-products such as nicotine enter the sewerage network via urine excretion of people consuming cigarettes. Concentrations of nicotine and cotinine are calculated at sewerage treatment plants and converted to population consumption estimates. A similar approach has been routinely used to estimate illicit drug use for some time. This presentation will outline the pros and cons of wastewater analysis for population nicotine consumption estimates. Methods Nicotine (cotinine) sampling occurred every two months from four wastewater treatment plants across the city of Adelaide, South Australia. Simultaneously, a South Australian telephone monitoring survey (n=600 per month) was used to calculate bi-monthly tobacco cigarette consumption among metropolitan residents. Data collection occurred from December 2011 and will include data until December 2017. The trends of both data sets will be compared. Results The wastewater and population survey data trends corresponded reasonably well until early 2015. Since then the trends have diverged, with the wastewater trend showing a small but steady decline in nicotine consumption whereas the population survey data trend shows large fluctuations in cigarette consumption. Potential reasons for the divergence include: wastewater analysis not distinguishing the source of nicotine (e.g. tobacco cigarettes, NRT, or e-cigarettes) and large confidence intervals for monthly population survey monitoring. Conclusions Nicotine and its metabolite cotinine are non-specific for tobacco smoking. Therefore, wastewater analysis for tobacco smoking may supplement population monitoring of nicotine consumption but is not sufficient for detecting changes in quitting activity and smoking prevalence. Further research is needed to determine whether other tobacco-specific metabolites can be monitored to address these limitations. One advantage of wastewater analysis is that it provides an objective measure that can be compared across jurisdictions.

Background In 2012 Australia was the first country in the world to implement plain tobacco packaging. Both public health agencies and the tobacco industry advocated their position on the legislation in the news media. This study comprehensively documents print media coverage of the plain packaging initiative over the duration of the policy initiation and implementation. Methods Major Australian print newspaper (n=17) articles on plain packaging were sourced through the Australian/New Zealand Reference Centre and Factiva online databases. Articles (n=701) were collected over the 7 year duration of the policy debate and pre- and post-implementation from January 2008 to December 2014. Content analysis regarding article type, topic and frame was undertaken. Results Print media coverage of plain packaging was initially low (2008-2009) and increased during the legislative process, and lead up to implementation. Print media coverage declined substantially post-implementation. News articles were the most common form of coverage (79.6%), followed by editorials (14.3%). Updates on progress of the policy were most commonly discussed (29.4%) followed by the tobacco industry's response to the proposed legislation including 'nanny state' objections (18.3%) and discussions of plain packaging as a tobacco control initiative (17.0%). As well as reporting of policy announcements, policy rationale, implementation, legal challenges and their outcomes, there was also reporting of industry arguments which centred around predictions of unintended consequences including illicit trade, youth smoking and harm to small business, as well as legal arguments about acquisition of intellectual property. Conclusions Plain packaging received significant media coverage in Australia in the years leading up to its implementation, and far less post implementation. Subsequently disproven industry predictions did receive substantial coverage, however they were countered by articles on the public health rationale and the policy's successful progression. Policy makers should expect but not be deterred by coverage of industry arguments through media.

Background Unassisted cessation is the most common method of quitting successfully among both men and women, yet women have lower quit rates overall. It is important to examine characteristics of unassisted cessation attempts with regard to gender. Methods Household surveys of approximately 3000 South Australians (aged 15+) were conducted each year from 1998 to 2014, yielding an overall sample size of 50100, including 4662 female smokers and 5866 male smokers. The survey assessed attitudes and behaviours regarding smoking and quitting. Results The proportion of cessation attempts that were unassisted decreased significantly over time, from 63.5% to 39.3% among males and 58.7% to 30.9% among females (logistic regressions, both p< .001). Females had lower average nicotine dependence than their male counterparts among assisted and unassisted attempts (t tests, p< .001). For unassisted cessation attempts resulting in abstinence of up to one year, females had a longer average period of abstinence (49.8 days) compared to males (37.6 days) and females that used assistance (37.2 days) (t-tests, both p< .001). There were no gender differences in the length of abstinence from unassisted attempts when only accounting for attempts lasting less than 3 months (89% of all attempts). Conclusions The high rate of using assistance used by female smokers despite having lower average nicotine dependence may be reflective of lower self-efficacy to quit, especially given that females do not have superior quitting outcomes resulting from their higher use of support. Females should not be discouraged from attempting to quit unassisted if they wish to do so as this can lead to lengthy periods of abstinence in excess of that achieved from assisted attempts. Trends in the use (and non-use) of cessation supports by female smokers should continue to be monitored given the potential for overuse of cessation support on non-successful attempts to ultimately damage self-efficacy to quit.

Autosomal recessive polycystic kidney disease is a truly catastrophic monogenetic disease, causing death and end stage renal disease in neonates and children. Using PCK female rats, an orthologous model of autosomal recessive polycystic kidney disease harboring mutant Pkhd1, we tested the hypothesis that intravenous renal cell transplantation with normal Sprague Dawley male kidney cells would improve the polycystic kidney disease phenotype. Cytotherapy with renal cells expressing wild type Pkhd1 and tubulogenic serum amyloid A1 had powerful and sustained beneficial effects on renal function and structure in the polycystic kidney disease model. Donor cell engraftment and both mutant and wild type Pkhd1 were found in treated but not control PCK kidneys 15 weeks after the final cell infusion. To examine the mechanisms of global protection with a small number of transplanted cells, we tested the hypothesis that exosomes derived from normal Sprague Dawley cells can limit the cystic phenotype of PCK recipient cells. We found that renal exosomes originating from normal Sprague Dawley cells carried and transferred wild type Pkhd1 mRNA to PCK cells in vivo and in vitro and restricted cyst formation by cultured PCK cells. The results indicate that transplantation with renal cells containing wild type Pkhd1 improves renal structure and function in autosomal recessive polycystic kidney disease and may provide an intra-renal supply of normal Pkhd1 mRNA.

Ciliopathies lead to multiorgan pathologies that include renal cysts, deafness, obesity and retinal degeneration. Retinal photoreceptors have connecting cilia joining the inner and outer segment that are responsible for transport of molecules to develop and maintain the outer segment process. The present study evaluated meckelin (MKS3) expression during outer segment genesis and determined the consequences of mutant meckelin on photoreceptor development and survival in Wistar polycystic kidney disease Wpk/Wpk rat using immunohistochemistry, analysis of cell death and electron microscopy. MKS3 was ubiquitously expressed throughout the retina at postnatal day 10 (P10) and P21. However, in the mature retina, MKS3 expression was restricted to photoreceptors and the retinal ganglion cell layer. At P10, both the wild type and homozygous Wpk mutant retina had all retinal cell types. In contrast, by P21, cells expressing rod- and cone-specific markers were fewer in number and expression of opsins appeared to be abnormally localized to the cell body. Cell death analyses were consistent with the disappearance of photoreceptor-specific markers and showed that the cells were undergoing caspase-dependent cell death. By electron microscopy, P10 photoreceptors showed rudimentary outer segments with an axoneme, but did not develop outer segment discs that were clearly present in the wild type counterpart. At p21 the mutant outer segments appeared much the same as the P10 mutant outer segments with only a short axoneme, while the wild-type controls had developed outer segments with many well-organized discs. We conclude that MKS3 is not important for formation of connecting cilium and rudimentary outer segments, but is critical for the maturation of outer segment processes.

Autosomal dominant polycystic kidney disease (ADPKD) is associated with a variety of cellular phenotypes in renal epithelial cells. Cystic epithelia are secretory as opposed to absorptive, have higher proliferation rates in cell culture and have some characteristics of epithelial to mesenchymal transitions. In this communication we describe a telomerase immortalized cell line that expresses proximal tubule markers and is derived from renal cysts of an ADPKD kidney. These cells have a single detectable truncating mutation (Q4004X) in polycystin-1. These cells make normal appearing but shorter cilia and fail to assemble polycystin-1 in the cilia, and less uncleaved polycystin-1 in membrane fractions. This cell line has been maintained in continuous passage for over 35 passages without going into senescence. Nephron segment specific markers suggest a proximal tubule origin for these cells and the cell line will be useful to study mechanistic details of cyst formation in proximal tubule cells.

The National Institutes of Health (NIH) supports 24 IDeA Networks of Biomedical Research Excellence (INBRE) Programs that help develop university-based biomedical research capacity in states that historically receive low levels of extramural grant support. To assess the effectiveness of the Arkansas INBRE in meeting its biomedical research capacity-building goals, we evaluated how the context (i.e., local and institutional settings) at two undergraduate institutions impacted variability in science faculty use of program resources. Data were collected by in-depth interviews with faculty and administrators (N = 9), focused observations, a review of Arkansas INBRE databases, and internet searches. Content analysis was used to code interview transcripts and field notes, and then qualitative data were integrated with data from databases and internet searches to construct two institutional case summaries. Constant comparison was used to identify similarities and differences between the institutions that helped to explain variability in how frequently faculty used Arkansas INBRE resources, including an enrollment crisis at undergraduate institutions in the United States and the presence or absence of a robust research culture at each institution. These findings were used to suggest program improvements (e.g., classroom-based research) that could further strengthen biomedical research capacity in Arkansas. As some barriers to program effectiveness are likely found in other IDeA-eligible states, improvements suggested for the Arkansas INBRE could apply to INBRE programs elsewhere. [ABSTRACT FROM AUTHOR]