Couples’ voluntary HIV counselling and testing (CVCT) is a high‐impact HIV prevention intervention in Rwanda and Zambia. Our objective was to model the cost‐per‐HIV infection averted by CVCT in six African countries guided by an HIV prevention cascade framework. The HIV prevention cascade as yet to be applied to evaluating CVCT effectiveness or cost‐effectiveness.We defined a priority population for CVCT in Africa as heterosexual adults in stable couples. Based on our previous experience nationalizing CVCT in Rwanda and scaling‐up CVCT in 73 clinics in Zambia, we estimated HIV prevention cascade domains of motivation for use, access and effectiveness of CVCT as model parameters. Costs‐per‐couple tested were also estimated based on our previous studies. We used these parameters as well as country‐specific inputs to model the impact of CVCT over a five‐year time horizon in a previously developed and tested deterministic compartmental model. We consider six countries across Africa with varied HIV epidemics . Outcomes of interest were the proportion of HIV infections averted by CVCT, nationwide CVCT implementation costs and costs‐per‐HIV infection averted by CVCT. We applied 3%/year discounting to costs and outcomes. Univariate and Monte Carlo multivariate sensitivity analyses were conducted.We estimated that CVCT could avert between 54% (Sierra Leone) and 62% (South Africa) of adult HIV infections. Average costs‐per‐HIV infection averted were lowest in Zimbabwe ($550) and highest in South Africa ($1272). Nationwide implementations would cost between 7% (Kenya) and 21% (Ivory Coast) of a country’s President’s Emergency Plan for AIDS Relief (PEPFAR) budget over five years. In sensitivity analyses, model outputs were most sensitive to estimates of cost‐per‐couple tested; the proportion of adults in heterosexual couples and HIV prevention cascade domains of CVCT motivation and access.Our model indicates that nationalized CVCT could prevent over half of adult HIV infections for 7% to 21% of the modelled countries’ five‐year PEPFAR budgets. While other studies have indicated that CVCT motivation is high given locally relevant promotional and educational efforts, without required indicators, targets and dedicated budgets, access remains low. Now morThe HIV prevention cascade has yet to be described or evaluated for couples’ voluntary HIV counselling and testing (CVCT), an evidence‐based intervention in which couples receive joint pre‐test counselling, testing and post‐test counselling with counsellor‐facilitated serostatus disclosure , 10. CVCBuilding on our technical support for the nationalization of CVCT in antenatal clinics (ANC) in Rwanda, where >80% of couples are now tested , we receIn the present analysis, we adapt this model to estimate the proportion of adult HIV infections averted, total costs and CHIA for nationalizing CVCT in six countries across sub‐Saharan Africa.22.1This retrospective costing and modelling study used de‐identified data from the publicly available sources cited. The Institutional Research Board at Emory University waived informed consent requirements.2.2Our CVCT CHIA model details are published . In summOur model uses HIV seroincidence rates in uncounselled (“pre‐CVCT”) serodiscordant and concordant‐negative couples  and applies the estimated effectiveness of CVCT among couples depending on their joint HIV serostatus and ART use. These effectiveness estimates are applied each year, and couples move from concordant negative to discordant and from discordant to concordant positive accordingly. Estimated “pre‐CVCT” ART use and ART initiation in the year following CVCT are also model parameters, with an additional proportion of HIV‐positive individuals taking up ART each year. Estimated costs‐per‐couple tested are based on our programmatic experience. The model outputs HIV infections averted by CVCT (by subtracting the cumulative infections that are projected to occur post‐CVCT from those occurring pre‐CVCT), total incremental financial costs to implement CVCT and incremental CHIA by CVCT . As evidIn the model, we conceptualize the expansion of CVCT in four phases: initiation, expansion, maturation and maintenance which are described in more detail below. These phases are defined by a changing set of estimated values for the HIV prevention cascade domains of motivation and access among the priority population for CVCT Figure  and costUsing this model, we previously estimated the cost‐effectiveness of nationalizing CVCT in Zambia by applying the actual financial expenditures and CVCT effectiveness observed when scaling‐up services in 73 government clinics in Lusaka, Copperbelt and Southern Provinces which reached 207,428 couples. We conducted sensitivity analyses to evaluate the effect of possible differential loss to follow‐up, informative censoring using inverse probability of censoring weighting , 27, and2.3Base‐case estimates for CVCT HIV prevention impact were derived from our CVCT implementation in 73 Zambian government clinics  Table 11. BrieflDuring the implementation, the impact of CVCT was assessed over longitudinal follow‐up. HIV seroincidence rates for discordant and concordant HIV‐negative couples were calculated as incident infections divided by HIV‐negative person‐years (PY) of follow‐up, stratified by whether couples had (“post‐CVCT”) or had not (“pre‐CVCT”) received CVCT. As shown in Table Base‐case estimates for cost‐per‐couple tested, motivation for CVCT, and access to CVCT were derived from both the Zambian implementation study described and our years of experience supporting nationalization of CVCT in Rwanda , 21. We 2.4South Africa, Zimbabwe, Kenya, Tanzania, Ivory Coast and Sierra Leone have diverse HIV epidemics and published data available for the model inputs Table . Country2.5The estimated proportion of adult HIV infections averted, total CVCT implementation costs, CHIA and proportion of President’s Emergency Plan for AIDS Relief (PEPFAR) budgets required for nationwide implementation in each selected country are outcomes of interest. These are presented alongside per capita gross domestic products (GDPs) for context. All outcomes and costs were discounted at 3%/year as recommended by the US Public Health Service Task Force . We adhe2.6We conducted one‐way sensitivity analyses for all model inputs by varying each parameter ±20%. Inputs which most influenced model outputs are reported. Because key model parameters of cost‐per‐couple tested and CVCT effectiveness were derived from just two countries, we also conducted probabilistic Monte Carlo simulation multivariate sensitivity analyses for each parameter of interest (±50% of base‐case estimates using a uniform distribution) with 1000 draws in Excel. Average outcomes and standard deviations from simulated results are reported. A uniform distribution was chosen to fix a functional form on the parameter estimates and to reflect a large degree of uncertainty around the selected parameters.3The total cost for nationwide CVCT implementation and cumulative infections averted are also shown in Table Figure 3.1One‐way sensitivity  to the proportion of concordant negative and discordant couples in the population (with higher proportions of at‐risk couples leading to increased infections averted and therefore lower CHIAs).A higher pre‐CVCT seroincidence rate in concordant‐negative couples and higher CVCT effectiveness in concordant‐negative couples both increased HIV infections averted. Finally, increasing CVCT effectiveness in ART using discordant couples by ±20% varied total infections averted by roughly ±10% (with higher prevention impact leading to increased infections averted and improved cost‐effectiveness).Examining the country‐specific parameters specifically, differences in model outcomes across countries are influenced by differences in seroincidence rates pre‐CVCT (with higher uncounselled seroincidence rates being associated with higher numbers of infections averted and improved cost‐effectiveness) and the proportion of couples who were discordant (with higher discordancy associated with higher numbers of infections averted and improved cost‐effectiveness).Probabilistic multivariate sensitivity analyses Table  also hig4Our model estimated that CVCT could prevent over half of adult HIV infections for 7% to 21% of selected countries’ five‐year PEPFAR budgets. Applying an HIV prevention cascade framework  is helpf4.1Sensitivity analyses indicated countries with a higher proportion of heterosexual couples motivated to uptake CVCT prevented more infections. Motivation for CVCT has been high across studies in diverse populations including heterosexual couples in Mozambique , 45, Tanstrengthens relationships [Reports highlight successful strategies to overcome these barriers and increase motivation including use transport reimbursement ; nonmoneionships , 64, 65.4.2Sensitivity analyses indicated that countries with a higher proportion of heterosexual couples with CVCT access will prevent more infections at a higher cost. The PEPFAR 2020 Country Operation Plan  highlighOur experience in Zambia reflected the initiation and expansion phases . GovernmIn addition to clinic‐based CVCT, mobile testing in Rwanda ; home‐ba4.3CVCT decreases sexual and perinatal HIV incidence , 15, 16 For the smaller though higher‐risk population of discordant couples, “Test‐and‐Treat” will continue to expand. Unfortunately, many country’s HIV incidence rates have not decreased as substantially as predicted in the test‐and‐treat era, and several large cluster‐randomized trials have failed to clearly demonstrate the population‐level prevention impact of universal test‐and‐treat policies . Where CFinally, an improved understanding of the effectiveness of CVCT in home‐based settings, mobile‐testing and via self‐testing is needed with regular monitoring and evaluation of these delivery platforms. With self‐testing in particular, how well couples disclose, understand their respective results and adopt appropriate risk reduction without facilitated joint post‐test counselling merits further investigation , 77, 78.4.4We found CVCT CHIA estimates to be similar to interventions largely considered cost‐effective including individual voluntary HIV counselling and testing (estimated in a previous systematic review of studies in sub‐Saharan Africa at $1315  and $4834.5As in all models, we attempt to simplify a complex reality, and outputs are dependent on assumptions. Extensive sensitivity analyses quantify the impact of these assumptions. Our model seeks to isolate the impact of CVCT on HIV infections averted given constant pre‐CVCT and post‐CVCT HIV incidence. We do not attempt to predict the course of the epidemic in the selected countries over time by considering myriad other prevention or treatment interventions. More detailed models isolating the prevention impact of CVCT attributable to condom use, VMMC uptake, improved ART uptake and adherence, and/or reductions in concurrent relationships are warranted. While deterministic compartmental models are well‐suited to examine average characteristics in a population and are thus appropriate for our goal, they do not evaluate individual‐level effects as do agent‐based models. Finally, while some studies of HIV prevention interventions translate infections averted into disability‐adjusted life‐years averted or quality‐adjusted life‐years gained, a recent systematic review did not find standard conversions applicable across country settings . While s5Our model indicated that nationalized CVCT could prevent over half of adult HIV infections for 7% to 21% of the modelled countries’ five‐year PEPFAR budgets. Unfortunately, WHO CVCT guidelines have yet to be broadly implemented. While studies indicate that CVCT motivation is high given locally relevant promotional and educational efforts, access remains low without dedicated budgets or required indicators.The authors have no conflicts of interest.KMW contributed to the analysis and interpretation of data; drafted the article and revised it critically for important intellectual content; and gave final approval of the version to be published. MI contributed to the conception and design of the study, revised the article critically for important intellectual content and gave final approval of the version to be published. WK contributed to the conception and design of the study, revised the article critically for important intellectual content and gave final approval of the version to be published. EK contributed to the conception and design of the study, revised the article critically for important intellectual content and gave final approval of the version to be published. EC contributed to the conception and design of the study, revised the article critically for important intellectual content and gave final approval of the version to be published. BV contributed to the conception and design of the study, revised the article critically for important intellectual content and gave final approval of the version to be published. JM contributed to the conception and design of the study, revised the article critically for important intellectual content and gave final approval of the version to be published. RP contributed to the analysis and interpretation of data; revised the article critically for important intellectual content and gave final approval of the version to be published. TS contributed to the analysis and interpretation of data; revised the article critically for important intellectual content and gave final approval of the version to be published. AT contributed to the study conception and design, revised the article critically for important intellectual content and gave final approval of the version to be published. EH contributed to the analysis and interpretation of data; revised the article critically for important intellectual content and gave final approval of the version to be published. RY contributed to the analysis and interpretation of data; revised the article critically for important intellectual content and gave final approval of the version to be published. GS contributed to the analysis and interpretation of data; revised the article critically for important intellectual content and gave final approval of the version to be published. PC contributed to the analysis and interpretation of data; revised the article critically for important intellectual content and gave final approval of the version to be published. SA contributed to the study design and conception, contributed to the analysis and interpretation of data; revised the article critically for important intellectual content and gave final approval of the version to be published.


The presence of health problems in a child is known to be negatively associated with later academic achievement, but less is known about the educational outcomes for siblings of children in poor health. The study investigated how having a sibling with health problems affects a healthy sibling's academic achievement.We utilized medical and social microdata from Swedish administrative population registers. Our sample consisted of N = 115,106 individuals (51.3% boys) born in 1990 in Sweden. We compared children with ill siblings to children whose siblings did not have poor health. Siblings' hospital admissions and the academic achievements of the healthy sibling during their final year of compulsory education (at the age of 15‐16) were analyzed using linear and logistic regression in relation to individual health‐ and family‐related confounders.Sibling hospitalization was significantly associated with lower overall grade points  and an increased odds ratio (OR) of ineligibility for upper secondary education .School and health personnel should also consider the needs of healthy siblings during their work with children in poor health, because they too can be disadvantaged. Poor health in childhood and adolescence is negatively related to academic achievement.However, children are nested in families, and if one member of a family has health problems, there are likely to be spillover effects on the other members of the family. To understand the implications of ill‐health for student achievement in a wider sense, it is therefore necessary to determine how the academic achievement of healthy children is affected by having a sibling in ill health. While research on the psychosocial consequences for healthy siblings is plentiful,We considered 2 research questions: (1) Is having a sibling with ill health related to academic achievement in the final year of compulsory education? (2) Do parental resources, measured by parental level of education, moderate the relationship between having a sibling with ill health and academic achievement in the final year of compulsory education? These questions are addressed using ordinary least squares and logistic modeling, adjusting for individual birth and later life health status as well as family‐level covariates. By drawing on resource dilution theoryexperiences of >1470 siblings of children with chronic illnesses, primarily cancer. Most of the studies were qualitative in their design and examined outcomes including academic functioning, psychological effects, peer relations, and school attendance. The authors concluded that “siblings experience negative effects in psychological, social and academic domains of school functioning” (p. 31). However they also noted that the conclusions of these studies “may not generalize well beyond the experiences of siblings of children diagnosed with cancer” (p. 30) because of the limitations of their samples. Additionally, academic achievement was not examined as an outcome in any of the reviewed studies. Regarding specific achievement outcomes, Fletcher et al.special educational needsAmong the many literature reviews on how childhood illness affects the well‐being, family adjustment, and psychosocial functioning of the ill child's siblings,Having a sibling with ill health can be considered to affect academic achievement through 2 main mechanisms. The first stems from how the sibling's ill health might affect the availability of familial resources. Because siblings typically grow up in the same household raised by the same parents, they share limited parental resources. According to resource dilution theory,The second mechanism relates to the impact of the sibling's ill health on the child's own resources. Having a sibling with health problems may impose psychological costs on a child. These can be considered to result from stress transmission mechanisms whereby the sibling's ill health acts as a stressor for other family members and has negative effects on their well‐being. While some positive psychological outcomes have been reported, such as a stronger sense of maturity and independence, the literature generally indicates that having a sibling in ill health limits a healthy child's psychological resources,per se are scarce, it is reasonable to assume that the reported negative psychosocial experiences of children with seriously ill siblingsIn summary, although previous studies linking sibling ill health to academic achievement This study was based on data from several national registers obtained via the Umeå SIMSAM Lab data infrastructure.The study population consisted of the cohort of individuals born in 1990 in Sweden, who were alive and residing in Sweden 2006, the last year of compulsory school for the cohort. Foreign‐born individuals were excluded because we wanted to account for health status at birth in our analyses. We also excluded singletons and compared children with ill siblings to children whose siblings did not have any indications of poor health. Our final analytical sample consisted of N = 115,106 individuals (51.3% boys), referred to below as index‐persons. Both full and half‐siblings  of the index‐persons are regarded as siblings.overall grade points and (2) eligibility for upper secondary education. Overall grade points reveal differences in levels of academic achievement, while eligibility for continuation to upper secondary education reveals problems with successfully completing compulsory education.Academic achievement was measured using 2 variables: (1) Overall grade points is the sum of the 16 best subject grades in the 9th and final grade of compulsory school, which are received at the age of 15‐16. For each subject, a student is assigned a grade ranging from 0 to 20, where 0 indicates failure. The overall grade points thus range from 0 to 320 and indicate the child's general academic achievement; an overall grade points value of 0 denotes failure in all tested subjects, while an overall grade points value of 320 indicates that the child achieved the highest possible grade in all 16 subjects. Overall grade points is a continuous variable with an approximately normal distribution (M = 205.5 SD = 64.7).Eligibility for upper secondary education was assessed when the cohort was in the ninth grade. It was assessed based on successful completion of compulsory schooling with passing grades in the core subjects of Swedish, English, and mathematics, which were required for admittance to national upper secondary level education programs. A binary variable was defined, with a score of 0 assigned for passing grades in all 3 core subjects (and thus eligibility for upper secondary education) and a score of 1 for failing one or more of the 3 core subjects (and thus non‐eligibility for upper secondary education).Because hospitalization results exclusively from detrimental accidents or severe health problems, we defined children having a sibling with ill health as those children who had at least one repeatedly hospitalized sibling. Specifically, sibling ill health is a dichotomous (no/yes) variable taking a value of “yes” only if the index person had one or more siblings who had at least 3 (or more) separate overnight hospitalization events during each of the following 3 periods of the index person's life, namely the years between the ages of 0 and 6, 7 and 12, and 13 and 16. This operationalization captures siblings of children with a broad range of different and recurring health problems.The parents' level of education is often used as an indicator of their socioeconomic status and indirectly influences children's academic achievement because it affects the parents' educational expectations and parenting behaviors. Higher educated parent's also spend more time with their children.The complexities, ambiguities, and stresses associated with new familial roles and relationships consume family resources that could otherwise be directed to different ends. Therefore, we included “family structure” in our analysis using a dichotomous variable indicating whether the child's biological parents were or were not (yes/no) married/cohabiting when the child received their final compulsory school grades.Dichotomous variables were defined for the child's mother and the child's father, indicating whether or not they had been born in a Scandinavian country  or a non‐Scandinavian country (yes/no).small for their gestational age (no/yes), large for their gestational age (no/yes), malformed (no/yes), and their Apgar score 5 minutes after birth, which quantifies the newborn's physical condition 5 minutes after birth . An Apgar score below 7 is considered low, while a score of 7‐10 is considered normal.To control for selection into poor health from birth, we included variables indicating whether the child was psychotropic drug prescription, indicates whether the child has ever been prescribed psycholeptic  or psychoanaleptic (for treatment of depression and attention deficit hyperactivity disorder) medication during their last year of lower secondary education (no/yes), according to the Swedish Prescribed Drug Register. The second such variable, hospitalization, indicates whether the index child had or had not been hospitalized for at least one night during their lower secondary education/early adolescence, between the ages of 13 and 16 (no/yes).Two dichotomous variables were used to characterize the health of index children later in life. The first, overall grade points. Independent variables were added stepwise to assess potential confounding; this was done by running 4 models separately. Model 1 included only the sibling ill health variable. Model 2 also included the family‐level control variables . Model 3 included the variables from model 2 together with the variables relating to the index child's birth health  and later life health . Finally, the fourth model included an analysis of the interaction between having had a sibling with ill health and parental level of education: 3 interaction terms were computed, one for each level of parental education defined above . We also performed analyses featuring 7 levels of parental education but found no significant differences between the 2 operationalizations. The same steps were taken to determine how sibling ill health was associated with eligibility for upper secondary education. However, due to the binary nature of that variable, logistic regression was used.The multiple linear regression procedure was used to assess how having had a sibling with ill health was associated with A total of 6945 children (6%) had one or more siblings with ill health according to the study's operationalization. Table overall grade points as the outcome. The coefficients in the table indicate how many more or fewer grade points (as a measure of achievement) a particular variable in the model is associated with. Model 1 shows that having had one or more siblings hospitalized for at least one night during 3 age periods  was significantly associated with lower overall grade points , corresponding to a 8.4% deviation (Gaussian distribution) from the sample mean (M = 205.5). Model 2 shows that adjusting for gender and parental resources/characteristics attenuates this association , resulting in a 5.4% deviation in overall grade points from the sample mean. In model 3, which is also adjusted for individual birth health and later health, the association was only marginally further attenuated , giving a 5.2% deviation in overall grade points from the sample mean. In model 4 we introduced the interaction terms “sibling ill health × parent's level of education.” No significant interaction effects between having had a sibling with ill health and parental level of education were found.Table eligibility for upper secondary education as the outcome. The first unadjusted model shows that sibling ill health significantly increased the odds ratio (OR) of ineligibility for upper secondary education . Both model 2 and model 3 show that despite being somewhat reduced after adjustments, sibling ill health still significantly increased the odds of ineligibility for upper secondary education , . In model 4 we added the interaction terms “sibling ill health × parents' level of education,” which revealed a non‐significant interaction between having had an ill sibling and the parents' level of education. Overall, the patterns in results for the 2 outcome measures were similar.Table Our findings show that having a sibling with poor health is significantly associated with lower academic achievement in the final year of compulsory school in Sweden. Whereas previous research has concluded that siblings of ill children have negative experiences of school,time with their children,We proposed 2 main mechanisms to explain how having a sibling in ill health might affect academic achievement. The first is based on an extension of the concept of resource dilution, which is generally hypothesized to be a function of sibling group size. We suggested that an ill sibling may consume more parental resources than a healthy sibling by prompting the parents to reallocate their time, attention and emotional support. As such, sibling illness would restrict a healthy sibling's access to these parental resources. As demonstrated previously, however, the extent of resource dilution due to sibling group size and child well‐being varies between national contexts.and later life health, we can infer that the effect of sibling ill health on school grades is significant.An advantage of using multiple sources of linked data from total population registers is that one obtains a very large sample size. Consequently, our findings can be generalized to a very large proportion of the Swedish population. The design of comparing children with ill siblings to children whose siblings did not have any indications of poor health provides support for causal inferences. Another strength of the study was the ability to control for many, although far from all, of the potentially relevant confounders. Because we adjusted for both individual birth health While there are many strengths to this study, it has some limitations that should be noted. The use of hospitalizations to identify ill siblings captures individuals that specifically required in‐hospital care, and would thus be a reliable indicator of severe health‐related problems. However, it might not capture some illnesses or other disabilities/impairments that can be debilitating without requiring hospitalization. Our results may thus underestimate the impact of sibling illness on academic achievement but are sufficient to reveal a general effect. Furthermore, differentiating the cause of the hospitalizations by diagnosis would have revealed condition‐specific effects. This was not feasible due to data limitations.Psychoeducational support to the sibling and the entire school regarding the ill child. This can include individual counseling, but could also be implemented as a feature of theme days on health and well‐being, in which parents can be involved to share experiences. This can improve the knowledge and attitudes of students and school personnel as well as sibling school functioning.Increase teacher and school personnel involvement in order to identify signs of maladaptive coping in siblings. This can also facilitate student‐teacher bonding and sibling school engagement which in turn could enhance school performance.In addition to receiving psychological support at school through a counselor, specific sibling support measures that schools can take are flexible assessment deadlines or offering extra orientation days to reduce sibling's anxiety in the event of the ill child's disease intensification.Our results showed that children with ill siblings achieve lower school grades as compared to children whose siblings did not have poor health. The study lends evidence to the existence of negative health spillover effects between siblings on academic achievement. Some practical implications can follow from these results. Because a student's final grades in compulsory education determine their eligibility for admission to higher education in Sweden, it is important for support services to acknowledge the adverse effects of sibling illness on adolescents' educational trajectories and future opportunities. Existing school support services primarily focus on the disadvantages facing children in poor health. However, our results indicate that school psychologists, counselors and teachers should also consider the needs of healthy siblings during their work with children in poor health, because they too can be disadvantaged. School‐based support services should adhere to a family‐centered approach which is inclusive of also the healthy sibling. A sibling support model in which the school and the parents share responsibility for stabilizing the sibling's experience and providing consistent support, as also suggested elsewhere,The Regional Ethical Vetting Board in Umeå approved all research based on data from the Umeå SIMSAM Lab, including the present study (Dnr.2010‐157‐31).All authors of this article declare they have no conflicts of interest.


Autism is difficult to identify in adults due to lack of validated self‐report questionnaires. We compared the effectiveness of the autism‐spectrum quotient (AQ) and the Ritvo autism–Asperger's diagnostic scale‐revised (RAADS‐R) questionnaires in adult mental health services in two English counties.A subsample of adults who completed the AQ and RAADS‐R were invited to take part in an autism diagnostic observation schedule (ADOS Module 4) assessment with probability of selection weighted by scores on the questionnaires.There were 364 men and 374 women who consented to take part. Recorded diagnoses were most commonly mood disorders (44%) and mental and behavioural disorders due to alcohol/substance misuse (19%), and 4.8%  were identified with autism (ADOS Module 4 10+). One had a pre‐existing diagnosis of autism; five (26%) had borderline personality disorders  and three (17%) had mood disorders. The AQ and RAADS‐R had fair test accuracy . AQ sensitivity was 0.79  and specificity was 0.77 ; RAADS‐R sensitivity was 0.75  and specificity was 0.71 .The AQ and RAADS‐R can guide decisions to refer adults in mental health services to autism diagnostic services. Improving recognition and diagnosis of ASD became a cross‐government policy in England in 2009 with the passing of the Autism Act, the Think Autism Strategy Health, , and staMost adults living with ASD do not have intellectual disability, though ASD is more prevalent within this group  agreed to help with recruitment.Between August 2011 and December 2012, adult (aged 18+) mental health service users from the participating mental health sites were approached by members of the research team and specially trained research volunteers to take part in the study. All adults, regardless of recorded diagnosis, were deemed eligible to be approached with a few exceptions, namely, adults who could not speak English, had intellectual disability or lacked capacity to consent , or whose contact was with one specialist service for eating disorders. Participants were asked to complete the AQ and RAADS‐R, with the option of completing them in the presence of the researcher or taking the questionnaires home to complete.As well as basic demographic information, recorded primary psychiatric diagnoses within 2 years prior to questionnaire completion and diagnoses of ASD or attention deficit hyperactivity disorder within 5 years prior to questionnaire completion were collected for all consenting adults. This was achieved via a combination of reviewing their clinical letters as well as accessing electronic healthcare records. In the case of service users recruited within the community setting, all were approached prior to their interview with the diagnostic clinician and thus any new diagnoses as a result of this subsequent clinical interview were not recorded.Adults were selected for a second home interview with the autism diagnostic observation schedule , adults with other mental disorders who were not autistic (n = 302), and adults with no previous mental health disorders (n = 276). The RAADS‐R discriminated well between the groups  of the other items in the respective questionnaire. Population demographics, psychiatric diagnoses, and the distribution of AQ and RAADS‐R scores were described and tested for normality. Internal consistency of items on the questionnaires was assessed using Cronbach's alpha  eligible patients from outpatient/community mental health team, inpatient, and other mental health settings agreed to take part in the study and to complete both the AQ and RAADS‐R questionnaires Figure . The resn = 144 AQ and n = 172 RAADS‐R) had between one and three missing items requiring imputation. The remaining 254 (34%) participants did not return or failed to fully complete the questionnaires  or depression  completed the AQ and 438 (59%) completed the RAADS‐R. About one‐third of the questionnaires  with the average inter‐item correlation lower than the recommended range . The scores appeared to be normally distributed (Shapiro–Wilk test p < .001). Internal consistency for items on the RAADS‐R using Cronbach's alpha was good (α = 0.95) with the average inter‐item correlation within the recommended range . We found evidence that the scores did not follow a normal distribution , usually in their own home. One participant had such complex difficulties that the interviewers did not feel confident in scoring the ADOS Module 4. This participant was excluded from the analyses, leaving 92 remaining.p = .11). Scores had good internal consistency (α = 0.85), but average inter‐item correlations were lower than the recommended range  and appeared to follow a normal distribution : 8 were men and 11 were women.n = 5; 28%) and mood disorders .Of these 19 research‐identified adult autism cases, only one had a recorded service coded diagnosis of ASD prior to entering the study. The most common service diagnoses in those remaining were personality disorders . Internal consistency for items was excellent (α = 0.95) and average inter‐item correlations were within the recommended range , and we found evidence that they did not follow a normal distribution  and mood disorders .Sixteen adults met the higher ADOS threshold of 10+ for autism: 6 were men and 10 were women. As before, the most common service recorded diagnosis, among those remaining research identified adult autism cases, were personality disorders . The intra‐class correlation coefficient for the two AQ tests was .90  and for the two RAADS‐R tests was .88  suggesting excellent test–retest reliability  and mean baseline RAADS‐R scores 87 (range 6–192). Using Bland–Altman plots Figure ,b, we fo4n = 44) of the participants could not complete either questionnaire, suggesting that a significant minority of mental health services users with capacity struggle with these self‐completion questionnaires and need to be assessed differently. This has implications for their use in clinical practice.Overall, the findings suggest that both the self‐completion questionnaires, the AQ and the RAADS‐R, may be useful in facilitating psychiatrists' and psychologists' referrals to ASD services for a diagnostic assessment. However, the questionnaires cannot be used in isolation, but in conjunction with clinical judgement and other ASD assessment tools if necessary. Of note, 6% . The optimal threshold for the RAADS‐R was also substantially higher than that recommended by the developers (120 vs. 65), which might, in part, be explained by the different study populations, but merits further investigation. More than half of our service users met the threshold for autism using this recommended (lower) cut off, which is concerning. Our study interviewers remarked that participants seemed to struggle more with the scoring options for RAADS‐R; also they appeared to become confused by what some of the questions were asking, especially those looking at sensory issues or emotions. The RAADS‐R developers encourage clinician support to patients when completing the test but do permit unsupervised use, which would reduce cost of use. In our study, although support was offered to all patients, a minority of patients would insist on taking the questionnaires away with them to complete on their own, potentially impacting on the effectiveness of this measure for such individuals.Although the male to female ratio was similar among the 392 individuals who completed the questionnaires (48.7% men and 51.3% women), we identified more autism cases among women than men, which is contrary to the literature in the general population where autism is more prevalent among men  of consenting participants lacking a pre‐existing mental health diagnosis is likely to be because these patients had yet to commence or were still undergoing an initial assessment of their mental health at the time their research assessment was completed, such that a formal diagnosis had not yet been determined and coded (and we did not make a record of delayed codings). Additionally, the approach towards coding for pre‐existing mental health diagnoses being limited to diagnoses within 2 years prior to questionnaire completion (or 5 years in the case of ASD and attention deficit hyperactivity disorder) could miss diagnoses made prior to this point.Both the AQ and RAADS‐R were evaluated by their original developers using a case–control design that is not recommended in test evaluations  and most recently by Wigham et al. . The sen5A major strength of this evaluation is the use of a representative sample of one population of clinical relevance; many such evaluations compare different populations  leading to biased overestimation of the sensitivity and specificity of a test . However, as pointed out earlier, the RAADS‐R did not satisfy this prerequisite; the cut point recommended by its developers was 65 and not 120 in our evaluation. Therefore, this new higher cut point does need to be evaluated independently.Strictly speaking, as noted above, a test should be evaluated in the population in which it is likely to be used; therefore, we do not know how these tests would perform in adult mental health patients clinically judged to need testing. Instead, we evaluated these two tests in the whole of a population in which practice until now has rarely been to consider the value of testing for autism. As autism awareness grows and as clinicians and Multi‐disciplinary team (MDTs) are increasingly supported and trained to be more aware of the presence of comorbid autism, the design of such studies should focus instead on those clinically judged to be more likely benefit from such a test. But an advantage of our study is that we have obtained an estimate of the prevalence of autism in the adult mental health service user population and an estimate of its under recognition, neither of which would have been possible if we focused on studying only those likely to be tested in practice.A final limitation for some users of our findings will be the fact that service users in contact with eating disorder services could not be included in this study.6The AQ and RAADS‐R can be used to facilitate referrals from mental health settings to autism diagnostic services, but not on their own to determine a diagnosis. But in order to develop the capacity to meet this largely unrecognised need, mental health services will have to adapt. Only one of the 19 cases of autism identified in the present research was already recognised by the specialist mental health service they were attending. This and the finding that almost one in 20 service users has autism suggests that adult psychiatrists and allied mental health professionals should all be trained and experienced in identifying autism.The authors have no conflict of interest to declare.


To present the feasibility, safety and outcomes of fetoscopic endoluminal tracheal occlusion (FETO) for the treatment of severe congenital diaphragmatic hernia (CDH).This was a single‐arm clinical trial of FETO for isolated left‐sided CDH with liver herniation and Kitano Grade 3 stomach position (>50% stomach herniation into the right chest). FETO was performed at 27–29 weeks of gestation for cases with observed/expected lung to head ratio (o/e LHR) <25% and at 30–31 weeks for cases with o/e LHR ≥25%.Eleven cases were enrolled between March 2014 and March 2016, and balloon insertion was successful in all cases. The median o/e LHR at entry was 27% . The median gestational age at FETO was 30.9  weeks. There were no severe maternal adverse events. One fetus died unexpectedly at 33 weeks of gestation due to cord strangulation by the detached amniotic membrane. There were 3 cases (27%) of preterm premature rupture of membranes. In all 10 cases, balloon removal at 34–35 weeks of gestation was successful. The median gestational age at delivery was 36.5  weeks. The median duration of occlusion and the median interval between balloon insertion and delivery were 26 days (range: 17–49 days) and 43 days , respectively. Both the survival rate at 90 days of age and the rate of survival to discharge were 45% (5/11).The FETO is feasible without maternal morbidity in Japan and could be offered to women whose fetuses show severe isolated left‐sided CDH to accelerate fetal lung growth. Advances in ultrasonography in prenatal care have facilitated the prenatal diagnosis of CDH.et al., which used a 5‐mm uterine port with laparotomy, failed to show the superiority of fetal intervention due to a high rate of preterm premature rupture of membranes (pPROM) and preterm delivery.et al. introduced fetoscopic endoluminal tracheal occlusion (FETO) as a minimally invasive procedure performed through a percutaneous approach with a 3.3‐mm cannula.The rationale for fetal therapy for CDH is to improve the growth of the hypoplastic lung before birth. After attempting some strategies,In 2014, we started a FETO program that was the first trial of FETO in Asia. The aim of the present study was to report the feasibility, safety and outcomes of FETO for the treatment of severe CDH at our center.http://www.umin.ac.jp). Women carrying fetuses with left‐sided CDH at 26–29 weeks of gestation were evaluated at the National Center for Child Health and Development (NCCHD) in Tokyo, Japan prior to participation in the trial. Entry evaluations included detailed ultrasonography, advanced echocardiography and a karyotype analysis by amniocentesis. The stomach position was determined according to Kitano's grading scale.This study was a single‐arm clinical trial registered as UMIN000012395 ,The FETO was performed under maternal spinal and epidural anesthesia. Fetal anesthesia and immobilization were performed by percutaneous ultrasound‐guided intramuscular injection of fentanyl (0.01–0.02 mg/kg), atropine (0.01 mg/kg) and vecuronium (0.2 mg/kg). FETO was performed in a procedure similar to that performed in the clinical research consortium.in utero was planned at 34 weeks of gestation at the NCCHD. Balloon removal was achieved by puncture under ultrasound guidance or using fetoscope . A 22 gage PTC needle (Hakko Company) was used for ultrasound‐guided puncture. Using a fetoscope, the balloon was punctured by a sharp stylet  with the balloon held by grasping forceps  and then the balloon was removed with the fetoscope. If these two methods were not applicable due to pPROM or the onset of labor before elective balloon removal, ex utero intrapartum treatment (EXIT) was performed to remove the balloon before birth.Perioperative management with prophylactic tocolysis and antibiotics and postoperative management until balloon removal were provided at the NCCHD. Patients were followed up with ultrasonography every week to evaluate the balloon location, fetal growth, fetal lung size and amniotic fluid volume. Patients were also followed up with electric fetal monitoring (EFM) twice a week. MRI was performed before balloon removal at 33–34 weeks of gestation. Balloon removal After balloon removal, standard prenatal management with a weekly ultrasound examination and planned delivery and standard neonatal management of CDH were provided at the NCCHD or at one of four referring perinatal centers . All neonates were treated by the standardized postnatal managements of each institute, including gentle ventilation with high‐frequency oscillatory ventilation. CDH repair was performed after respiratory and circulatory stabilization.Data on the prenatal ultrasound findings, MRI findings, FETO and balloon removal procedure findings, adverse events of fetal therapy,A total of 11 cases were enrolled between March 2014 and 2016. The perioperative findings and outcomes of the cases are shown in Table The adverse events of the cases are shown in Table Table In all 11 registered cases, FETO was successfully performed without severe maternal adverse events. In all 10 cases in which balloon removal was required, the balloon was successfully removed and the fetus was delivered at or after 34 weeks of gestation. This study demonstrated that it was feasible to perform FETO at an appropriately prepared fetal therapy center in Japan. This is the first successful FETO trial in Asia. FETO could be offered to women carrying fetuses with severe isolated left‐sided CDH to accelerate fetal lung growth.The major obstacle to FETO is preterm delivery, which is the strongest determinant of mortality and morbidity in CDH.The survival rate in the initial prospective study of FETO for severe CDH (liver herniation and LHR < 1) was 48% (10/21).et al. defined severe CDH as CDH with an o/e LHR < 25% in which the predicted survival rate was <20%, with cases without liver herniation showing better outcomes than those with liver herniation.et al. also demonstrated the predictive value of the stomach position using a little different grading system.Observed/expected LHR and the liver position are the best‐studied prenatal prognostic predictors of CDH.Unexpected fetal death after FETO was reported in 1 of 28 caseswww.totaltrial.ed). Although the performance of FETO prior to 29 weeks of gestation seems to be associated with a better lung response,Regarding the timing of FETO, the median gestational age at FETO was 30.9 weeks and more than half of the cases in this study underwent FETO after 30 weeks of gestation. We intended to include cases of severe CDH by using liver herniation and Kitano Grade 3 stomach position as the entry criteria. However, we ultimately followed the method of an ongoing randomized controlled trial in which FETO was performed at 30–31 weeks of gestation for cases with an o/e LHR value of 25–44% to reduce the risk of preterm deliverywww.totaltrial.ed). The second limitation of the present study was the timing of FETO. Cases with o/e LHR ≥25% underwent FETO at 30–31 weeks of gestation, although these cases were recognized as severe CDH due to Kitano Grade 3 stomach position.The present study was associated with several strengths and limitations. The strength of this study was that the feasibility study was conducted for severe CDH cases characterized by Kitano Grade 3 stomach position, which predicted survival independently of o/e LHR. This is the only FETO study in which stomach position was an inclusion criterion. One limitation of this study was that FETO was performed in a relatively small number of cases and there was no expectantly managed control group. A large number of cases with well‐designed controls will be required to evaluate the effectiveness of FETO. An ongoing randomized controlled trial will draw conclusions regarding the usefulness of FETOIn conclusion, FETO is feasible and was not associated with maternal morbidity in Japan, however, FETO is associated with a potential risk of fetal death in association with CMS. FETO could be offered to women carrying fetuses with severe isolated left‐sided CDH to accelerate fetal lung growth.None declared.


BCR‐ABL1 kinase domain (KD) is a common mechanism of resistance to tyrosine kinase inhibitor (TKI)‐based therapies in Philadelphia chromosome‐positive (Ph+) acute lymphoblastic leukemia (ALL). Sanger sequencing (SS) is the most frequently used method for diagnostic BCR‐ABL1 KD mutation screening, but it has some limitations—it is poorly sensitive and cannot robustly identify compound mutations. Next‐generation sequencing (NGS) may overcome these problems. NSG is increasingly available and has the potential to become the method of choice for diagnostic BCR‐ABL1 KD mutation screening. A group discussion within an ad hoc constituted Panel of Experts has produced a series of consensus‐based statements on the potential value of NGS testing before and during first‐line TKI‐based treatment, in relapsed/refractory cases, before and after allo‐stem cell transplantation, and on how NGS results may impact on therapeutic decisions. A set of minimal technical and methodological requirements for the analysis and the reporting of results has also been defined. The proposals herein reported may be used to guide the practical use of NGS for BCR‐ABL1 KD mutation testing in Ph+ ALL.Emergence of clones carrying point mutations in the  BCR‐ABL1 kinase domain mutation screening in Philadelphia‐positive acute lymphoblastic leukemia patients receiving tyrosine kinase inhibitor‐based therapies. Minimal technical and methodological requirements for the analysis and the reporting of results have also been proposed.This consensus paper presents the results of an initiative by an expert panel to define a set of indications for the practical use of next‐generation sequencing for  Mutation testing is commonly performed by bidirectional Sanger sequencing (SS) of the entire BCR‐ABL1 KD amplified by polymerase chain reaction.BCR‐ABL1 transcripts.BCR‐ABL1‐positive cells.BCR‐ABL1 KD mutation testing by NGS in patients with Ph+ ALL, and this does not allow the formulation of evidence‐based recommendations. The aim of this project was thus to generate consensus‐based indications for the possible clinical use of NGS in Ph+ ALL.There is increasing evidence that a rational use of minimal residual disease (MRD) monitoring and 2A Panel of Experts was appointed on the basis of their nationally and internationally recognized expertise in the treatment and molecular monitoring of ALL. An initial meeting was held in June 2018, during which the outline of the project was defined and the topics of the expert discussion were decided. A series of key questions were identified and addressed through questionnaires. Each panelist drafted statements related to one or a few questions, while the remaining panelists scored their agreement with those statements or provided suggestions for modifications. Subsequently, the Panel convened for a consensus conference in Milan in November 2018, where final proposals were defined using the nominal group technique.33.1BCR‐ABL1 KD mutations have been identified in de novo Ph+ ALL.When using highly sensitive methods of detection, Using denaturing high‐performance liquid chromatography (D‐HPLC), Pfeifer et alRousselot et alBCR‐ABL1 transcript levels in Ph+ ALL patients is universally accepted as a strong prognostic factor and is performed at regular intervals during treatment.BCR‐ABL1 KD mutations.BCR‐ABL1 mutations in parallel to MRD assessment may thus provide meaningful information on the subclonal sensitivity of Ph+ leukemic cells to the current therapy. As a matter of fact, a strikingly rapid expansion of the mutated clones as early as after 4 weeks since TKI initiation was observed,Real‐time PCR‐based assessment of residual 3.1.1BCR‐ABL1 KD mutation testing by NGS is indicated in patients with Ph+ ALL before frontline treatment. The Panel argued that the detection of BCR‐ABL1 KD mutations that might lead to the emergence of TKI‐resistant clones could allow the identification of patients at a higher risk of MRD persistence and early relapse, and help in planning an individualized molecular and mutation monitoring.BCR‐ABL1 transcript levels decrease below 0.1%, or until the increase in mutation and BCR‐ABL1 transcript levels leads to therapeutic intervention.In patients with pretherapy low‐level mutations known to confer resistance to one or more TKIs, monthly retesting should be performed to monitor mutation kinetics, until residual 3.2BCR‐ABL1 KD mutation status is important for treatment decision‐making.Relapses after therapy may be associated with the emergence or persistence of clones harboring mutations that confer resistance to the TKI incorporated in the treatment regimen. Since for each TKI there is a well‐defined spectrum of sensitive and resistant mutations, an accurate assessment of BCR‐ABL1 KD mutational status in 55% of samples. Indeed, low‐level mutations were detected not only in SS‐negative patients, but also in addition to the dominant clone(s) detected by SS. Compound mutations were frequent in advanced phase CML and in Ph+ ALL, and could easily be recognized by NGS in the majority of cases. In another study,BCR‐ABL1 KD proved capable of anticipating an impending recurrence with a median of 5 weeks  compared to the classical SS‐based analysis.Using NGS, Soverini et al3.2.1BCR‐ABL1 KD mutation testing by NGS is indicated in patients who do not reach a CHR after induction therapy.BCR‐ABL1 KD mutation testing by NGS is also indicated in patients who do not reach a complete molecular response after induction therapy. In the latter, however, the BCR‐ABL1 transcript level should be >0.1% to ensure the feasibility of NGS library preparation. Given the variability of the induction protocols, at least 4 weeks of induction therapy should be completed before NGS testing.BCR‐ABL1 KD mutation testing by NGS testing is indicated in patients with a relapsing disease before receiving salvage therapy. The Panel argued that the information provided by NGS testing in refractory and relapsing patients may allow the personalization of an optimal TKI treatment choice.3.3Allogeneic hematopoietic stem cell transplant  is still considered the best option in attempting to pursue long‐term disease control in Ph+ ALL.Several retrospective, comparative analyses have been performed with the aim of evaluating the impact of the use of TKIs after allo‐SCT on outcome. The largest analysis, restricted to patients treated with allo‐SCT in first complete remission, showed that imatinib or dasatinib for primary prophylaxis against relapse resulted in an improvement of OS and leukemia‐free survival along with a lower incidence of grade 2‐4 acute graft versus host disease.BCR‐ABL1 KD mutations before allo‐SCT predominantly relapse with the same mutation. Therefore, empiric selection of any one TKI in the posttransplant management will almost certainly result in predictable treatment failures in a subset of patients with preexisting mutations. In addition to considerations of cost and toxicity, the pretransplant mutation status of patients with detectable residual disease should thus be considered when choosing the TKI for posttransplant prophylaxis.Unfortunately, TKI resistance mechanisms in the transplantation setting have not been extensively investigated; indeed, there are very few data about the mutational status of MRD‐positive patients both before and after allo‐SCT, as well as about the patterns of clonal evolution of preexisting mutations. Egan et al3.3.1BCR‐ABL1 KD mutation status prior to an allo‐SCT could provide useful information about the risk of recurrence of the disease after transplant and about the posttransplant TKI to be utilized. Thus, patients who did not have NGS testing done at the time of transplant decision should have it carried out prior to the transplant (if the BCR‐ABL1 transcript level is greater than 0.1%).The Panel agreed that knowledge of the BCR‐ABL1 KD mutation screening by NGS should be performed whenever a patient tests MRD positive, with BCR‐ABL1 levels greater than 0.1%. If a low‐level mutation is detected, mutation kinetics should be monitored at monthly intervals, and the TKI to which the mutation is known to confer resistance should be avoided.After transplant, 3.4BCR‐ABL1 mutation profiling may be useful before changing therapy since the detection of specific mutations may influence the choice of the second‐generation TKI.In Ph+ ALL patients who fail imatinib treatment, The setting in which the greater sensitivity of NGS could be most useful is when a Ph+ ALL patient with a nonoptimal response to imatinib has to be shifted to second‐line therapy, and in the transplant setting. Typically, patients candidate for the use of second‐generation TKIs in the pretransplant or posttransplant setting are represented by those who have experienced resistance to pretransplant treatment with imatinib. In fact, in the posttransplant setting, early prophylactic or MRD‐triggered imatinib was not always effective in reducing the risk of clinical or molecular relapse.3.4.1In general, the interpretation of NGS testing results and the therapeutic decisions should involve both biologists/biotechnologists and physicians expert in Ph+ ALL monitoring and treatment, respectively.Since there is no established evidence of a real clinical advantage of a personalized therapy tailored according to the detection of low‐level mutations, at the present time, any therapeutic decision based on the results of NGS testing may only derive from inductive reasoning.The majority of Panel members agreed that the NGS results obtained prior to front‐line therapy should restrain from modifying the approved conventional treatment, but should rather trigger monthly evaluation of mutation kinetics (in the presence of quantifiable disease).BCR‐ABL1 KD mutation by NGS in patients who are MRD‐positive after TKI‐based induction or consolidation should prompt to consider switching TKI when the mutation is known to be not sensitive to the TKI currently used by the patient. In this case, the detection of mutations by NGS should encourage an individualized therapy or a therapeutic switch that depends on the type and level of mutation(s) and on the toxicity profile of the various options.On the contrary, the identification of a low‐level BCR‐ABL1 KD mutation testing by NGS has an important role in patients who are candidate for the posttransplant use of TKIs in order to reduce the risk of relapse. In the case of persistence or reappearance of MRD positivity after allo‐SCT, the choice of an alternative TKI should be based on the results of NGS analysis.The Panel claimed that 3.5BCR‐ABL1 KD mutation issued by this document should be for clinical centers that do not have access to the NGS technology. The Panel agreed that NGS testing should be encouraged, in the proper indications of use, in all the clinical centers caring for patients with Ph+ ALL. However, the Panel also acknowledged that there is currently no evidence demonstrating that the lack of NGS testing hampers the possibility to properly manage Ph+ ALL patients, thus failure to use NGS because of the lack of access to it, at present, should not be regarded as an inappropriate clinical management.The Panel addressed the matter of how mandatory the indications for the use of NGS testing for The Panel also advocated that NGS testing should be performed in a restricted number of highly qualified laboratories within regional or national networks, already engaged in MRD monitoring of Ph+ ALL patients. Important aims of these networks should be: centralization of the analysis in a few highly specialized laboratories; harmonization of techniques among the network laboratories; central coordination for continuous technology development and also through worldwide collaborations with other reference laboratories; development of an inter‐lab quality control system for sensitivity, accuracy, and reproducibility of the results; organization of periodical quality control rounds.3.6BCR‐ABL1 mutation testing in CML underlined the importance of using sequencing approaches rather than mutation‐specific assays, enabling screening for a limited number of mutations only. No commercial assay is, as yet, available.ABL1, implemented on various NGS platforms.BCR‐ABL1 KD mutation screening by NGS is feasible in expert laboratories, and that NGS results are accurate and reproducible down to variant frequencies of 1%BCR‐ABL1 KD mutation screening is presented in Figure Although in Ph+ ALL P‐loop mutations and T315I are the most frequent,3.6.1BCR‐ABL1 KD mutation screening in Ph+ ALL. At least 5 mL of BM should be obtained using ethylenediaminetetraacetic acid or sodium citrate as an anticoagulant; heparin must be avoided. RNA from mononuclear cells is the recommended template. Selective amplification of the ABL1 KD of the fusion BCR‐ABL1 allele is recommended. This may be accomplished using either of two forward primers, on BCR exon 1  or on BCR exons 12/13  and a reverse primer on ABL1 exon 10. The resulting amplicon may be either used as a template for a nested PCR or may be fragmented, provided that the final amplicons or fragments are not shorter than 300‐400 bp, to maximize the likelihood to detect compound mutations. Accordingly, sequencing chemistries/cycles producing reads shorter than 400 bp are not recommended. For the above reasons, commercial gene panels incorporating ABL1 but using genomic DNA as input material and sequencing short fragments are not recommended.Bone marrow (BM) should be the preferred specimen for ABL1 1a protein isoform, known to correspond to the KD (reference Genbank sequence: NM_005157.5). No mutations should be reported outside this region.The minimal mRNA region to be screened for mutations is that encoding amino acids 235 through 498 of the ABL1 KD of the BCR‐ABL1 transcript);whether the sample is evaluable or not and why  to whom the variant is known to be insensitive should be clearly indicated.The recommended minimum depth of coverage is 1000×. Unless commercial kits become available, each individual laboratory will be responsible for the optimization of assay conditions and for the evaluation of accuracy, precision and analytical sensitivity. Given the inherent differences between NGS platforms, chemistries, and bioinformatics tools, specific recommendations on ranges and thresholds cannot be provided. To ensure optimal analytical performance, each laboratory will have to define means and criteria for quality control and to engage in regular proficiency testing programs. The Panel suggests that mutations with a variant allele frequency below 3% should not be reported. Any variant >3% should be reported irrespective of the availability of experimental or clinical information regarding its sensitivity profile. Laboratory reports should include the following minimal set of information:The turnaround time for reporting results should be 2 weeks or shorter.4BCR‐ABL1 KD mutation testing in Ph+ ALL and judged whether it was sufficiently robust to provide recommendations. So far, there has been no randomized clinical trial formally assessing the efficacy of a proactive change of therapy based on the detection of low‐level mutations by NGS, and considering the low incidence of Ph+ ALL cases and the heterogeneity of TKI and chemotherapy combination regimens used by different cooperative study groups, such a trial will hardly be feasible. This forced the expert Panel to use the method of consensus to shape the statements herein presented.Many laboratories are currently in the process of introducing NGS into their routine diagnostic procedures since it has proven a robust, reproducible and, in the case of gene panels, cost‐effective alternative to SS. Here, Ph+ ALL experts analyzed the body of data on the use of NGS for The Panel assessed the potential value of NGS testing in three distinct settings: before and during first‐line TKI‐based treatment; in relapsed/refractory cases; before and after allo‐SCT. The first was the most debated setting. The Panel discussion highlighted the lack of prospective data and the paucity of retrospective data—all obtained with other technologies  characterized by variable levels of sensitivity, accuracy, and reproducibility. In the great majority of cases, the same TKI‐resistant mutation detected at low levels at diagnosis coincided with that harbored by the dominant clone detected at relapse, although some exceptions (patients not relapsing or relapsing with a different mutation) have been reported.BCR‐ABL1 KD mutation screening may be activated in a timely manner on the same RNA or cDNA samples used for MRD analysis whenever necessary. The centralization of testing will also be required for cost‐effectiveness. Several regional or national networks of expert laboratories are already in place, which in turn are involved in worldwide cooperative efforts . It would be advisable for such networks to take the lead in future standardization and organization of periodical quality control rounds. Harmonization of protocols and coordinated definition of standard requirements for sensitivity, accuracy, and reproducibility of the results are particularly critical issues. At present, unfortunately, no commercial kit for NGS‐based BCR‐ABL1 KD mutation testing yet exists. A common NGS kit to be standardized across centers is eagerly awaited, since that would increase the number of centers that can perform in house analyses.The Panel, that also included experts in molecular biology and NGS testing, additionally engaged in the definition of a set of minimal technical and methodological requirements for analysis and result reporting. They also underlined that NGS should be implemented only in a limited number of highly qualified laboratories already involved in MRD monitoring of Ph+ ALL patients, so that BCR‐ABL1 KD mutation screening can be performed on the same RNA or cDNA used for MRD testing. Indeed, real‐time PCR should always be performed first, and MRD results should guide the decision of whether to proceed to NGS testing. It has been reported that MRD persistence in Ph+ ALL patients may hide emerging clinically actionable mutations that NGS may timely identify, thus enabling treatment optimization aimed to prevent hematologic relapse.BCR‐ABL1 transcript levels is also important to assess the feasibility of NGS testing. In CML samples, it has been reported that at values below 0.1% library preparation is not always successful, and even when it is successful, repeatability is reduced, and false negative results are not infrequent.From a technical point of view, NGS‐based BCR‐ABL1 KD mutation screening in Ph+ ALL. Table BCR‐ABL1 KD mutation testing in CML.In conclusion, we here report the first attempt at defining indications for the use of NGS for BCR‐ABL1 KD mutation monitoring of Ph+ ALL patients in the framework of TKI‐based clinical trials. Such studies, that would greatly benefit from the international cooperation of different study groups, would help to establish the role of NGS at diagnosis and to find the best timing and integration of MRD and mutation testing into the clinical decision algorithms.Although a consensus on a series of position statements was reached, the literature review and the Panel discussion highlighted the strong need for prospective studies aimed at systematically applying NGS for Simona Soverini has received honoraria from Incyte Biosciences, Novartis, Bristol‐Myers Squibb. Francesco Albano has received honoraria for advisory board from Incyte. Renato Bassan has received honoraria advisory board from Amgen, Pfizer, Shire, Servier, Jazz, Incyte. Francesco Fabbiano has received honoraria for advisory board from Incyte. Robin Foà has received honoraria for consultancies/advisory board from Janssen, Novartis, Amgen, Abbvie, Roche, Incyte, Shire, Pfizer. Attilio Olivieri has received honoraria for advisory board from Incyte. Alessandro Rambaldi has received honoraria for travel, accommodation expenses and fees for consultancies and participation to meetings, boards and symposia sponsored by Amgen, Pfizer, Incyte, Italfarmaco, Astellas, Celgene, Novartis, Roche, Jazz. Giuseppe Rossi has received honoraria from Novartis, BMS, Incyte and participated to advisory boards from Amgen, Pfizer. Simona Sica has received honoraria for advisory board from Incyte, Sanofi, Alexion. Adriano Venditti has received personal fees from Pfizer, Novartis, Astellas, Jazz Pharmaceuticals, Amgen, Incyte and Daiichi‐Sankyo outside the submitted work. Fabrizio Pane has received honoraria for advisory board from Amgen, Pfizer. The remaining authors have no conflicts of interest to disclose.All authors contributed to conception and design of the work, analysis, and interpretation of the literature and manuscript drafting and gave final approval for submission.


Earlandia. The distribution of the faunal components within the microbial fabrics suggests that, except for the keratose sponges and some microconchids, most of the metazoans were transported into the microbial framework via wave currents. The presence of both microbialites and metazoan associations were limited to oxygenated settings, suggesting that a factor other than anoxia resulted in a relaxation of ecological constraints following the mass extinction event. It is inferred that the end‐Permian mass extinction event decreased the diversity and abundance of metazoans to the point of significantly reducing competition, allowing photosynthesis‐based microbial mats to flourish in shallow water settings and resulting in the formation of widespread microbialites.During the earliest Triassic microbial mats flourished in the photic zones of marginal seas, generating widespread microbialites. It has been suggested that anoxic conditions in shallow marine environments, linked to the end‐Permian mass extinction, limited mat‐inhibiting metazoans allowing for this microbialite expansion. The presence of a diverse suite of proxies indicating oxygenated shallow sea‐water conditions  from microbialite successions have, however, challenged the inference of anoxic conditions. Here, the distribution and faunal composition of Griesbachian microbialites from China, Iran, Turkey, Armenia, Slovenia and Hungary are investigated to determine the factors that allowed microbialite‐forming microbial mats to flourish following the end‐Permian crisis. The results presented here show that Neotethyan microbial buildups record a unique faunal association due to the presence of keratose sponges, while the Palaeotethyan buildups have a higher proportion of molluscs and the foraminifera  After the end‐Permian mass extinction, microbialites filled the ecological niche previously occupied by metazoan reefs. The factors that allowed microbialite‐forming microbial mats to flourish are, however, hotly debated. By investigating the faunal composition and depositional setting of Permian/Triassic boundary microbialites, we propose that the impact of the extinction event on the abundance of metazoans suppressed the biological controls that were previously excluding microbialite development from subtidal environments.  This wo2Twenty‐one stratigraphic sections with microbialites that developed immediately following the end‐Permian mass extinction event were logged and sampled; these include sections in China , south‐west Iran (Zagros Mountains: Kuh‐e‐Surmeh and Kuh‐e‐Dena sections), central Iran (Shahreza and Baghuk Mountain sections), Turkey (Çürük Dag and Oznur Tepee sections), Armenia (Chanakhchi Hill and Ogbin sections), Slovenia  and Hungary ; see Figure et al., et al., et al., Bioclasts were counted by placing an acetate sheet that had been divided into 5 mm square divisions over the entire thin section of each sample. All the bioclasts within each quadrant were identified to measure taxonomic richness and tallied to obtain abundance data. In this study, taxonomic identifications are mostly confined to class‐level, comparable to Early and Middle Triassic investigations  was used to calculate relative abundances, as this allows different groups of animals that develop differently  and organisms of different sizes to be compared fairly. The Kruskal–Wallis test was used to statistically test the differences in the median diversity between different groups of samples. A non‐metric multidimensional scaling (nMDS) was then applied to visualize trends and groupings of the samples. For the nMDS, samples with no bioclasts were removed because such samples would have zero similarity to fossiliferous samples and would plot randomly in an ordination. Relative, rather than absolute, abundances were used, as preservation varies between samples. Most of the samples are dominated by a few taxa, and so the relative abundance data were square‐root transformed to de‐emphasize the influence of the most dominant taxon. A Bray–Curtis similarity matrix was then applied to recognize those taxa that tend to co‐occur in samples of similar taxonomic compositions. Statistical analysis and visualization was done using the ‘vegan’, and ‘ggplot2’ packages in R , Kuh‐e‐Surmeh, and Kuh‐e‐Dena  also represent deposition above storm wave base, but on a platform setting on the south‐west margin of the Neotethys Ocean Figures  and 3B. et al., et al., et al., Hindeodus praeparvus and H. parvus zones (both in Hungary and Slovenia) and in Slovenia extend up through the I. isarcica Zone, associated with the mass extinction event , the microbialites are thinner than in Armenia, and do not exceed 2 m in height . In the field, keratose sponges are also observed as being abundant in central Iran (Shahreza and the Baghuk Mountains). Where the keratose sponges are absent, the Neotethyan samples display a closer relationship to the Great Bank of Guizhou assemblages dominated by ostracods, gastropods, microconchids and bivalves. The Great Bank of Guizhou microbialites also contain abundant echinoid spines, which appear to be unique to China. They are also significantly more diverse than the microbialites elsewhere  and Japan  that are inferred to limit microbialite development  suppressed competition, as a result of the mass extinction event, allowed microbialite‐forming microbial mats to flourish and (b) that carbonate supersaturation in seawater favoured widespread microbialite formation following the end‐Permian mass extinction.The authors have no conflict of interest to declare. Click here for additional data file.


Atmospheric aerosol over the North Atlantic Ocean impacts regional clouds and climate. In this work, we use a set of sun photometer observations of aerosol optical depth (AOD) located on the Graciosa and Cape Verde islands, along with the GEOS‐Chem chemical transport model to investigate the sources of these aerosol and their transport over the North Atlantic Ocean. At both locations, the largest simulated contributor to aerosol extinction is the local source of sea‐salt aerosol. In addition to this large source, we find that signatures consistent with long‐range transport of anthropogenic, biomass burning, and dust emissions are apparent throughout the year at both locations. Model simulations suggest that this signal of long‐range transport in AOD is more apparent at higher elevation locations; the influence of anthropogenic and biomass burning aerosol extinction is particularly pronounced at the height of Pico Mountain, near the Graciosa Island site. Using a machine learning approach, we further show that simulated observations at these three sites  can be used to predict the simulated background aerosol imported into cities on the European mainland, particularly during the local winter months, highlighting the utility of background AOD monitoring for understanding downwind air quality. Sun photometer AOD observations at island sites characterize long‐range transport of aerosol species across the North Atlantic OceanModel simulations suggest that higher elevation observations provide a pronounced signature of anthropogenic and biomass burning aerosolThese island sites contain information useful for predicting imported aerosol to the European continent These suspended liquid droplets and particles directly influence the global radiative balance by absorbing and scattering radiation and indirectly by influencing cloud formation and radiative properties  located on the islands of Graciosa and Cape Verde. Both locations are in the Eastern North Atlantic, with Graciosa off the coast of Portugal and Cape Verde off the coast of Senegal. Sun photometer observations offer potentially continuous, automated remote sensing of atmospheric composition without the sample transport and analysis needed for in situ sampling and are thus highly useful for long‐term atmospheric monitoring. To date, research at the Graciosa location has largely been focused on understanding the links between aerosol concentrations, cloud properties, and precipitation . The HOx‐NOx‐VOC gas‐phase scheme coupled with the‐sulfate‐nitrate‐ammonium (SNA) aerosol scheme used here was first described in Park  user facility. Observations of AOD began on the Graciosa island in 2009, persisted for 2 years, and then came online once again at what is now the current ENA user facility in late 2013. The site is located at 15 m above sea level, approximately 1,200 km from mainland Europe. The Cape Verde island site is operated by the Laboratoire d'Optique Atmosphèrique, Université des Sciences et Technologies de Lille. Observations of AOD have been made regularly at this location since 1994. The site is located at 60 m above sea level, approximately 570 km off the coast of Senegal, Africa.33.1Seasonal simulated AOD across the entire North Atlantic region is shown in Figure −1 for Graciosa and 0.05 km−1 for Cape Verde) with the largest interannual variability corresponding to the largest total extinction magnitudes .To better understand the spatiotemporal variability shown in Figure We perform a set of sensitivity experiments to further explore the AOD variability at both the Graciosa and Cape Verde locations. Given that the majority of the variability at each location comes from local or natural sources , we design these sensitivity experiments to investigate sources that are more likely related to long‐range anthropogenic transport. We explore three scenarios where we remove the emissions from shipping, anthropogenic emissions over North America, and anthropogenic emissions over Europe. In this way, we isolate the effect of different non‐sea salt and dust emissions sources on total AOD variability. The contribution of these sources to AOD per month at both island locations is shown in Figure 3.2R = 0.56) and captures the dominant year to year variability at both sites, suggesting no major model errors in the representation of the aerosol lifecycle. The model indicates that at Graciosa, the AOD is usually dominated by this local sea salt aerosol, though elevated concentrations of dust and SNA aerosol dominate specific events. The speciation of extinction at Cape Verde is more consistent, dominated by dust aerosol. At both locations, there is large variability on weekly and interannual time scales, which is consistent with plume transport processes.We assess the GEOS‐Chem model performance using observations from the AERONET sites at both Graciosa and Cape Verde. A time‐series comparison is shown in Figure R = 0.52, RMSE = 0.05) than over Cape Verde . As evident in the summary statistics and the fairly wide scatter throughout Figure Related to Figure 3.3In situ observations at the higher elevation site at Pico Mountain in the Azores, near Graciosa, have previously been used to constrain long‐range transport of pollutants  and reproduces the overall magnitude of the full model well (RMSE = 0.03). This correlation is much higher than the correlation of the GEOS‐Chem simulated observations with the imported AOD alone (Cape Verde R = 0.36 and Graciosa R = 0.3) and indicates a potential value in these island observations as non‐linear constraints on European air quality. Much of the missing variability in Figure We evaluate if the 24‐hour median imported column AOD to Lisbon can be predicted 1 week in advance using a 14‐day time series of 3‐hourly simulated island observations at the Graciosa and Cape Verde locations. We use these 224 total observations as predictors, along with temporal information of the observations (month of the year), to forecast the median imported AOD 7 days after the final observation was made. In the model space, we define the imported aerosol extinction as the aerosol extinction in the model gridcell just west of the gridcell containing Lisbon. We split the data set into two components by time: a training data set (2010–2012) and a test data set (2013). This enables a robust assessment of the model confidence and uncertainty. The XGBoost model reproduces the full GEOS‐Chem simulation very well for the training data set, consistent with many machine learning approaches. Since good performance on training data is not necessarily related to performance on unknown model inputs, we only describe the performance on a test set (the year 2013) from here forward. In the test data, the XGBoost model captures the broad variability of the evaluation data , used in the boosted regression. In this context, gain is a metric for the improvement in accuracy achieved by the addition of a given feature  where it is used in the model. The most important features are related to the temporal context (month) of the simulated observations, likely capturing the large‐scale seasonality in the imported AOD . Following the monthly gain values, Cape Verde is the most common location of the top 30 ranked gain features in the prediction, followed by Graciosa island. In general, the most important AOD lag times were larger over Cape Verde  than over the site in the Azores , consistent with shorter transport times from the Azores to Lisbon, compared to the transit from Cape Verde to the same destination. This importance ranking selecting both the month feature and lagged simulated observations at Cape Verde is consistent with large imported aerosol events being dominated by seasonal dust transport from Africa in the European winter months. However, the importance of the other island location points to complementary information provided by this site for forecasting imported aerosol to European cities downwind.We investigate the potential added value of long‐term AOD observations from an AERONET observatory on Pico Mountain by rerunning the XGBoost predictor using lagged AOD at the location of Pico Mountain , demonstrating the potential for these island sites to provide relevant information for forecasting surface, and thus human health exposure‐relevant, imported aerosol concentrations.We perform an additional prediction task to explore how well AOD can be used to predict downwind simulated surface aerosol concentrations, rather than AOD. The prediction technique and setup are identical to that described for AOD, except model surface concentrations of total aerosol mass are predicted (instead of AOD) as a function of AOD at the island sites. The XGBoost model performs similarly well to the AOD prediction (It is important to note that aerosol abundances (and thus AOD) are highly influenced by meteorological conditions, and without explicitly including this information , it is difficult to fully assess the utility of these data for forecasting imported aerosol to Europe. This model is potentially overconfident due to the relatively consistent seasonal pattern apparent in the training data. If a year with a different relative seasonal pattern were weighted heavily in model training, or if a different set of input parameters were selected , the performance of the model may be worse on the test set. Additionally, the machine learning model takes as input average AOD across a 2° × 2.5° grid box, which does not perfectly represent the total variability seen in the point observations (see section 5The work presented in this manuscript explores the constraints that island observatories can provide on the long‐range transport of aerosols over the oceans, a region with a dearth of in situ observations. We focus on AOD, a measurement that is largely automated at a global network of sun photometers, and thus provides long‐term atmospheric monitoring. Over the North Atlantic, simulated AOD is dominated by local emissions of sea salt and intercontinental transport of dust, with short‐term variability controlled primarily by meteorology. Given this variability and dominant local sources, there is strong value in the complementarity of the two different island sites at Graciosa and Cape Verde for exploring the influence of different sources on AOD throughout the region, constraining the aerosol lifecycle, and evaluating chemical transport model skill. We show that though these sites are located far from the continents, they provide valuable information for predicting imported aerosol extinction above the European continent. Though we focus here on using automated remote sensing observations of AOD to get insight into key transport processes, long‐term continuous in situ measurements of aerosol composition would allow for improved constraints on the variability and trends of aerosol sources across the North Atlantic. Additional work could explore model fidelity by using speciated aerosol mass concentrations from short‐term aircraft campaigns. Integrating these point measurements with machine learning methods could potentially be used to improve air quality forecasting in regions across the globe.Long‐term measurements like those available from the AERONET island sites are critical to understanding trends, causes, and ultimate impacts of AOD worldwide. Measurements at a few locations can provide critical insight into regional and hemispheric processes and ultimate impacts on air quality and climate. In a changing Earth system that is in part driven by changes in aerosol abundance, it is ever critical to understand these processes.The authors declare no conflict of interest.