Adjustable Cortical Fixation Repair Is a Safe and Effective Technique for Quadriceps Tendon Rupture.

Purpose: To report the clinical outcomes of quadriceps tendon repair using adjustable cortical fixation devices at a minimum 2-year follow-up. Methods: A retrospective chart review identified patients who underwent quadriceps tendon repair using adjustable cortical fixation devices between January 2017 and March 2020. Patients with a partial tendon rupture were excluded. Demographic and injury-specific variables were gathered preoperatively and postoperatively from the electronic medical record and patient-reported outcomes (Lysholm Knee Questionnaire, Lower Extremity Functional Scale, and SF-12) were collected via telephone at a minimum of 2 years postoperatively. Results: Fourteen quadriceps tendon repairs were included in a total of 13 patients. The average time to follow-up was 3.5 ± 1.2 years with a range of 1.9 to 5.7 years. The mean age of this cohort was 55.7 ± 11.6 years, and the mean body mass index was 32.9 ± 6.0. Ten injuries (71.4%) were sustained by mechanical fall, 2 patients (14.3%) suffered a direct blow to the knee, and 2 patients (14.3%) reported a noncontact injury mechanism. Thirteen quadriceps ruptures (13/14, 92.9%) underwent surgery within 10 days of their injury. One knee (7.1%) had a postoperative extensor lag of 5°, whereas another knee (7.1%) required a reoperation for manipulation under anesthesia and arthroscopic lysis of adhesions at 3 months' postoperatively. None of the included patients (0.0%) developed a tendon re-rupture, venous thromboembolism, delayed wound healing, surgical-site infection, neuropraxia or nerve injury, hardware irritation, patella fracture, or heterotopic ossification. Conclusions: In this study, adjustable cortical fixation was a safe and effective surgical technique for quadriceps tendon repair, with adequate restoration of quadriceps function and a low rate of adverse events at 2 years postoperatively. Level of Evidence: Level IV, therapeutic case series.

Portable HEPA filtration successfully augments natural-ventilation-mediated airborne particle clearance in a legacy design hospital ward.

As the severe acute respiratory syndrome coronavirus-2 pandemic has proceeded, ventilation has been recognized increasingly as an important tool in infection control. Many hospitals in Ireland and the UK do not have mechanical ventilation and depend on natural ventilation. The effectiveness of natural ventilation varies with atmospheric conditions and building design. In a challenge test of a legacy design ward, this study showed that portable air filtration significantly increased the clearance of pollutant aerosols of respirable size compared with natural ventilation, and reduced spatial variation in particle persistence. A combination of natural ventilation and portable air filtration is significantly more effective for particle clearance than either intervention alone.

Earthworm-Collembola interactions affecting water-soluble nutrients, fauna and physiochemistry in a mesocosm manure-straw composting experiment.

A mesocosm fermentation experiment was undertaken to investigate interactions between Eisenia fetida and Collembola affecting composting processes. Earthworms, Collembola, respiration, water soluble nutrients and compost characteristics (near infrared spectra - NIRS) were monitored on four occasions over 136 days. Earthworms were the main drivers of early changes in composts, increasing the general abundance of Collembola, although responses varied with species. Earthworms accelerated substrate mineralisation and release of soluble nutrients whilst also changing compost characteristics. Collembola alone had little direct effect on soluble nutrient concentrations or respiration; they did however alter compost characteristics (NIR spectra). Earthworm-Collembola interactions affecting respiration and soluble nutrients were mainly antagonistic in the early stages of composting but synergistic in later stages. In the later stages of composting, the higher abundance of Collembola when combined with earthworms resulted in greater concentrations of soluble nitrate and phosphate. These findings emphasise the importance in vermicomposting practice of different invertebrate groups having access to feedstock at appropriate stages of the process. The high concentrations of soluble nutrients released during vermicomposting indicate the need for control measures to avoid off-site pollution and loss of this resource.

Implementing the Mindfulness-Based Interventions; Teaching Assessment Criteria (MBI:TAC) in Mindfulness-Based Teacher Training.

The Mindfulness-Based Interventions: Teaching Assessment Criteria (MBI:TAC) was originally developed as a tool to assess the teaching competence of mindfulness-based program (MBP) teachers. The tool was made freely available and has since been used by mindfulness-based teacher training organisations internationally. During this time the MBI:TAC has evolved in its usage, from an assessment tool to one which informally supports how MBP teachers are trained. In this article, we first examine the rationale for implementing the MBI:TAC in MBP teacher training; second, we offer practical guidance on ways of integrating the tool into teacher training pathways with awareness of its potential and possible pitfalls; and third, we offer guidance on using the tool as a framework for giving effective feedback to trainees on their teaching practice. Implementing the MBI:TAC in teacher training may support the quality and integrity of MBP teacher training, and thus ensure high quality MBP teachers graduating. In turn this may help avoid the 'implementation cliff' - that is, the quality of an intervention delivery is delivered in optimal conditions when it is being researched, and drops in quality when delivered in sub-optimal, 'real world' conditions.

The microstructural evolution of water ice in the solar system through sintering.

Ice sintering is a form of metamorphism that drives the microstructural evolution of an aggregate of grains through surface and volume diffusion. This leads to an increase in the grain-to-grain contact area ("neck") and density of the aggregate over time, resulting in the evolution of its strength, porosity, thermal conductivity, and other properties. This process plays an important role in the evolution of icy planetary surfaces, though its rate and nature are not well constrained. In this study, we explore the model of Swinkels and Ashby (1981), and assess the extent to which it can be used to quantify sintering timescales for water ice. We compare predicted neck growth rates to new and historical observations of ice sintering, and find agreement to some studies at the order of magnitude level. First-order estimates of neck growth timescales on planetary surfaces show that ice may undergo significant modification over geologic timescales, even in the outer solar system. Densification occurs over much longer timescales, suggesting some surfaces may develop cohesive, but porous, crusts. Sintering rates are extremely sensitive to temperature and grain size, occurring faster in warmer aggregates of smaller grains. This suggests that the microstructural evolution of ices may vary not only throughout the solar system, but also spatially across the surface and in the near-surface of a given body. Our experimental observations of complex grain growth and mass redistribution in ice aggregates point to components of the model that may benefit from improvement, and areas where additional laboratory studies are needed.

Pharmacokinetics and tissue disposition of meloxicam in beef calves after repeated oral administration.

The objective of this study was to investigate the pharmacokinetics and tissue disposition of meloxicam after repeated oral administration in calves. Thirteen male British × Continental beef calves aged 4 to 6 months and weighing 297-392 kg received 0.5 mg/kg meloxicam per os once daily for 4 days. Plasma meloxicam concentrations were determined in 8 calves over 6 days after first treatment. Calves were randomly assigned to be euthanized at 5, 10, 15 (n = 3/timepoint), and 19 days (n = 4) after final administration. Meloxicam concentrations were determined in plasma (LOQ= 0.025 µg/mL) and muscle, liver, kidney, and fat samples (LOQ = 2 ng/g) after extraction using validated LC-MS-MS methods. The mean (± SD) Cmax , Cmin , and Caverage plasma meloxicam concentrations were 4.52 ± 0.87 µg/mL, 2.95 ± 0.77 µg/mL, and 3.84 ± 0.81 µg/mL, respectively. Mean (± SD) tissue meloxicam concentrations were highest in liver (226.67 ± 118.16 ng/g) and kidney samples (52.73 ± 39.01 ng/g) at 5 days after final treatment. Meloxicam concentrations were below the LOQ in all tissues at 15 days after treatment. These findings suggest that tissue from meloxicam-treated calves will have low residue concentrations by 21 days after repeated oral administration.

Mothers' expressed emotion towards children with autism spectrum disorder and their siblings.

BACKGROUND: Expressed emotion (EE) is a construct used to measure the emotional climate within families. EE is of interest to researchers in the field of autism spectrum disorder (ASD) because of its putative implications for child development. The aim was to explore whether maternal EE differs towards a child with ASD and a non-disabled sibling. METHODS: We adopted a within-family design with 143 mothers of children with ASD and a non-disabled sibling. EE was measured using the Five-Minute Speech Sample. RESULTS: Wilcoxon signed-rank tests were utilised. Mothers were coded as significantly more critical and less warm towards their child with ASD than towards the sibling. There were no significant differences in maternal emotional overinvolvement or overall EE towards the child with ASD and a sibling. CONCLUSIONS: The data support the results of previous research suggesting that EE is linked to the relationship a mother has with individual children, rather than being evidence of the character disposition of mothers. More research is needed to understand the emotional dimensions of parent-child relationships in families with children with ASD.

'He's hard work, but he's worth it'. The experience of caregivers of individuals with intellectual disabilities and challenging behaviour: a meta-synthesis of qualitative research.

BACKGROUND: The purpose of this review is to synthesize the qualitative literature on the perspectives of those caring for a family member with intellectual disabilities and challenging behaviour, with a focus on their experiences of support services. MATERIALS AND METHODS: A thorough literature search resulted in 17 studies being selected for inclusion in the meta-synthesis. RESULTS: Five primary themes were identified: (i) love, (ii) altered identity, (iii) crisis management, (iv) support is not just 'challenging behaviour' services, and (v) the future: low expectations, high hopes. CONCLUSIONS: Carers spoke of the deep love for their family member and of the chronic strain the demands of caregiving placed upon them. Support services often caused additional problems and high levels of stress for caregivers, although there were also reports of good practice. The findings may inform clinicians and service providers about how best to support families of individuals with challenging behaviour.

Clinical effectiveness and cost-effectiveness of endobronchial and endoscopic ultrasound relative to surgical staging in potentially resectable lung cancer: results from the ASTER randomised controlled trial.

OBJECTIVE: To assess the clinical effectiveness and cost-effectiveness of endosonography (followed by surgical staging if endosonography was negative), compared with standard surgical staging alone, in patients with non-small cell lung cancer (NSCLC) who are otherwise candidates for surgery with curative intent. DESIGN: A prospective, international, open-label, randomised controlled study, with a trial-based economic analysis. SETTING: Four centres: Ghent University Hospital, Belgium; Leuven University Hospitals, Belgium; Leiden University Medical Centre, the Netherlands; and Papworth Hospital, UK. INCLUSION CRITERIA: known/suspected NSCLC, with suspected mediastinal lymph node involvement; otherwise eligible for surgery with curative intent; clinically fit for endosonography and surgery; and no evidence of metastatic disease. EXCLUSION CRITERIA: previous lung cancer treatment; concurrent malignancy; uncorrected coagulopathy; and not suitable for surgical staging. INTERVENTIONS: Study patients were randomised to either surgical staging alone (n = 118) or endosonography followed by surgical staging if endosonography was negative (n = 123). Endosonography diagnostic strategy used endoscopic ultrasound-guided fine-needle aspiration combined with endobronchial ultrasound-guided transbronchial needle aspiration, followed by surgical staging if these tests were negative. Patients with no evidence of mediastinal metastases or tumour invasion were referred for surgery with curative intent. If evidence of malignancy was found, patients were referred for chemoradiotherapy. MAIN OUTCOME MEASURES: The main clinical outcomes were sensitivity (positive diagnostic test/nodal involvement during any diagnostic test or thoracotomy) and negative predictive value (NPV) of each diagnostic strategy for the detection of N2/N3 metastases, unnecessary thoracotomy and complication rates. The primary economic outcome was cost-utility of the endosonography strategy compared with surgical staging alone, up to 6 months after randomisation, from a UK NHS perspective. RESULTS: Clinical and resource-use data were available for all 241 patients, and complete utilities were available for 144. Sensitivity for detecting N2/N3 metastases was 79% [41/52; 95% confidence interval (CI) 66% to 88%] for the surgical arm compared with 94% (62/66; 95% CI 85% to 98%) for the endosonography strategy (p = 0.02). Corresponding NPVs were 86% (66/77; 95% CI 76% to 92%) and 93% (57/61; 95% CI 84% to 97%; p = 0.26). There were 21/118 (18%) unnecessary thoracotomies in the surgical arm compared with 9/123 (7%) in the endosonography arm (p = 0.02). Complications occurred in 7/118 (6%) in the surgical arm and 6/123 (5%) in the endosonography arm (p = 0.78): one pneumothorax related to endosonography and 12 complications related to surgical staging. Patients in the endosonography arm had greater EQ-5D (European Quality of Life-5 Dimensions) utility at the end of staging (0.117; 95% CI 0.042 to 0.192; p = 0.003). There were no other significant differences in utility. The main difference in resource use was the number of thoracotomies: 66% patients in the surgical arm compared with 53% in the endosonography arm. Resource use was similar between the groups in all other items. The 6-month cost of the endosonography strategy was £9713 (95% CI £7209 to £13,307) per patient versus £10,459 (£7732 to £13,890) for the surgical arm, mean difference £746 (95% CI -£756 to £2494). The mean difference in quality-adjusted life-year was 0.015 (95% CI -0.023 to 0.052) in favour of endosonography, so this strategy was cheaper and more effective. CONCLUSIONS: Endosonography (followed by surgical staging if negative) had higher sensitivity and NPVs, resulted in fewer unnecessary thoracotomies and better quality of life during staging, and was slightly more effective and less expensive than surgical staging alone. Future work could investigate the need for confirmatory mediastinoscopy following negative endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), the diagnostic accuracy of EUS-FNA or EBUS-TBNA separately and the delivery of both EUS-FNA or EBUS-TBNA by suitably trained chest physicians. TRIAL REGISTRATION: Current Controlled Trials ISRCTN 97311620. FUNDING: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 16, No. 18. See the HTA programme website for further project information.

The economic cost of farm-related fatalities in Australia.

Farm-related fatalities are a significant problem in Australian agriculture. Over the period 2001-2004, there were 404 fatalities that occurred as a direct consequence of visiting, residing, or working on a farm. This study employed a human capital approach to establish the economic costs of farm-related fatalities to the Australian economy. Modeling of direct and indirect costs associated with farm-related fatalities estimated that the 404 traumatic deaths over the period 2001-2004 cost the Australian economy $650.6 million in 2008 Australian dollars (AUD). This equates to 2.7% of the 2008 farm gross domestic product (GDP) due to potentially preventable farm accidents and injuries. Farm-related deaths are a significant economic cost to the Australian economy. Greater resources need to be directed to farm health and safety interventions to increase their effectiveness at reducing the risk exposure of those visiting, residing, and working on Australian farms.

Psychological well-being in parents of children with Angelman, Cornelia de Lange and Cri du Chat syndromes.

BACKGROUND: The current study focuses on mothers and fathers of children with three rare genetic syndromes that are relatively unexplored in terms of family experience: Angelman syndrome, Cornelia de Lange syndrome and Cri du Chat syndrome. METHOD: Parents of children with Angelman syndrome (n =15), Cornelia de Lange syndrome (n = 16) and Cri du Chat syndrome (n = 18), and a matched comparison group of parents of children with autism and intellectual disabilities (n = 20) completed questionnaires on both psychological distress (stress, anxiety, depression) and positive psychological functioning. RESULTS: Parents of children with Angelman syndrome consistently reported the highest levels of psychological distress, and parents of children with Cornelia de Lange syndrome the lowest, with parents of children with Cri du Chat syndrome and autism scoring between these two. Positive psychological functioning was similar across the four aetiology groups. CONCLUSIONS: Parents of children with rare genetic syndromes are at risk for high levels of stress and mental health problems. Methodological issues and the practical applications of these results are discussed.

The global momentum for smokefree public places: best practice in current and forthcoming smokefree policies.

The Global Smokefree Partnership has recently prepared a map of smokefree campaigns and policies around the world. It focuses primarily on countries that are parties to the WHO Framework Convention on Tobacco Control, but other countries were included. The smokefree status of 172 countries was mapped. Of these countries, 31 (18.0%) have established comprehensive smokefree policies, either nationally or at state or city level - best practice; 25 (14.6%) are planning to implement smokefree policies in 2008 or 2009; and 51(29.6%) are making significant progress with smokefree policies. Only 65 countries (37.8%) have limited or no smokefree polices. A selection of countries representing best practices in smokefree policies or planning to implement smokefree policies in 2008 or 2009 is highlighted. They illustrate the significant global momentum for smokefree policies, the success of established policies, the importance of civil society and the sharing of experience between countries.

Treatment of arteriovenous malformations with hydrocoils in a Swine model.

SUMMARY: Arteriovenous malformations (AVM) of the brain are the most common symptomatic congenital vascular malformation of the central nervous system, with significant associated morbidity and mortality. This study compared the feasibility and efficacy of treating AVMs by embolization with hydrocoils with similar treatment with bare platinum coils, using the swine rete mirabile as a model. A right carotid-jugular fistula was created in ten swine.A microcatheter was positioned into the rete mirabile, which was unilaterally (contralateral to the fistula) embolized with hydrocoils in six and bare platinum coils in four swine. Angiograms were evaluated during and immediately after embolization. Embolization with complete cessation of bloodf low in the unilateral rete mirabile was achieved in all animals treated with hydrocoils. The number of coils needed varied from four to seven (diameter 2-4 mm; mean coil length 22.3 cm). Embolization with platinum coils of similar number (seven) and slightly longer length (mean 37.75 cm) had a minimal effect on blood flow, resulting in occlusion of only small compartments. No immediate complications were noted with either coil. Hydrocoils are more effective in achieving embolization than bare platinum coils. Expansion of the hydrocoil over only a few minutes allows precise placement and stabilization of the coil before detachment. Hydrocoilscan be safely placed into small vessels. This approach may be particularly useful to decrease the flow rate, as a first stage of AVM embolizationin high flow AVMs that contain arteriovenous fistulae.

The global momentum for smokefree public places: best practice in current and forthcoming smokefree policies / El momento global para espacios públicos libres de tabaco: mejores prácticas en políticas actuales y futuras

The Global Smokefree Partnership has recently prepared a map of smokefree campaigns and policies around the world. It focuses primarily on countries that are parties to the WHO Framework Convention on Tobacco Control, but other countries were included. The smokefree status of 172 countries was mapped. Of these countries, 31 (18.0 percent) have established comprehensive smokefree policies, either nationally or at state or city level - best practice; 25 (14.6 percent) are planning to implement smokefree policies in 2008 or 2009; and 51(29.6 percent) are making significant progress with smokefree policies. Only 65 countries (37.8 percent) have limited or no smokefree polices. A selection of countries representing best practices in smokefree policies or planning to implement smokefree policies in 2008 or 2009 is highlighted. They illustrate the significant global momentum for smokefree policies, the success of established policies, the importance of civil society and the sharing of experience between countries.

El Global Smokefree Partnership recién completó un mapa de las campañas para promover políticas de ambientes libres de humo (ALH) a nivel mundial. El mapa se centra en los países Partes al Convenio Marco para el Control del Tabaco de la OMS, aunque otros países también se incluyen, y documenta el estatus de 172 países en el tema de los ALH. De estos países, 31 (18.0 por ciento) tienen políticas comprehensivas de ALH, a nivel nacional, provincial, y/o estatal - mejores prácticas; 25 (14.6 por ciento) prevén la implementación de políticas de ALH en 2008 o 2009; y 51 (29.6 por ciento) han progresado significativamente con estas políticas. Sólo 65 países (37.8 por ciento) no tienen políticas de ALH, o sólo políticas limitadas en este ámbito. Este ensayo destaca una selección de países que representan las mejores prácticas en las políticas de ALH o que prevén la implementación de estas políticas en 2008 o 2009, con tal de ilustrar el movimiento global hacia los ambientes libres de humo; el éxito de las políticas ya establecidas; la importancia de la sociedad civil en este proceso; y el intercambio de experiencias entre países.

Vacuum packing: a model system for laboratory-scale silage fermentations.

AIMS: To determine the utility of vacuum-packed polythene bags as a convenient, flexible and cost-effective alternative to fixed volume glass vessels for lab-scale silage studies. METHODS AND RESULTS: Using perennial ryegrass or red clover forage, similar fermentations (as assessed by pH measurement) occurred in glass tube and vacuum-packed silos over a 35-day period. As vacuum-packing devices allow modification of initial packing density, the effect of four different settings (initial packing densities of 0.397, 0.435, 0.492 and 0.534 g cm(-3)) on the silage fermentation over 16 days was examined. Significant differences in pH decline and lactate accumulation were observed at different vacuum settings. Gas accumulation was apparent within all bags and changes in bag volume with time was observed to vary according to initial packing density. CONCLUSIONS: Vacuum-packed silos do provide a realistic model system for lab-scale silage fermentations. SIGNIFICANCE AND IMPACT OF THE STUDY: Use of vacuum-packed silos holds potential for lab-scale evaluations of silage fermentations, allowing higher throughput of samples, more consistent packing as well as the possibility of investigating the effects of different initial packing densities and use of different wrapping materials.

A micro costing of NHS cancer genetic services.

This paper presents the first full micro costing of a commonly used cancer genetic counselling and testing protocol used in the UK. Costs were estimated for the Cardiff clinic of the Cancer Genetics Service in Wales by issuing a questionnaire to all staff, conducting an audit of clinic rooms and equipment and obtaining gross unit costs from the finance department. A total of 22 distinct event pathways were identified for patients at risk of developing breast, ovarian, breast and ovarian or colorectal cancer. The mean cost per patient were pound sterling 97- pound sterling 151 for patients at moderate risk, pound sterling 975- pound sterling 3072 for patients at high risk of developing colorectal cancer and pound sterling 675- pound sterling 2909 for patients at high risk of developing breast or ovarian cancer. The most expensive element of cancer genetic services was labour. Labour costs were dependent upon the amount of labour, staff grade, number of counsellors used and the proportion of staff time devoted to indirect patient contact. With the growing demand for cancer genetic services and the growing number of national and regional cancer genetic centers, there is a need for the different protocols being used to be thoroughly evaluated in terms of costs and outcomes.

Hematological changes during short-term tidal flow extracorporeal life support.

Various methods exist in the clinical practice of long-term venovenous (VV) extracorporeal life support (ECLS). Among the clinical techniques used are single venous access with a dual-lumen catheter, and cannulation of the jugular and femoral veins. Tidal flow VV ECLS uses a single-lumen catheter to achieve both venous drainage and arterialized reinfusion through a series of tubing occluders that are automated by a pump. A single venous occluder tidal flow system with a 15 Fr single-lumen cannula (n = 6) and passive filling M pump was compared to a conventional 14 Fr dual-lumen cannula (n = 7) and roller pump for four hours of VV ECLS. The changes in platelet count and plasma-free hemoglobin (pHgb) were compared. The results showed a decline in platelet counts typical of ECLS in both groups that were not significantly different from each other. A small elevation in pHgb did not rise above normal clinical levels of 15 mg/dL in either group after four hours of ECLS. Some recirculation was observed and needs to be addressed in future studies. Single occluder tidal flow ECLS may be feasible and efficacious for long-term application once recirculation is resolved and the system evaluated for long-term support.

Estimating the survival benefits gained from providing national cancer genetic services to women with a family history of breast cancer.

The aim of this paper is to compare a service offering genetic testing and presymptomatic surveillance to women at increased risk of developing breast cancer with its predecessor of no service at all in terms of survival and quality-adjusted survival (QALYs) by means of a Markov cohort chain simulation model. Genetic assessment and presymptomatic care provided between 0.07-1.61 mean additional life years and 0.05-1.67 mean QALYs over no services. Prophylactic surgery and surveillance extended mean life expectancy by 0.41-1.61 and 0.32-0.99 years, respectively over no services for high-risk women. Model outcomes were sensitive to all the parameters varied in the sensitivity analysis. Providing cancer genetic services increase survival and as long as services do not induce adverse psychological effects they also provide more QALYs. The greatest survival and QALY benefits were found for women with identified mutations. As more cancer genes are identified, the survival and cost-effectiveness of genetic services will improve. Although mastectomy provided most additional life years, when quality of life was accounted for oophorectomy was the optimal strategy. Delayed entry into coordinated genetic services was found to diminish the average survival and QALY gains for a woman utilising these services.

Cancer genetics services: a systematic review of the economic evidence and issues.

This paper systematically reviews the published economic research upon cancer genetics services for families at risk of having familial breast, ovarian or colorectal cancer. A structured search was made of 15 electronic databases. The search identified 1030 papers, of which 31 fulfilled the inclusion criteria, two were cost-benefit studies, five were cost consequences, four were cost-effectiveness studies, one was a cost analysis, two were cost-minimisation studies, one was a cost-utility study, 10 modelled life years and six were reviews. Modelling studies indicate that surveillance, prophylactic and chemoprevention techniques extend survival for carriers of identified mutations. Genetic testing has been estimated to cost 70-2400 USD [48-1591 UK pounds] and genetic counselling 129-800 USD [89-551 UK pounds]. The technology of genetic testing has been found to be cost effective. Cost effectiveness was particularly influenced by targeting genetic services for patients with a strong family history of cancer rather than screening the entire population. Future economic evaluation must go beyond merely assessing health outcomes and mutation identification, and account for the impact of genetic services upon the individual, the family and society, establish the value of services to these groups and determine the most effective ways of delivering genetic services.