Life expectancy associated with different ages at diagnosis of type 2 diabetes in high-income countries: 23 million person-years of observation

BACKGROUND

The prevalence of type 2 diabetes is increasing rapidly, particularly among younger age groups. Estimates suggest that people with diabetes die, on average, 6 years earlier than people without diabetes. We aimed to provide reliable estimates of the associations between age at diagnosis of diabetes and all-cause mortality, cause-specific mortality, and reductions in life expectancy.

METHODS

For this observational study, we conducted a combined analysis of individual-participant data from 19 high-income countries using two large-scale data sources: the Emerging Risk Factors Collaboration (96 cohorts, median baseline years 1961-2007, median latest follow-up years 1980-2013) and the UK Biobank (median baseline year 2006, median latest follow-up year 2020). We calculated age-adjusted and sex-adjusted hazard ratios (HRs) for all-cause mortality according to age at diagnosis of diabetes using data from 1 515 718 participants, in whom deaths were recorded during 23·1 million person-years of follow-up. We estimated cumulative survival by applying age-specific HRs to age-specific death rates from 2015 for the USA and the EU.

FINDINGS

For participants with diabetes, we observed a linear dose-response association between earlier age at diagnosis and higher risk of all-cause mortality compared with participants without diabetes. HRs were 2·69 (95% CI 2·43-2·97) when diagnosed at 30-39 years, 2·26 (2·08-2·45) at 40-49 years, 1·84 (1·72-1·97) at 50-59 years, 1·57 (1·47-1·67) at 60-69 years, and 1·39 (1·29-1·51) at 70 years and older. HRs per decade of earlier diagnosis were similar for men and women. Using death rates from the USA, a 50-year-old individual with diabetes died on average 14 years earlier when diagnosed aged 30 years, 10 years earlier when diagnosed aged 40 years, or 6 years earlier when diagnosed aged 50 years than an individual without diabetes. Using EU death rates, the corresponding estimates were 13, 9, or 5 years earlier.

INTERPRETATION

Every decade of earlier diagnosis of diabetes was associated with about 3-4 years of lower life expectancy, highlighting the need to develop and implement interventions that prevent or delay the onset of diabetes and to intensify the treatment of risk factors among young adults diagnosed with diabetes.

FUNDING

British Heart Foundation, Medical Research Council, National Institute for Health and Care Research, and Health Data Research UK.

The Heart Failure Optimization Study (HF-OPT): rationale and design

BACKGROUND

According to the current guidelines, implantable cardioverter-defibrillators (ICD) for primary prevention in patients with heart failure and reduced ejection fraction (HFrEF) should not be considered until optimal guideline-directed medical therapy (GDMT) has been achieved for a minimum of 3 months. Optimization of GDMT often needs time beyond 3 months after diagnosis. The aim of the Heart Failure Optimization Study (HF-OPT) is to evaluate the recovery of left ventricular function beyond 3 months after diagnosis of newly diagnosed HFrEF.

METHODS

The HF-OPT multicenter study is comprised of two non-randomized phases (registry and study). During the first 90 days a wearable cardioverter-defibrillator (WCD) is prescribed and patients are enrolled in an observational pre-study registry. Registry subjects meeting inclusion criteria for the study portion at day 90 have ongoing left ventricular ejection fraction (LVEF) reassessment at 90, 180 and 360 days after the index hospital discharge, regardless of continued WCD use. Approximately 600 subjects will be enrolled in the study portion. Of those, one-third are anticipated to start the study phase at day 90 with reduced LVEF. The primary objective of this study is to observe the rate of recovery of LVEF > 35% between 90 and 180 days, while key secondary endpoints include mortality and WCD recorded arrhythmias and shocks.

DISCUSSION

The HF-OPT study will provide important information on the rate of additional recovery of LVEF > 35%, between 90 and 180 days, in newly diagnosed HF with reduced LVEF patients being titrated with GDMT. The results of the study may impact indications for primary prophylactic ICD implantation.

Cardiomyocyte stretch mediates the relation between left ventricular amyloid burden and adverse outcomes in light chain amyloidosis: a 18F-florbetapir positron emission tomography study

Background

Patients with light chain (AL) amyloidosis and cardiac involvement have poor prognosis. Mayo stage accounts for severity of plasma cell dyscrasia and cardiac biomarker release, and provides powerful risk stratification. Myocardial amyloid burden can be quantified by 18F-florbetapir positron emission tomography (PET), but its prognostic value is not known.

Purpose

To test our hypothesis that (1) myocardial amyloid burden predicts adverse outcomes and (2) the relationship between amyloid burden and adverse outcomes is mediated by cardiomyocyte stretch and injury. Amyloid burden was estimated by left ventricular 18F-florbetapir retention index (RI) and cardiomyocyte stretch and injury by NT proBNP and troponin T respectively.

Methods

We performed 18F-florbetapir PET (median dose 9.05 mCi) in prospectively enrolled subjects with newly diagnosed AL amyloidosis with abnormal cardiac biomarkers or with normal cardiac biomarkers and normal left ventricular wall thickness (NCT02641145). Left ventricular RI was calculated as the activity concentration between 10 and 30 min. after injection divided by the integral of the left atrial blood time-activity curve from 0 to 20 min. RI was categorized as normal (<0.06/min, based on controls), increased (0.06–0.12/min), or high risk (>0.12/min, based on log-rank statistic maximization). Mayo stages I–IV were based on elevated serum cardiac biomarkers: NT-proBNP ≥1800 pg/ml, troponin T ≥0.025 ng/ml, and difference in free light chains ≥180 mg/l. Adverse outcomes of all-cause death or heart failure hospitalization were evaluated. Survival analysis was performed using Kaplan-Meier and Cox regression including Mayo stage and RI. Mediation analysis was used to elucidate the role of cardiomyocyte stretch (as NT-proBNP) and injury (as troponin T) in the association between amyloid burden estimated by RI and adverse outcomes.

Results

We studied 80 subjects with median age 62 years (IQR 57–67), 46 men (57%), 60 with abnormal cardiac biomarkers (75%), and median RI of 0.10/min (IQR 0.06–0.16). At follow-up (median 15 months), adverse outcomes occurred in 34 subjects (42%), with 17 deaths (21%) and 23 heart failure hospitalizations (29%). The incidence of adverse outcomes increased across Mayo stages from 9% to 44% (log-rank p<0.001), and across RI levels from 29% to 57% (log-rank p=0.037, Figure 1). In multivariable Cox regression, only Mayo stage independently predicted adverse outcomes (HR 2.0 [95% CI 1.4–3.0], p<0.001). Multivariable mediation analysis showed that 83% of the association between RI and adverse outcomes was mediated by NT-proBNP (p<0.001, Figure 2), without contribution from troponin T.

Conclusion

Myocardial amyloid burden estimated by F-18 florbetapir RI predicts adverse outcomes in AL amyloidosis, but not independently of Mayo stage. Cardiomyocyte stretch mediates the relationship between myocardial amyloid burden and adverse outcomes in AL amyloidosis.

Funding Acknowledgement

Type of funding sources: Private company.

Candida auris: Diagnostic Challenges and Emerging Opportunities for the Clinical Microbiology Laboratory

Purpose of Review

This review summarises the epidemiology of Candida auris infection and describes contemporary and emerging diagnostic methods for detection and identification of C. auris.

Recent Findings

A fifth C. auris clade has been described. Diagnostic accuracy has improved with development of selective/differential media for C. auris. Advances in spectral databases of matrix-associated laser desorption ionisation time-of-flight mass spectrometry (MALDI-TOF MS) systems have reduced misidentification. Direct detection of C. auris in clinical specimens using real time PCR is increasingly used, as is whole genome sequencing (WGS) to track nosocomial spread and to study phylogenetic relationships and drug resistance.

Summary

C. auris is an important transmissible, nosocomial pathogen. The microbiological laboratory diagnostic capacity has extended beyond culture-based methods to include PCR and WGS. Microbiological techniques on the horizon include the use of MALDI-TOF MS for early echinocandin antifungal susceptibility testing (AST) and expansion of the versatile and information-rich WGS methods for outbreak investigation.

Survey of spiking in the mouse visual system reveals functional hierarchy

The anatomy of the mammalian visual system, from the retina to the neocortex, is organized hierarchically¹. However, direct observation of cellular-level functional interactions across this hierarchy is lacking due to the challenge of simultaneously recording activity across numerous regions. Here we describe a large, open dataset-part of the Allen Brain Observatory²-that surveys spiking from tens of thousands of units in six cortical and two thalamic regions in the brains of mice responding to a battery of visual stimuli. Using cross-correlation analysis, we reveal that the organization of inter-area functional connectivity during visual stimulation mirrors the anatomical hierarchy from the Allen Mouse Brain Connectivity Atlas³. We find that four classical hierarchical measures-response latency, receptive-field size, phase-locking to drifting gratings and response decay timescale-are all correlated with the hierarchy. Moreover, recordings obtained during a visual task reveal that the correlation between neural activity and behavioural choice also increases along the hierarchy. Our study provides a foundation for understanding coding and signal propagation across hierarchically organized cortical and thalamic visual areas.

A systematic review of droplet and aerosol generation in dentistry

OBJECTIVES

This review aimed to identify which dental procedures generate droplets and aerosols with subsequent contamination, and for these, characterise their pattern, spread and settle.

DATA RESOURCES

Medline(OVID), Embase(OVID), Cochrane Central Register of Controlled Trials, Scopus, Web of Science and LILACS databases were searched for eligible studies from each database's inception to May 2020 (search updated 11/08/20). Studies investigating clinical dental activities that generate aerosol using duplicate independent screening. Data extraction by one reviewer and verified by another. Risk of bias assessed through contamination measurement tool sensitivity assessment.

STUDY SELECTION

A total eighty-three studies met the inclusion criteria and covered: ultrasonic scaling (USS, n = 44), highspeed air-rotor (HSAR, n = 31); oral surgery (n = 11), slow-speed handpiece (n = 4); air-water (triple) syringe (n = 4), air-polishing (n = 4), prophylaxis (n = 2) and hand-scaling (n = 2). Although no studies investigated respiratory viruses, those on bacteria, blood-splatter and aerosol showed activities using powered devices produced greatest contamination. Contamination was found for all activities, and at the furthest points studied. The operator's torso, operator's arm and patient's body were especially affected. Heterogeneity precluded inter-study comparisons but intra-study comparisons allowed construction of a proposed hierarchy of procedure contamination risk: higher (USS, HSAR, air-water syringe, air polishing, extractions using motorised handpieces); moderate (slow-speed handpieces, prophylaxis, extractions) and lower (air-water syringe [water only] and hand scaling).

CONCLUSION

Gaps in evidence, low sensitivity of measures and variable quality limit conclusions around contamination for procedures. A hierarchy of contamination from procedures is proposed for challenge/verification by future research which should consider standardised methodologies to facilitate research synthesis.

CLINICAL SIGNIFICANCE

This manuscript addresses uncertainty around aerosol generating procedures (AGPs) in dentistry. Findings indicate a continuum of procedure-related aerosol generation rather than the common binary AGP or non-AGP perspective. The findings inform discussion around AGPs and direct future research to support knowledge and decision making around COVID-19 and dental procedures.

Integrated Morphoelectric and Transcriptomic Classification of Cortical GABAergic Cells

Neurons are frequently classified into distinct types on the basis of structural, physiological, or genetic attributes. To better constrain the definition of neuronal cell types, we characterized the transcriptomes and intrinsic physiological properties of over 4,200 mouse visual cortical GABAergic interneurons and reconstructed the local morphologies of 517 of those neurons. We find that most transcriptomic types (t-types) occupy specific laminar positions within visual cortex, and, for most types, the cells mapping to a t-type exhibit consistent electrophysiological and morphological properties. These properties display both discrete and continuous variation among t-types. Through multimodal integrated analysis, we define 28 met-types that have congruent morphological, electrophysiological, and transcriptomic properties and robust mutual predictability. We identify layer-specific axon innervation pattern as a defining feature distinguishing different met-types. These met-types represent a unified definition of cortical GABAergic interneuron types, providing a systematic framework to capture existing knowledge and bridge future analyses across different modalities.

Change in health-related quality of life among patients with a reduced ejection fraction initiating guideline-directed medical therapy

Background

Management of patients with heart failure (HF) should include patient reported outcomes (PROs). The Kansas City Cardiomyopathy Questionnaire is self-administered with subscales to evaluate HF symptom burden, physical limitations, social limitations (recreational participation), and quality of life (QoL). Change in PROs among newly diagnosed patients with HF and reduced ejection fraction (HFrEF) prescribed a wearable cardioverter defibrillator (WCD) and initiating guideline-directed medical therapy (GDMT) has not been assessed.

Purpose

Examine PROs over 180 days of receiving GDMT for newly diagnosed HFrEF.

Methods

Patients (n=93, 75.3% male) were enrolled ≤10 days post-hospitalization for new onset HF; all patients had an EF ≤35% and were prescribed a WCD. Health status, as measured by PRO was assessed at baseline, day 90, and day 180. Controlling for age and EF at baseline, changes in PROs over the 180-day study period were evaluated using repeated measures modeling. Pairwise comparisons with Bonferroni adjustments were used to compare adjacent timepoints. Higher scores reflect better health status.

Results

After controlling for age (mean 56±13.4) and baseline EF (mean 22±7.7) improvements in health status were observed. From baseline to day 90, physical limitation, symptom frequency, QoL, and the summary score all increased (Δ: 17.8, 23.7, 28.4, 23.7, respectively; all p's <0.05). From day 90 to day 180, only QoL continued to improve (Δ 7.5, p=0.001). Change in social limitations over time was not significant (p=0.42).

Conclusion

Patients report improved health status in the months following a new diagnosis of HFrEF when prescribed a WCD and GDMT.

Change in Quality of Life

Funding Acknowledgement

Type of funding source: None

A United Kingdom Multicenter Study of Icodextrin in Continuous Ambulatory Peritoneal Dialysis

While glucose remains the only osmotic agent used universally for peritoneal dialysis, its various shortcomings for the long dwell equilibration continuous ambulatory peritoneal dialysis (CAPD) has led to a search for alternative agents. The large molecular weight group has been of interest, because these agents theoretically would lead to greater ultrafiltration and a better metabolic profile. Mostsubstances (dextrans, charged macromolecules) have been found unsuitable for reasons of insolubility, allergenicity, and peritoneal toxicity. Short-chain polypeptides have been studied in humans, but the experience is limited, and there is the potential for allergenicity with long-term use.

The only large molecular weight agent that has been studied in some detail but hitherto in one center only and in a limited number of patients is glucose polymer (generic name, icodextrin). Because of the promise shown by these initial studies, a randomized controlled multicenter investigation of icodextrin in CAPD (MIDAS Study Group) was undertaken to evaluate the long-term safety and efficacy by comparing daily overnight (8 12 hours) use of a slightly hypo-osmolar solution (282 mOsm/ kg) with 1.36% (346 mOsm/kg) and 3.86% (484 mOsm/kg) glucose exchanges. Over a 6-month period 209 patients from 11 centers in the United Kingdom were randomized, with 106 allocated to receive icodextrin (study group) and 103 to remain on glucose (control group). One hundred and thirty-eight patients completed the 6-month study (71 control, 67 study).

The mean net ultrafiltration overnight with icodextrin was 3.5 times greater than 1.36% at 8 hours and 5.5 times greater at 12 hours (p<0.0001), but no different from that of 3.86% glucose at 8 and 12 hours (although for the latter dwell the net mean ultrafiltration volume was greater by about 140 mL). Biochemical profiles were no different except for a small fall in serum sodium and chloride in the icodextrin group. The mean serum maltose rose to a steady-state level of 1.2 g/L within 2 weeks and remained stable. The mean carbohydrate absorbed for icodextrin (29±5 g) was lower than with 3.86% glucose (62±5 g). The use of icodextrin did not increase the incidence of peritonitis, nor did it alter its outcome, affect uptake of icodextrin from the peritoneum, alter serum osmolality or sodium levels. There were no adverse effects associated with the use of icodextrin, and the overall CAPD-related symptom score was significantly better for icodextrin than control subjects.

This study and subsequent extensive use and clinical experience has demonstrated that the daily use of an iso-osmolar icodextrin solution is generally well tolerated, effective, and could replace the overnight use of hyperosmotic glucose solution. Its use was of equal efficacy in peritonitis and in diabetic patients. The elevated levels of maltose did not appear to have any clinical side effects.

Peritonitis Occurrence in a Multicenter Study of Icodextrin and Glucose in Capd

Objective

To compare peritonitis occurrence and outcome in a large U.K. study Multicentre Investigation of Icodextrin in Ambulatory Dialysis (MIDAS).

Design

Prospective, randomized, controlled 6-month comparison of icodextrin with glucose for the long dwell in continuous ambulatory peritoneal dialysis (CAPD) patients.

Setting

Eleven CAPD units in U.K. teaching hospitals.

Patients

A total of 209 patients established on CAPD for at least 3 months (103 control, 106 icodextrin). Twentythree control (C) and 22 icodextrin (I) patients experienced peritonitis during the study.

Intervention

Patients who had peritonitis remained on treatment (unless CAPD was withdrawn, temporarily or permanently).

Main Outcome Measures

The main outcome measures were the rate of peritonitis and duration of CAPD treatment prestudy; the rate of peritonitis episodes and their outcome during study; the effect of peritonitis on laboratory variables, serum icodextrin metabolites, and ultrafiltration efficacy.

Results

Prestudy: Nine (39%) of C but 14 (64%) of I patients had suffered previous peritonitis episode(s), with overall rates of 0.58 and 0.78 episodes per patientyear, respectively.

During study

There were 31 C episodes and 35 I episodes, with overall rates of 0.76 and 0.93 per patientyear, respectively. The increase in the C and I groups was 31% and 19%, respectively. Serum osmolality and sodium levels were unaffected by peritonitis, and there was no increase in serum icodextrin metabolites during peritonitis. Overnight ultrafiltration volume during peritonitis (mean±SD) declined slightly from 218±354 mL to 185±299 mL (NS) in the control group, but increased in the icodextrin group from 570±146 mL to 723±218 mL (p < 0.01).

Conclusions

Using icodextrin for the long dwell in CAPD does not increase the rate of peritonitis, nor does it alter the outcome of peritonitis. Peritonitis does not affect uptake of icodextrin from the peritoneum.

A large-scale standardized physiological survey reveals functional organization of the mouse visual cortex

To understand how the brain processes sensory information to guide behavior, we must know how stimulus representations are transformed throughout the visual cortex. Here we report an open, large-scale physiological survey of activity in the awake mouse visual cortex: the Allen Brain Observatory Visual Coding dataset. This publicly available dataset includes the cortical activity of nearly 60,000 neurons from six visual areas, four layers, and 12 transgenic mouse lines in a total of 243 adult mice, in response to a systematic set of visual stimuli. We classify neurons on the basis of joint reliabilities to multiple stimuli and validate this functional classification with models of visual responses. While most classes are characterized by responses to specific subsets of the stimuli, the largest class is not reliably responsive to any of the stimuli and becomes progressively larger in higher visual areas. These classes reveal a functional organization wherein putative dorsal areas show specialization for visual motion signals.

Child Caries Management: A Randomized Controlled Trial in Dental Practice

This multicenter 3-arm, parallel-group, patient-randomized controlled trial compared clinical effectiveness of 3 treatment strategies over 3 y for managing dental caries in primary teeth in UK primary dental care. Participants aged 3 to 7 y with at least 1 primary molar with dentinal carious lesion were randomized across 3 arms (1:1:1 via centrally administered system with variable-length random permuted blocks): C+P, conventional carious lesion management (complete carious tooth tissue removal and restoration placement) with prevention; B+P, biological management (sealing in carious tooth tissue restoratively) with prevention; and PA, prevention alone (diet, plaque removal, fluorides, and fissure sealants). Parents, children, and dentists were not blind to allocated arm. Co–primary outcomes were 1) the proportion of participants with at least 1 episode of dental pain and/or infection and 2) the number of episodes of dental pain and/or infection during follow-up (minimum, 23 mo). In sum, 1,144 participants were randomized (C+P, n = 386; B+P, n = 381; PA, n = 377) by 72 general dental practitioners, of whom 1,058 (C+P, n = 352; B+P, n = 352; PA, n = 354) attended at least 1 study visit and were included in the primary analysis. The median follow-up was 33.8 mo (interquartile range, 23.8 to 36.7). Proportions of participants with at least 1 episode of dental pain and/or infection were as follows: C+P, 42%; B+P, 40%; PA, 45%. There was no evidence of a difference in incidence of dental pain and/or infection when B+P (adjusted risk difference [97.5% CI]: −2% [−10% to 6%]) or PA (4% [−4% to 12%]) was compared with C+P. The mean (SD) number of episodes of dental pain and/or infection were as follows: C+P, 0.62 (0.95); B+P, 0.58 (0.87); and PA, 0.72 (0.98). Superiority could not be concluded for number of episodes between B+P (adjusted incident rate ratio (97.5% CI): 0.95 [0.75 to 1.21]) or PA (1.18 [0.94 to 1.48]) and C+P. In conclusion, there was no evidence of a difference among the 3 treatment approaches for incidence or number of episodes of dental pain and/or infection experienced by these participants with high caries risk and established disease (trial registration: ISRCTN77044005).

Method Extension Study to Validate Applicability of AOAC Official Method 997.03 Visual Immunoprecipitate Assay (VIP®) for Listeria monocytogenes and Related Listeria spp. from Environmental Surfaces: Collaborative Study

Test portions from 3 environmental surface types, representative of typical surfaces found in a food production facility, were analyzed by the Visual Immunoprecipitate assay (VIP®) and the U.S. Department of Agriculture/Food Safety and Inspection Service (USDA/FSIS) culture method for Listeria monocytogenes and related Listeria species. In all cases, naturally contaminated environmental test samples were collected from an actual food production facility by sponge or swab. Test samples from concrete surfaces were collected by both swab and sponge; sponge test samples were collected from rubber surfaces, and swabs were used to sample steel surfaces. Test portions from each surface type were simultaneously analyzed by both methods. A total of 27 laboratories, representing government agencies as well as private industry in both the United States and Canada, participated in the study. During this study, a total of 615 test portions and controls was analyzed and confirmed, of which 227 were positive and 378 were negative by both methods. Nine test portions were positive by culture, but negative by the VIP. Five test portions were negative by culture, but positive by the VIP. Four test portions were negative by VIP and by culture, but confirmed positive when VIP enrichment broths were subcultured to selective agars. The data reported here indicate that the VIP method and the USDA/FSIS culture method are statistically equivalent for detection of L. monocytogenes and related Listeria species from environmental surfaces taken by sponges or swabs.

Classification of electrophysiological and morphological neuron types in the mouse visual cortex

Understanding the diversity of cell types in the brain has been an enduring challenge and requires detailed characterization of individual neurons in multiple dimensions. To systematically profile morpho-electric properties of mammalian neurons, we established a single-cell characterization pipeline using standardized patch-clamp recordings in brain slices and biocytin-based neuronal reconstructions. We built a publicly accessible online database, the Allen Cell Types Database, to display these datasets. Intrinsic physiological properties were measured from 1,938 neurons from the adult laboratory mouse visual cortex, morphological properties were measured from 461 reconstructed neurons, and 452 neurons had both measurements available. Quantitative features were used to classify neurons into distinct types using unsupervised methods. We established a taxonomy of morphologically and electrophysiologically defined cell types for this region of the cortex, with 17 electrophysiological types, 38 morphological types and 46 morpho-electric types. There was good correspondence with previously defined transcriptomic cell types and subclasses using the same transgenic mouse lines.

Biological Activity of Bacillus thuringiensis in Drosophila suzukii (Diptera: Drosophilidae)

Whole-culture extracts of Bacillus thuringiensis Berliner strains were assayed against larval and adult Drosophila suzukii (Matsumura), an important invasive pest of many thin-skinned soft fruit crops in North America. Of the 22 serovars tested versus larval D. suzukii , strains of Bacillus thuringiensis var. thuringiensis , kurstaki , thompsoni , bolivia , and pakistani caused high (75 to 100%) first-instar mortalities. Pupal mortality, measured as a failure of adults to emerge, varied with serovar. The first D. suzukii instar was the most susceptible of the three larval instars to B. thuringiensis var. kurstaki HD-1. Larval D. suzukii are shielded from crop treatments, as they develop under the skin of infested fruit, and adults would be a more vulnerable target for an efficacious strain of B. thuringiensis . Only one of the 21 B. thuringiensis serovars, var. thuringiensis , prepared as oral suspensions in sucrose for adult D. suzukii ingestion resulted in significant, albeit low mortality within 7 d. It is not a candidate for use in pest management, as it produces β -exotoxin that is toxic to vertebrates.

Cost-effectiveness of the Hall Technique in a Randomized Trial

Clinical and patient-reported outcomes were reported for carious primary molars treated with the Hall technique (HT) as compared with conventional carious tissue removal and restorations (i.e., conventional restoration [CR]) in a 5-y randomized controlled practice-based trial in Scotland. We interrogated this data set further to investigate the cost-effectiveness of HT versus CR. A total of 132 children who had 2 matched occlusal/occlusal-proximal carious lesions in primary molars ( n = 264 teeth) were randomly allocated to HT or CR, provided by 17 general dental practitioners. Molars were followed up for a mean 5 y. A societal perspective was taken for the economic analysis. Direct dental treatment costs were estimated from a Scottish NHS perspective (an NHS England perspective was taken for a sensitivity analysis). Initial, maintenance, and retreatment costs, including rerestorations, endodontic treatments, and extractions, were estimated with fee items. Indirect/opportunity costs were estimated with time and travel costs from a UK perspective. The primary outcome was tooth survival. Secondary outcomes included 1) not having pain or needing endodontic treatments/extractions and 2) not needing rerestorations. Cost-effectiveness and acceptability were estimated from bootstrapped samples. Significantly more molars in HT survived (99%, 95% CI: 98% to 100%) than in CR (92%; 87% to 97%). Also, the proportion of molars retained without pain or requiring endodontic treatment/extraction was significantly higher in HT than CR. In the base case analysis (NHS Scotland perspective), cumulative direct dental treatment costs (Great British pound [GBP]) of HT were 24 GBP (95% CI: 23 to 25); costs for CR were 29 (17 to 46). From an NHS England perspective, the cost advantage of HT (29 GBP; 95% CI: 25 to 34) over CR (107; 86 to 127) was more pronounced. Indirect/opportunity costs were significantly lower for HT (8 GBP; 95% CI: 7 to 9) than CR (19; 16 to 23). Total cumulative costs were significantly lower for HT (32 GBP; 95% CI: 31 to 34) than CR (49; 34 to 69). Based on a long-term practice-based trial, HT was more cost-effective than CR with HT retained for longer and experiencing less complications at lower costs.

Efficacy and safety of 12 weeks of elbasvir ± grazoprevir ± ribavirin in participants with hepatitis C virus genotype 2, 4, 5 or 6 infection: The C-SCAPE study

People with hepatitis C virus (HCV) infection other than genotype 1 represent a heterogeneous group. The aim of the phase 2 C-SCAPE study was to evaluate elbasvir/grazoprevir (EBR/GZR), with or without ribavirin (RBV), in participants with HCV genotype 2, 4, 5 or 6 infection. This was a part randomised, open-label, parallel-group study (NCT01932762; PN047-03) of treatment-naive, noncirrhotic participants. Participants with HCV genotype 2 infection received GZR 100 mg + RBV ± EBR 50 mg for 12 weeks and those with genotype 4, 5 or 6 infection were randomized to receive EBR/GZR ± RBV for 12 weeks. The primary endpoint was sustained virological response 12 weeks after completion of treatment (SVR12; HCV RNA <25 IU/mL). Among participants with genotype 2 infection, SVR12 was achieved by 80% (24/30) of those receiving EBR/GZR + RBV and 73% (19/26) of those receiving GZR + RBV. SVR rates were high in participants with HCV genotype 4 infection receiving EBR/GZR with and without RBV (100% [10/10] and 90% [9/10]; respectively). In contrast, the addition of RBV to EBR/GZR appeared to increase SVR12 in participants with genotype 5 infection (EBR/GZR, 25%; EBR/GZR + RBV 100% [4/4]). In participants with genotype 6 infection, SVR12 was 75% (3/4) in both those receiving EBR/GZR and those receiving EBR/GZR + RBV. The safety profile was similar across treatment arms, with adverse events tending to occur more frequently among participants receiving RBV. In conclusion, these data support the inclusion of participants with genotype 4 or 6 infection in the EBR/GZR phase 3 studies. EBR/GZR ± RBV was unsatisfactory for participants with genotype 2 or 5 infection.