203 TRANSITIONS TO LONG-TERM CARE: EXPERIENCE OF A COHORT OF COMMUNITY-DWELLING OLDER ADULTS RECEIVING INTEGRATED CARE

Background

Data from the Nursing Home support scheme 2018 (NHSS) shows the majority of applications to the NHSS come from acute hospitals (44%) followed by referrals from the community (38%). We examined this transition in a cohort of community dwelling older adults to assess how many transition from home to nursing home and, when admission to nursing home from hospital occurred, the indications for same.

Methods

Retrospective examination of Integrated Care Team (ICT) and Acute Hospital data from 2019 in respect of a cohort of older adults. Transitions in care to nursing home including residence at time of admission, last acute hospital presentation prior to nursing home admission and commencement of NHSS application recorded.

Results

319 patients referred to the integrated care service in 2019, average age 81 and 58% female, predominantly from outpatient clinics in the Medicine for the Older Person’s service. 47 patients had moved to nursing home; within this cohort 14 (29.7%) transitioned from home, 28 (59.6%) transitioning after acute hospital admission. Main reasons for presentation to hospital were: Intercurrent acute illness (n=11); Falls (n=6); progression of dementia (n=4). Fair Deal application commenced in community by ICT in 20 of the 47 (42.5%) patients including 8 of 28 patients (28.5%) admitted to hospital prior to moving to nursing home.

Conclusion

This preliminary evaluation highlights the importance of advance care planning in this population when acute hospital admissions can be difficult to predict. Involvement of the ICT can help this transition and lead to shorter hospital stays.

Changes in Multidisciplinary Tracheostomy Team Practice Over Time

Aim Increasing numbers of tracheostomy patients are discharged from the Intensive Care Unit (ICU) to general hospital wards. There is evidence that a Multidisciplinary Tracheostomy Team (MTT) can have a positive impact on the care of tracheostomy patients discharged from the ICU. We compared tracheostomy management and patient outcome in two time periods, at the start of our MTT practice in 2009-2011 and again in 2017. Methods In a retrospective audit, we compared tracheostomy management and patient outcome in 117 patients who had a tracheostomy in 2009-2011 with 81 patients who had a tracheostomy in 2017. Results The duration of tracheostomy cannulation was significantly shorter (21 vs 31 days, p=0.0005) in 2017 compared to 2009-2011. A Mini-Trach was used after tracheostomy decannulation in 56 of the 81 (69%) tracheostomy patients in 2017. Conclusions The continued development of our MTT service over 8 years was associated with a significantly shorter duration of tracheostomy cannulation and the introduction of Mini-Trach use after tracheostomy decannulation. These results support the importance of maintaining an active MTT service to manage tracheostomy patients after discharge from the ICU.

The Development of a National Paediatric Psycho-Oncology Service

Aims To investigate the psychological care provided to children and young adolescents with cancer and their families within the National Children's Cancer Service (NCCS), Ireland, in respect of the national and international standards of care. Methods A retrospective audit of 316 referrals made over 32 months by the NCCS to the psychology service in malignant haematology and oncology was performed. Results The audit revealed that out of 316 patients, a yearly average of 189 (50%) of urgently referred patients received psychological support within the NCCS between January 2013 and August 2016. Furthermore only 20 (22%) undergoing haematopoietic stem cell transplantation (HSCT), 14 (22%) referred to the paediatric palliative care team, and 84 (62%) of teenage patients received psychological input during this timeframe. Conclusion The audit revealed that the current psychology service provision is failing to meet the international standards of care. Due to the data provided by this audit, in conjunction with a clinical risk assessment of the service, funds for the post of principal psychologist have been secured. Further psychology posts (HSCT, late-effects and neuropsychology), and development of the psycho-oncology model of care are required to ensure equality of access and evidence-based psychological care for all children with cancer.

Growth plate extracellular matrix-derived scaffolds for large bone defect healing

Limitations associated with demineralised bone matrix and other grafting materials have motivated the development of alternative strategies to enhance the repair of large bone defects. The growth plate (GP) of developing limbs contain a plethora of growth factors and matrix cues which contribute to long bone growth, suggesting that biomaterials derived from its extracellular matrix (ECM) may be uniquely suited to promoting bone regeneration. The goal of this study was to generate porous scaffolds from decellularised GP ECM and to evaluate their ability to enhance host mediated bone regeneration following their implantation into critically-sized rat cranial defects. The scaffolds were first assessed by culturing with primary human macrophages, which demonstrated that decellularisation resulted in reduced IL-1β and IL-8 production. In vitro, GP derived scaffolds were found capable of supporting osteogenesis of mesenchymal stem cells via either an intramembranous or an endochondral pathway, demonstrating the intrinsic osteoinductivity of the biomaterial. Furthermore, upon implantation into cranial defects, GP derived scaffolds were observed to accelerate vessel in-growth, mineralisation and de novo bone formation. These results support the use of decellularised GP ECM as a scaffold for large bone defect regeneration.

Dynamic population pharmacokinetic-pharmacodynamic modelling and simulation supports similar efficacy in glycosylated haemoglobin response with once or twice-daily dosing of canagliflozin

AIM

Canagliflozin is an SGLT2 inhibitor approved for the treatment of type-2 diabetes. A dynamic population pharmacokinetic-pharmacodynamic (PK/PD) model relating 24-h canagliflozin exposure profiles to effects on glycosylated haemoglobin was developed to compare the efficacy of once-daily and twice-daily dosing.

METHODS

Data from two clinical studies, one with once-daily, and the other with twice-daily dosing of canagliflozin as add-on to metformin were used (n = 1347). An established population PK model was used to predict full 24-h profiles from measured trough concentrations and/or baseline covariates. The dynamic PK/PD model incorporated an E_max relationship between 24-h canagliflozin exposure and HbA1c-lowering with baseline HbA1c affecting the efficacy.

RESULTS

Internal and external model validation demonstrated that the model adequately predicted HbA1c-lowering for canagliflozin once-daily and twice-daily dosing regimens. The differences in HbA1c reduction between the twice-daily and daily mean profiles were minimal (at most 0.023% for 100 mg total daily dose [TDD] and 0.011% for 300 mg TDD, up to week 26, increasing with time and decreasing with TDD) and not considered clinically meaningful.

CONCLUSIONS

Simulations using this model demonstrated the absence of clinically meaningful between-regimen differences in efficacy, supported the regulatory approval of a canagliflozin-metformin immediate release fixed-dose combination tablet and alleviated the need for an additional clinical study.

Intra-articular basic calcium phosphate and monosodium urate crystals inhibit anti-osteoclastogenic cytokine signalling

OBJECTIVE

Basic calcium phosphate (BCP) and monosodium urate (MSU) crystals are particulates with potent pro-inflammatory effects, associated with osteoarthritis (OA) and gout, respectively. Bone erosion, due to increased osteoclastogenesis, is a hallmark of both arthropathies and results in severe joint destruction. The aim of this study was to investigate the effect of these endogenous particulates on anti-osteoclastogenic cytokine signalling.

METHODS

Human osteoclast precursors (OcP) were treated with BCP and MSU crystals prior to stimulation with Interleukin (IL-6) or Interferon (IFN-γ) and the effect on Signal Transducer and Activator of Transcription (STAT)-3 and STAT-1 activation in addition to Mitogen Activated Protein Kinase (MAPK) activation was examined by immunoblotting. Crystal-induced suppressor of cytokine signalling (SOCS) protein and SH-2 containing tyrosine phosphatase (SHP) expression was assessed by real-time polymerase chain reaction (PCR) in the presence and absence of MAPK inhibitors.

RESULTS

Pre-treatment with BCP or MSU crystals for 1 h inhibited IL-6-induced STAT-3 activation in human OcP, while pre-treatment for 3 h inhibited IFN-γ-induced STAT-1 activation. Both crystals activated p38 and extracellular signal-regulated (ERK) MAPKs with BCP crystals also activating c-Jun N-terminal kinase (JNK). Inhibition of p38 counteracted the inhibitory effect of BCP and MSU crystals and restored STAT-3 phosphorylation. In contrast, STAT-1 phosphorylation was not restored by MAPK inhibition. Finally, both crystals potently induced the expression of SOCS-3 in a MAPK dependent manner, while BCP crystals also induced expression of SHP-1 and SHP-2.

CONCLUSION

This study provides further insight into the pathogenic effects of endogenous particulates in joint arthropathies and demonstrates how they may contribute to bone erosion via the inhibition of anti-osteoclastogenic cytokine signalling. Potential targets to overcome these effects include p38 MAPK, SOCS-3 and SHP phosphatases.

The Development and Analysis of a Database to Record Critical Incidents Associated with Intravenous Drug Administration in Critically III Patients

Staff were asked to report critical incidents associated with intravenous medications across a critical care network. These were categorised using a database by drug and drug class, seriousness and level of harm, process stage and communication factors. 139 critical incidents were identified in 3848 patient days. Noradrenaline, omeprazole, gentamicin and insulin were most commonly involved (range 6 to 9 incidents). Twenty two incidents involved drug supply, 61 prescriptions, 10 preparation and 58 administration.

The use of a structured database allowed a clearer understanding of incidents to be established and we make some recommendations to improve safety. The classification database could be established across many intensive care units to improve understanding of incidents associated with intravenous medications.

The method of averaging applied to pharmacokinetic/pharmacodynamic indirect response models

The computational effort required to fit the pharmacodynamic (PD) part of a pharmacokinetic/pharmacodynamic (PK/PD) model can be considerable if the differential equations describing the model are solved numerically. This burden can be greatly reduced by applying the method of averaging (MAv) in the appropriate circumstances. The MAv gives an approximate solution, which is expected to be a good approximation when the PK profile is periodic (i.e. repeats its values in regular intervals) and the rate of change of the PD response is such that it is approximately constant over a single period of the PK profile. This paper explains the basis of the MAv by means of a simple mathematical derivation. The NONMEM® implementation of the MAv using the abbreviated FORTRAN function FUNCA is described and explained. The application of the MAv is illustrated by means of an example involving changes in glycated hemoglobin (HbA1c%) following administration of canagliflozin, a selective sodium glucose co-transporter 2 inhibitor. The PK/PD model applied to these data is fitted with NONMEM® using both the MAv and the standard method using a numerical differential equation solver (NDES). Both methods give virtually identical results but the NDES method takes almost 8 h to run both the estimation and covariance steps, whilst the MAv produces the same results in less than 30 s. An outline of the NONMEM® control stream and the FORTRAN code for the FUNCA function is provided in the appendices.

A novel TLR2 agonist from Bordetella pertussis is a potent adjuvant that promotes protective immunity with an acellular pertussis vaccine

Bordetella pertussis causes whooping cough, a severe and often lethal respiratory infection in infants. A recent resurgence of pertussis has been linked with waning or suboptimal immunity induced with acellular pertussis vaccines (Pa) that were introduced to most developed countries in the 1990s because of safety concerns around the use of whole-cell pertussis vaccines (Pw). Pa are composed of individual B. pertussis antigens absorbed to alum and promote strong antibody, T helper type 2 (Th2) and Th17 responses, but are less effective at inducing cellular immunity mediated by Th1 cells. In contrast, Pw, which include endogenous Toll-like receptor (TLR) agonists, induce Th1 as well as Th17 responses. Here we report the identification and characterization of novel TLR2-activating lipoproteins from B. pertussis. These proteins contain a characteristic N-terminal signal peptide that is unique to Gram-negative bacteria and we demonstrate that one of these lipoproteins, BP1569, activates murine dendritic cells and macrophages and human mononuclear cells via TLR2. Furthermore, we demonstrated that a corresponding synthetic lipopeptide LP1569 has potent immunostimulatory and adjuvant properties, capable of enhancing Th1, Th17, and IgG2a antibody responses induced in mice with an experimental Pa that conferred superior protection against B. pertussis infection than an equivalent vaccine formulated with alum.

Shrinkage in nonlinear mixed-effects population models: quantification, influencing factors, and impact

Shrinkage of empirical Bayes estimates (EBEs) of posterior individual parameters in mixed-effects models has been shown to obscure the apparent correlations among random effects and relationships between random effects and covariates. Empirical quantification equations have been widely used for population pharmacokinetic/pharmacodynamic models. The objectives of this manuscript were (1) to compare the empirical equations with theoretically derived equations, (2) to investigate and confirm the influencing factor on shrinkage, and (3) to evaluate the impact of shrinkage on estimation errors of EBEs using Monte Carlo simulations. A mathematical derivation was first provided for the shrinkage in nonlinear mixed effects model. Using a linear mixed model, the simulation results demonstrated that the shrinkage estimated from the empirical equations matched those based on the theoretically derived equations. Simulations with a two-compartment pharmacokinetic model verified that shrinkage has a reversed relationship with the relative ratio of interindividual variability to residual variability. Fewer numbers of observations per subject were associated with higher amount of shrinkage, consistent with findings from previous research. The influence of sampling times appeared to be larger when fewer PK samples were collected for each individual. As expected, sample size has very limited impact on shrinkage of the PK parameters of the two-compartment model. Assessment of estimation error suggested an average 1:1 relationship between shrinkage and median estimation error of EBEs.

A dose-finding trial of the effect of long-term folic acid intervention: implications for food fortification policy

BACKGROUND

The lowest dose of folic acid required to achieve effective reductions in homocysteine is controversial but important for food fortification policy given recent concerns about the potential adverse effects of overexposure to this vitamin.

OBJECTIVE

We compared the effectiveness of 0.2 mg folic acid/d with that of 0.4 and 0.8 mg/d at lowering homocysteine concentrations over a 6-mo period.

DESIGN

A randomized dose-finding trial with folic acid was conducted. Of 203 participants screened, 101 patients with ischemic heart disease and 71 healthy volunteers completed the study. Participants were randomly assigned to receive placebo or folic acid at doses of 0.2, 0.4, or 0.8 mg/d for 26 wk; subsamples of patients with ischemic heart disease were also examined at 6 or 12 wk.

RESULTS

Participants with higher baseline homocysteine concentrations had the greatest reductions in homocysteine in response to folic acid doses of 0.2 mg (-20.6%), 0.4 mg (-20.7%), and 0.8 mg (-27.8%); in those with lower baseline homocysteine concentrations, the responses were -8.2%, -8.9%, and -8.3%, respectively. No significant differences in homocysteine responses to the different doses were observed. In the patient group sampled at intervals during the intervention, the maximal homocysteine response appeared to be achieved by 6 wk in the 0.8-mg/d group and by 12 wk in the 0.4-mg/d group. However, the homocysteine response was suboptimal in the 0.2-mg/d group at both 6 and 12 wk compared with that at 26 wk.

CONCLUSIONS

A folic acid dose as low as 0.2 mg/d can, if administered for 6 mo, effectively lower homocysteine concentrations. Higher doses may not be necessary because they result in no further significant lowering, whereas doses even lower than 0.2 mg/d may be effective in the longer term. Previous trials probably overestimated the folic acid dose required because of a treatment duration that was too short. This trial was registered at clinicaltrials.gov as ISRCTN45296887.

Likelihood based approaches to handling data below the quantification limit using NONMEM VI

PURPOSE

To evaluate the likelihood-based methods for handling data below the quantification limit (BQL) using new features in NONMEM VI.

METHODS

A two-compartment pharmacokinetic model with first-order absorption was chosen for investigation. Methods evaluated were: discarding BQL observations (M1), discarding BQL observations but adjusting the likelihood for the remaining data (M2), maximizing the likelihood for the data above the limit of quantification (LOQ) and treating BQL data as censored (M3), and like M3 but conditioning on the observation being greater than zero (M4). These four methods were compared using data simulated with a proportional error model. M2, M3, and M4 were also compared using data simulated from a positively truncated normal distribution. Successful terminations and bias and precision of parameter estimates were assessed.

RESULTS

For the data simulated with a proportional error model, the overall performance was best for M3 followed by M2 and M1. M3 and M4 resulted in similar estimates in analyses without log transformation. For data simulated with the truncated normal distribution, M4 performed better than M3.

CONCLUSIONS

Analyses that maximized the likelihood of the data above the LOQ and treated BQL data as censored provided the most accurate and precise parameter estimates.

Gene expression profiles in HPV-infected head and neck cancer

Epidemiological and laboratory evidence indicate that, in addition to tobacco and alcohol, human papillomaviruses (HPV) play an important aetiological role in a subset of head and neck squamous cell carcinoma (HNSCC). To evaluate the molecular pathogenesis of HPV-infected HNSCC, we compared gene expression patterns between HPV-positive and -negative HNSCC tumours using cDNA microarrays. Tumour tissue was collected from 42 histologically confirmed HNSCC patients from an inner-city area of New York. Total DNA and RNA were extracted and purified from frozen tumour samples and gene expression levels were compared to a universal human reference RNA standard using a 27 323 cDNA microarray chip. HPV detection and genotyping were performed using an MY09/11-PCR system and RT-PCR. HPV was detected in 29% of HNSCC tumours. Most harboured only HPV16 and expressed the HPV16-E6 oncogene. HPV prevalence was highest in pharyngeal tumours (45%). Gene expression patterns that differentiated HPV-positive from negative tumours were compared by supervised classification analysis, and a multiple-gene signature was found to predict HPV16 prevalence in primary HNSCC with a false discovery rate < 0.2. Focusing on never-smokers, we further identified a distinct subset of 123 genes that were specifically dysregulated in HPV16-positive HNSCC. Overexpressed genes in HPV-positive HNSCC tumours included the retinoblastoma-binding protein (p18), replication factor-C gene, and an E2F-dimerization partner transcription factor (TFDP2) that have also been found to be overexpressed in cervical cancer. An additional subset of genes involved in viral defence and immune response, including interleukins and interferon-induced proteins, was found to be down-regulated in HPV-positive tumours, supporting a characteristic and unique transcriptional profile in HPV-induced HNSCC.

Effect of a voluntary food fortification policy on folate, related B vitamin status, and homocysteine in healthy adults

BACKGROUND

Mandatory folic acid fortification of food is effective in reducing neural tube defects and may even reduce stroke-related mortality, but it remains controversial because of concerns about potential adverse effects. Thus, it is virtually nonexistent in Europe, albeit many countries allow food fortification on a voluntary basis.

OBJECTIVE

The objective of the study was to examine the effect of a voluntary but liberal food fortification policy on dietary intake and biomarker status of folate and other homocysteine-related B vitamins in a healthy population.

DESIGN

The study was a cross-sectional study. From a convenience sample of 662 adults in Northern Ireland, those who provided a fasting blood sample and dietary intake data were examined (n = 441, aged 18-92 y). Intakes of both natural food folate and folic acid from fortified foods were estimated; we used the latter to categorize participants by fortified food intake.

RESULTS

Fortified foods were associated with significantly higher dietary intakes and biomarker status of folate, vitamin B-12, vitamin B-6, and riboflavin than were unfortified foods. There was no difference in natural food folate intake (range: 179-197 microg/d) between the fortified food categories. Red blood cell folate concentrations were 387 nmol/L higher and plasma total homocysteine concentrations were 2 micromol/L lower in the group with the highest fortified food intake (median intake: 208 microg/d folic acid) than in the nonconsumers of fortified foods (0 microg/d folic acid).

CONCLUSIONS

These results show that voluntary food fortification is associated with a substantial increase in dietary intake and biomarker status of folate and metabolically related B vitamins with potential beneficial effects on health. However, those who do not consume fortified foods regularly may have insufficient B vitamin status to achieve the known and potential health benefits.

Torsades de pointes and self-terminating ventricular fibrillation in a prescription methadone user

Methadone is known to prolong the QT interval and precipitate torsades de pointes. A 54-year-old prescription methadone user with hypokalaemia was referred to Critical Care with acute confusion and respiratory distress. Alcohol withdrawal was the presumed precipitant. The real precipitant only became evident on analysis of a 24-h ECG (Holter monitor) attached to the patient at the time. The patient had suffered prolonged (10 min) ventricular arrhythmias including torsades de pointes and self-terminating ventricular fibrillation. The patient made a full recovery. Risk factors for acquired long QT syndrome and the treatment of torsades de pointes are discussed.

The effects of the fibre content and physical structure of carrots on satiety and subsequent intakes when eaten as part of a mixed meal

Previous research indicates that vegetables yield relatively high satiety scores, and that fibre content and structure may both contribute to these effects. This study evaluated the effects of the fibre content and physical structure (gross anatomy and cell structure) of carrots on postprandial satiety and subsequent food intakes when consumed as part of a mixed meal. Using a randomised, repeated-measures, within-subject cross-over design, young women consumed a standardised breakfast and test lunches on three occasions, 4 weeks apart. The test lunches (3329 kJ) comprised boiled rice (200 g) with sweet and sour sauce (200 g) that included chicken (200 g) and carrots (200 g) in three conditions: whole carrots (fibre and structure; n 34), blended carrots (fibre but no structure; n 34) or carrot nutrients (no fibre or structure; n 32). The carrot nutrients had the same energy, major nutrients and portion weight as the other two conditions. Post-lunch satiety was assessed by visual analogue scales. Intakes were covertly weighed at a meal eaten ad libitum (3 h later), and for the remainder of the day using food diaries. Compared with the meal with carrot nutrients, meals with whole carrots and blended carrots resulted in significantly (P<0.05) higher satiety. There were significant (P<0.05) differences between conditions in intakes at the meal eaten ad libitum and for the remainder of the day, and intakes consistently decreased in the order: carrot nutrients, blended carrots, whole carrots, indicating that both fibre content and structure played a role in these effects.

Investigation of the medium-term effects of Olibra™ fat emulsion on food intake in non-obese subjects

OBJECTIVE

To investigate the effect of Olibra fat emulsion on medium-term food intake and appetite in non-obese subjects.

DESIGN

Double-blind, placebo-controlled, within-subject crossover.

SETTING

University of Ulster, Coleraine.

SUBJECTS

A total of 28 subjects (14 male, 14 female).

INTERVENTIONS

Subjects were randomly assigned to receive either a 200 g portion of test (5 g of Olibra fat) or control (5 g milk fat) yoghurt for breakfast for 2 x 3 week 'study' phases, separated by a 3-week 'wash-out' phase. On days 1, 8 and 22 of the study phases, food intake 4 h post-consumption of the yoghurt was assessed by pre- and post-covert weighing at an ad libitum buffet-style test lunch. Throughout each of these study days, appetite was assessed using visual analogue scales (VAS) at regular intervals. For the remainder of the study days, and the following 24 h ('post-study days'), subjects reported their food intake using weighed dietary records.

RESULTS

Consumption of the Olibra emulsion had no significant effect on mean energy, macronutrient or amounts of food consumed at the lunch 4 h post-consumption. Self-reported food intakes indicated that there was no significant effect of the emulsion on energy intakes for the remainder of each study day and post-study days. There was considerable individual variation in food intakes following consumption of the Olibra emulsion, with 46, 59 and 57% of subjects reducing their energy intakes at lunch on days 1, 8 and 22. There was no consistent effect of the emulsion on appetite ratings.

CONCLUSIONS

In contrast to earlier studies, there was no evidence of a short- or medium-term effect of the Olibra emulsion on food intake or appetite. This could be owing to numerous confounding factors influencing eating behaviour and/or the different study design used in the present study.

Riboflavin Lowers Homocysteine in Individuals Homozygous for the MTHFR 677C→T Polymorphism

Background— Meta-analyses predict that a 25% lowering of plasma homocysteine would reduce the risk of coronary heart disease by 11% to 16% and stroke by 19% to 24%. Individuals homozygous for the methylenetetrahydrofolate reductase ( MTHFR ) 677C→T polymorphism have reduced MTHFR enzyme activity resulting from the inappropriate loss of the riboflavin cofactor, but it is unknown whether their typically high homocysteine levels are responsive to improved riboflavin status.

Methods and Results— From a register of 680 healthy adults 18 to 65 years of age of known MTHFR 677C→T genotype, we identified 35 with the homozygous (TT) genotype and age-matched individuals with heterozygous (CT, n=26) or wild-type (CC, n=28) genotypes to participate in an intervention in which participants were randomized by genotype group to receive 1.6 mg/d riboflavin or placebo for a 12-week period. Supplementation increased riboflavin status to the same extent in all genotype groups (8% to 12% response in erythrocyte glutathione reductase activation coefficient; P <0.01 in each case). However, homocysteine responded only in the TT group, with levels decreasing by as much as 22% overall (from 16.1±1.5 to 12.5±0.8 μmol/L; P =0.003; n=32) and markedly so (by 40%) in those with lower riboflavin status at baseline (from 22.0±2.9 and 13.2±1.0 μmol/L; P =0.010; n=16). No homocysteine response was observed in the CC or CT groups despite being preselected for suboptimal riboflavin status.

Conclusions— Although previously overlooked, homocysteine is highly responsive to riboflavin, specifically in individuals with the MTHFR 677 TT genotype. Our findings might explain why this common polymorphism carries an increased risk of coronary heart disease in Europe but not in North America, where riboflavin fortification has existed for >50 years.

Mixed Effects versus Fixed Effects Modelling of Binary Data with Inter-subject Variability

The question of whether or not a mixed effects model is required when modelling binary data with inter-subject variability and within subject correlation was reported in this journal by Yano et al. (J. Pharmacokin. Pharmacodyn. 28:389-412 [2001]). That report used simulation experiments to demonstrate that, under certain circumstances, the use of a fixed effects model produced more accurate estimates of the fixed effect parameters than those produced by a mixed effects model. The Laplace approximation to the likelihood was used when fitting the mixed effects model. This paper repeats one of those simulation experiments, with two binary observations recorded for every subject, and uses both the Laplace and the adaptive Gaussian quadrature approximations to the likelihood when fitting the mixed effects model. The results show that the estimates produced using the Laplace approximation include a small number of extreme outliers. This was not the case when using the adaptive Gaussian quadrature approximation. Further examination of these outliers shows that they arise in situations in which the Laplace approximation seriously overestimates the likelihood in an extreme region of the parameter space. It is also demonstrated that when the number of observations per subject is increased from two to three, the estimates based on the Laplace approximation no longer include any extreme outliers. The root mean squared error is a combination of the bias and the variability of the estimates. Increasing the sample size is known to reduce the variability of an estimator with a consequent reduction in its root mean squared error. The estimates based on the fixed effects model are inherently biased and this bias acts as a lower bound for the root mean squared error of these estimates. Consequently, it might be expected that for data sets with a greater number of subjects the estimates based on the mixed effects model would be more accurate than those based on the fixed effects model. This is borne out by the results of a further simulation experiment with an increased number of subjects in each set of data. The difference in the interpretation of the parameters of the fixed and mixed effects models is discussed. It is demonstrated that the mixed effects model and parameter estimates can be used to estimate the parameters of the fixed effects model but not vice versa.

Interpretation and Optimization of the Dissolution Specifications for a Modified Release Product with an In Vivo–In Vitro Correlation (IVIVC)

This article considers the in vivo significance attached to in vitro dissolution testing. Almost invariably, the in vitro dissolution test is interpreted in terms of bioequivalence. The literature that describes methods for setting in vitro dissolution specifications is reviewed. The most common interpretation of these specifications is a deterministic one, that is, those batches passing the dissolution specifications would be bioequivalent with the reference if tested in vivo and those failing the dissolution specifications would not be bioequivalent if tested in vivo. Due to random variation, the deterministic interpretation is not appropriate. Instead, we need to consider the conditional probability that a batch that has passed the in vitro dissolution test would demonstrate bioequivalence if tested in vivo, and that a batch known to have failed the in vitro dissolution test would demonstrate bioinequivalence if tested in vivo. One way to estimate these probabilities is by means of a simulated experiment in which the production and testing (in vivo and in vitro) of a large number of batches is computer simulated. Such a simulation can only be performed if the relationship between the in vitro dissolution characteristics and the in vivo performance of the product has been modeled. These models are generally referred to as in vivo-in vitro correlations (IVIVC). The results of one such experiment are described. The above-mentioned conditional probabilities are shown to depend on the choice of dissolution specifications. This result leads to the notion of optimal dissolution specifications. However, both of the conditional probabilities cannot be maximized simultaneously. The probability of making a correct decision on the basis of the in vitro dissolution test is introduced as a possible optimality criterion. This probability is a linear combination of the two conditional probabilities of interest. Using this criterion, the optimal dissolution specifications can be found by searching over the multidimensional space defined by the half width of each interval used in the specifications to find the combination that maximizes this probability. This process is demonstrated using the Nelder-Mead search routine. The choice of dissolution specifications has profound implications for the routine production of the product because if the specifications were very narrow the probability of a batch passing would be low, resulting in a low hit rate. The same computer program used to perform the simulation experiment can be used to estimate the hit rate. Furthermore, it can be used to explore the magnitude of changes required in the parameters describing the test product (particularly variability) to increase a low hit rate to an acceptable level.

Dose-response effects of a novel fat emulsion (Olibra) on energy and macronutrient intakes up to 36 h post-consumption

OBJECTIVE

To investigate the dose-response effects of a novel fat emulsion (Olibra) on energy and macronutrient intakes up to 36 h post-consumption in non-overweight subjects.

DESIGN

A single-blind, placebo-controlled, within-subject cross-over design was used.

SETTING

Metabolic suite of the University of Ulster, Coleraine.

SUBJECTS

Fifty subjects (30 female, 20 male) from the student and staff population of the University of Ulster, Coleraine.

INTERVENTIONS

Subjects were given in random order, 7 days apart, a 200 g portion of yoghurt containing a total of 15 g of fat, which varied in quantity of Olibra fat (0, 2, 4, 6 g) at 09:00 h. At 13:00 h subjects were given ad libitum access to a range of foods. Amounts of food consumed were measured by covert pre- and post-consumption weighing of individual serving dishes. For the remainder of the day and the following 24 h, subjects weighed and recorded all food intakes.

RESULTS

Relative to the control yoghurt, mean energy (7.42 vs 5.83, 5.60, 5.24 MJ), fat (97.4 vs 74.4, 74.2, 67.5 g; 48.8 vs 46.8, 48.9, 47.6% energy), protein (59.1 vs 50.0, 44.0, 40.8 g; 13.2 vs 13.9, 12.9, 12.8% energy), and carbohydrate (171.5 vs 140.9, 130.2, 126.0 g; 38.0 vs 39.3, 38.2, 39.6% energy), intakes were progressively reduced with increasing doses of Olibra fat in the total group (P<0.001). A similar response was observed in the female group up to 4 g (P<0.001) and in the male group after 2 and 6 g (P<0.05). Energy and macronutrient intakes for the remainder of each study day and over the following 24 h were significantly lower after all dose levels compared to the control (P<0.001).

CONCLUSION

The results suggest that Olibra fat reduced the effect of overeating during an ad libitum lunch meal and subsequent food intake up to 36 h post-consumption.

The effects of yoghurt containing a novel fat emulsion on energy and macronutrient intakes in non-overweight, overweight and obese subjects

OBJECTIVE

To investigate the effects of a yoghurt containing a novel fat emulsion on energy and macronutrient intakes up to 8 h post-consumption in non-overweight, overweight and obese subjects, and to assess energy compensation over the following 24 h.

DESIGN

A double-blind, placebo-controlled, within-subject crossover design was used. Twenty (10 female, 10 male) non-overweight (body mass index (BMI) 20-24.9 kg/m(2)), 20 (10 female, 10 male) overweight (BMI 25-29.9 kg/m(2)) and 20 (13 female, 7 male) obese (BMI>30 kg/m(2)) subjects participated in the study. Subjects were given in random order, 7 days apart, either a 200 g portion of a test (5 g of a novel fat emulsion+1 g milk fat) or control (6 g milk fat) yoghurt at 09:00 h. At 4 and 8 h post-consumption subjects were given ad libitum access to a range of foods. Amounts of food consumed were determined by pre and post-covert weighing of individual serving dishes. Over the following 24 h subjects weighed and recorded all food intakes.

RESULTS

Mean energy intakes were significantly lower after the test yoghurt compared with the control yoghurt in non-overweight (3.79 vs 5.43 MJ; P<0.01) and overweight (4.43 vs 6.12 MJ; P<0.001) subjects 4 h post-consumption and in non-overweight (3.82 vs 5.38 MJ; P<0.001), overweight (3.94 vs 5.80 MJ; P<0.001) and obese (4.91 vs 6.26 MJ; P<0.01) subjects 8 h post-consumption. The corresponding macronutrient intakes were also significantly reduced in non-overweight and overweight subjects (P<0.01) at 4 h post-consumption and in all subjects 8 h post-consumption (P<0.01). In the total group, energy intakes over the following 24 h were also significantly reduced (6.35 vs 7.70 MJ; P<0.01) after the test yoghurt relative to the control yoghurt.

CONCLUSIONS

These results suggest that the effects of this novel fat emulsion are maintained at least up to 8 h and are evident in non-overweight, overweight and obese subjects.

Does plasma HIV RNA predict outcome in a cohort of treated HIV-infected individuals followed over 3 years?

BACKGROUND

Despite reductions in AIDS illness and mortality, it is increasingly apparent that a significant proportion of individuals treated with combination antiretroviral (cARV) therapy have continuing or recrudescent HIV RNA in plasma. The predictive value of plasma HIV RNA in treated individual remains uncertain and rates of and risk factors for adverse outcomes such as hospitalisation, opportunistic infections and deaths are needed.

OBJECTIVES

The objectives of this study were to establish a retrospective cohort of individuals treated with cARVs, to assess factors associated with detectable HIV RNA and to determine rates of and risk factors for hospitalisation, opportunistic infection and mortality over 3 years of follow-up.

STUDY DESIGN

All individuals treated at The Alfred Hospital, Melbourne, Victoria between January and June 1997 who had had plasma HIV RNA measured were included in the retrospective cohort. Clinical, virological and hospitalisation data were recorded and validated by cross-reference with electronically stored laboratory, hospital activity and state notification databases. Outcome was assessed at October 2000.

RESULTS

Amongst the 555 individuals tested, 438 (60.7%) had detectable (>500 copies/ml) HIV RNA (bDNA assay, version 2) at baseline. The overall mortality rate was 5.5 per 100 person years; the AIDS rate 1.99 per 100 person years and hospitalisation rate 16.4 per 100 person years. Risk factors for death in this population identified by univariate analysis were HIV RNA concentration at baseline and at follow-up October 2000, nadir and most recent CD4 lymphocyte number, not receiving cARV as initial treatment, total number of ARV agents and number of changes in ARV per year, developing AIDS and being hospitalised during follow-up. In a multivariate model, the most recent CD4 lymphocyte number, the number of different ARVs per year and having more than one hospitalisation remained predictive of death.

CONCLUSIONS

HIV RNA remained detectable in the majority (60.7%) of this treatment-experienced population over 3 years, yet mortality rate remained relatively low at 5.5 per 100 person years. Factors associated with death were immunological (CD4 lymphocyte number) and treatment related (numbers of changes of ARV and hospitalisation) rather than virological (HIV RNA) in this cohort. We believe hospitalisation rates may be a useful marker of HIV disease in cARV treated populations and may identify groups at risk of poorer outcome and in need of intervention.

Mal (MyD88-adapter-like) is required for Toll-like receptor-4 signal transduction

The recognition of microbial pathogens by the innate immune system involves Toll-like receptors (TLRs), which recognize pathogen-associated molecular patterns. Different TLRs recognize different pathogen-associated molecular patterns, with TLR-4 mediating the response to lipopolysaccharide from Gram-negative bacteria. All TLRs have a Toll/IL-1 receptor (TIR) domain, which is responsible for signal transduction. MyD88 is one such protein that contains a TIR domain. It acts as an adapter, being involved in TLR-2, TLR-4 and TLR-9 signalling; however, our understanding of how TLR-4 signals is incomplete. Here we describe a protein, Mal (MyD88-adapter-like), which joins MyD88 as a cytoplasmic TIR-domain-containing protein in the human genome. Mal activates NF-kappaB, Jun amino-terminal kinase and extracellular signal-regulated kinase-1 and -2. Mal can form homodimers and can also form heterodimers with MyD88. Activation of NF-kappaB by Mal requires IRAK-2, but not IRAK, whereas MyD88 requires both IRAKs. Mal associates with IRAK-2 by means of its TIR domain. A dominant negative form of Mal inhibits NF-kappaB, which is activated by TLR-4 or lipopolysaccharide, but it does not inhibit NF-kappaB activation by IL-1RI or IL-18R. Mal associates with TLR-4. Mal is therefore an adapter in TLR-4 signal transduction.

In vivo-in vitro correlation (IVIVC) modeling incorporating a convolution step

The purpose of in vivo-in vitro correlation (IVIVC) modeling is described. These models are usually fitted to deconvoluted data rather than the raw plasma drug concentration/time data. Such a two-stage analysis is undesirable because the deconvolution step is unstable and because the fitted model predicts the fraction of a dosage unit dissolved/absorbed in vivo which generally is not the primary focus of our attention. Interest usually centers on the plasma drug concentration or some function of it (e.g., AUC, Cmax). Incorporation of a convolution step into the model overcomes these difficulties. Odds, hazards, and reversed hazards models which include a convolution step are described. The identity model (which states that average in vivo and in vitro dissolution/time curves are coincident or directly superimposable) is a special case of these models. The odds model and the identity model were fitted to data sets for two different products using nonlinear mixed effects model fitting software. Results show that the odds model describes both data sets reasonably well and is a significantly better fit than the identity model in each case.

Monocytes harbour replication-competent, non-latent HIV-1 in patients on highly active antiretroviral therapy

OBJECTIVE

To determine whether HIV-1 can be recovered from blood monocytes as well as resting, memory CD4 T lymphocytes of patients on highly active antiretroviral therapy (HAART) with undetectable plasma viraemia and whether infection is active or latent.

DESIGN

Five patients with plasma HIV-1-RNA levels of less than 500 copies/ml for at least 3 months and less than 50 copies/ml at the time of sampling were initially selected, followed by an additional five patients with viral loads of less than 50 copies/ml for 3 months or more.

METHODS

Monocytes were isolated from blood by plastic adherence, then further purified by a second adherence step or CD3 depletion before co-culture with CD8-depleted donor peripheral blood mononuclear cells. Virus isolates were examined for mutations conferring resistance to reverse transcriptase or protease inhibitors and for genotype. The highly purified monocytes were also analysed for the presence of proviral and unintegrated viral DNA and multiply spliced (MS) viral mRNA by polymerase chain reaction.

RESULTS

Virus was recovered from monocytes of five patients. Sequencing of the recovered viruses did not reveal multiple drug resistance, and was consistent with a non-syncytium-inducing/CCR5 phenotype. Proviral DNA was detectable in monocytes from all subjects, and unintegrated HIV-1 DNA and MS RNA was found in four out of five populations examined.

CONCLUSION

Recovery of replication-competent virus from some HAART patients indicates that monocytes can also harbour HIV-1. Detection of circular, viral DNA and spliced RNA, albeit at very low levels, in these cells suggests that their infection is recent and transcriptionally active rather than latent.

Short-term effects of yoghurt containing a novel fat emulsion on energy and macronutrient intakes in non-obese subjects

BACKGROUND

The satiating properties of fat remain poorly understood, particularly with reference to its physicochemical characteristics.

OBJECTIVE

To investigate the short-term effects of consumption of yoghurt containing either a novel fat emulsion or normal milk fat, on the energy and macronutrient intakes of non-obese subjects.

DESIGN

Two double-blind, placebo-controlled, within-subject crossover studies were conducted three months apart. Twenty-nine (15 F, 14 M) and thirty (16 F, 14 M) subjects participated in Study 1 and Study 2 respectively. In each study, subjects were given in random order, 7 days apart, either a 200g portion of a test (5g of a novel fat emulsion + 1 g milk fat) or control (6g milk fat) yoghurt at 1300 h. At 4h post-consumption subjects were given ad libitum access to a range of foods. Amounts of food consumed by individuals were determined by pre- and post-covert weighing of individual serving dishes.

RESULTS

Mean energy intakes were significantly lower after the test yoghurt compared with the control yoghurt in Study 1 (6.4 vs 7.6 MJ; P< 0.001), Study 2 (6.9 vs 7.9 MJ; P<0.001), and for both studies combined (6.7 vs 7.7 MJ; P<0.001). The corresponding fat intakes in Study 1, Study 2 and in the combined studies were all significantly reduced (P< 0.001). Protein and carbohydrate intakes were also significantly reduced in Study 1 (P< 0.05), Study 2 (P< 0.01), and for the combined studies (P< 0.001).

CONCLUSIONS

These results suggest that the physicochemical characteristics of small amounts of dietary fat affect short-term satiety.

Studies on the specificity of the tetrapyrrole substrate for human biliverdin-IXalpha reductase and biliverdin-IXbeta reductase. Structure-activity relationships define models for both active sites

A comparison of the initial rate kinetics for human biliverdin-IXalpha reductase and biliverdin-IXbeta reductase with a series of synthetic biliverdins with propionate side chains "moving" from a bridging position across the central methene bridge (alpha isomers) to a "gamma-configuration" reveals characteristic behavior that allows us to propose distinct models for the two active sites. For human biliverdin-IXalpha reductase, as previously discussed for the rat and ox enzymes, it appears that at least one "bridging propionate" is necessary for optimal binding and catalytic activity, whereas two are preferred. All other configurations studied were substrates for human biliverdin-IXalpha reductase, albeit poor ones. In the case of mesobiliverdin-XIIIalpha, extending the propionate side chains to hexanoate resulted in a significant loss of activity, whereas the butyrate derivative retained high activity. For human biliverdin-IXalpha reductase, we suggest that a pair of positively charged side chains play a key role in optimally binding the IXalpha isomers. In the case of human biliverdin-IXbeta reductase, the enzyme cannot tolerate even one propionate in the bridging position, suggesting that two negatively charged residues on the enzyme surface may preclude productive binding in this case. The flavin reductase activity of biliverdin-IXbeta reductase is potently inhibited by mesobiliverdin-XIIIalpha and protohemin, which is consistent with the hypothesis that the tetrapyrrole and flavin substrate bind at a common site.

Sociodemographic determinants of perceived influences on food choice in a nationally representative sample of Irish adults

OBJECTIVE

To identify the most important motivations for food choice from the point of view of the consumer in the Irish population, and to characterize those subjects who do and do not regard nutrition as a significant consideration in food choice.

DESIGN

As part of a pan-European Union (EU) survey on consumer attitudes to food, nutrition and health, a quota-controlled, nationally representative sample of Irish adults (n = 1009) aged 15 years upwards, completed an interview-assisted, close-ended questionnaire. Subjects selected three factors, from a list of 15, which they believed had the greatest influence on their food choice.

SETTING

The interviews for the survey were conducted in subjects' homes.

RESULTS

'Quality/freshness of food' was the most frequently selected food choice factor (51%) followed by 'taste' (43%) and 'trying to eat a healthy diet' (36%). Female gender, increasing age and higher levels of education were found to be independent sociodemographic factors affecting the selection of 'trying to eat a healthy diet' as an important factor in food choice.

CONCLUSIONS

Although included in the top five most frequently selected factors affecting food choice, nutrition/healthy eating does not appear to have top priority for the majority of Irish adults. There are differences between the various sociodemographic groups within the population; males and younger subjects appear to require specific nutrition promotion messages.

Enhancing the capacity of food consumption surveys of short duration to estimate long-term consumer-only intakes by combination with a qualitative food frequency questionnaire

In principle, a proper risk assessment for a food chemical requires that the time-frame for food chemical intake estimates matches the time-frame for the toxicological assessments upon which the safety statements (ADI, PTWI, etc.) are based. For food additives, the toxicological assessments are based on exposure over a lifetime. While food consumption data cannot be collected over the lifetimes of individuals, the information should reflect habitual intakes as closely as possible. This study investigated the possibility of combining a 3-day food diary with a food frequency questionnaire to estimate mean consumer-only food intakes comparable to estimates based on a 14-day diary. The study population consisted of 948 teenagers and analysis was based on 32 clearly defined foods. For 47% of the foods, the difference was < or = 1 g/day. When expressed as portion sizes, 56% of the foods showed differences representing < 5% of an average portion and no food showed a difference > 14% of an average portion. When between-method differences (portions/day) were plotted against the mean of the methods, the mean between-method difference was 0.02(+/- 0.06) portions/day with limits of agreement of -0.10 to 0.14. This preliminary investigation suggests that the combined 3-day diary and FFQ method provides comparable estimates of mean consumer only intakes to a 14-day diary. Therefore, a qualitative FFQ may be a useful adjunct to a food consumption survey of short duration if estimates of longer term food intakes are required.

Adolescent males' experience of the counselling process

This study examines 11 adolescent males' self-reports of their experiences of 23 counselling sessions to identify what they found helpful and unhelpful during key moments in the therapeutic process. The findings suggest that the experiences of the adolescent males in this study are similar in many ways to the to the reported experiences of adults in counselling. In particular, the experience of emotional support and relief appears to be highly significant for adolescent males, who give significantly lesser importance to cognitive task factors.

The influence of survey duration on estimates of food intakes and its relevance for public health nutrition and food safety issues

OBJECTIVE

To examine the influence of food consumption survey duration on estimates of percentage consumers, mean total population intakes and intakes among consumers only and to consider its relevance for public health nutrition and food safety issues.

DESIGN

Prospective food consumption survey.

SETTING

A multicentre study in five centres in the European Union-Dublin, Ghent, Helsinki, Potsdam and Rome.

SUBJECTS

Teenage subjects were recruited through schools; 948 (80%) out of 1180 subjects completed the survey.

INTERVENTIONS

14-day food diaries were used to collect the food consumption data.

RESULTS

For mean total population intakes, 53% of the foods had slopes significantly different to 0 (P<0.05). In practical terms (g/day), these differences were small, with 41% of foods having differences of </=1 g/day and a further 35% having differences of 1-5 g/day. Estimates of percentage consumers based on 3 days and 14 days were 1.9 and 3.6 times the 1-day estimate, respectively. For 72% of foods, at least 50% of non-consumers on day 1 became consumers over the subsequent 13 days. Estimates of mean consumer only intakes based on 3 days and 14 days were 53% and 32% of the 1 day value.

CONCLUSION

In practical terms, survey duration influences estimates of percentage consumers and intakes among consumers only but not mean total population intakes. Awareness of this influence is important for improved interpretation of dietary data for epidemiological studies, development of food-based dietary guidelines and food chemical intakes.

SPONSORSHIP

The Institute of European Food Studies, a non-profit research organization based in Trinity College Dublin. European Journal of Clinical Nutrition (2000) 54, 166-173

Dietary antioxidant supplementation and DNA damage in smokers and nonsmokers

Deficiencies of antioxidant nutrients have been implicated in the etiology of lung and other cancers. However, most intervention trials with antioxidant nutrients have not shown beneficial effects, and some have indicated that beta-carotene may be deleterious. This randomized, double-blind, placebo-controlled study evaluated the effects of five short-term (4-wk) antioxidant nutrient supplement regimens [ascorbic acid (350 mg), RRR-alpha-tocopherol (250 mg), beta-carotene (60 mg), selenium (80 micrograms as sodium selenite), ascorbic acid (350 mg) + RRR-alpha-tocopherol (250 mg)] on plasma antioxidants and mononuclear leukocyte DNA damage in male smokers (n = 9) and nonsmokers (n = 12). Plasma concentrations of ascorbic acid and tocopherol were significantly increased by supplementation, but there was no significant change in plasma beta-carotene or blood glutathione peroxidase activity after supplementation with beta-carotene or selenium. DNA damage in mononuclear leukocytes, as assessed by comet assay, was not affected by any supplementation regimen. DNA damage, as assessed by 8-hydroxydeoxyguanosine in mononuclear leukocytes, was not influenced by ascorbic acid, alpha-tocopherol, or selenium supplementation in smokers or nonsmokers, but beta-carotene supplementation resulted in significant differences between smokers and nonsmokers in the level of oxidative DNA damage, with decreases in smokers and increases in smokers. This is a further indication of the differential effects of supplemental beta-carotene in smokers and nonsmokers.

A new approach to modelling the relationship between in vitro and in vivo drug dissolution/absorption

A major goal of the pharmaceutical scientist is finding a relationship between an in vitro characteristic of an oral dosage form and its in vivo performance. One such relationship between drug dissolution (or absorption) in vivo and that in vitro is known as an 'in vitro-in vivo correlation' (IVIVC) whose importance stems from the fact that it may be used to minimize the number of human studies required during product development, assist in setting meaningful in vitro dissolution specifications and justify biowaivers for scale-up and post approval changes. A number of ways of describing an IVIVC have been reported with 'level A' being the most informative and therefore most desirable. In the majority of cases reported to date, both the model and the statistical methods employed for level A IVIVC are very simplistic. The model assumes that the rate and extent of dissolution in vivo are the same as those in vitro. The statistical methods ignore the repeated measures nature of the data and use a response variable as an independent variable without accounting for measurement error. This paper describes some new models which include the simple model as a special case. The modelling approach is based on considering the time at which a drug molecule enters solution (in vitro or in vivo) to be a random variable. The in vitro and in vivo distributions are then related to one another using a proportional odds, proportional hazards or proportional reversed hazards model. The models can be extended by adding a linear time component which describes a time varying relationship. Following the addition of random effects to these structural models in order to account for the repeated measures nature of the data collected, the models may be described as generalized linear mixed effects models. The models were fitted to some data sets using a maximum likelihood based method and the results indicate that these models have potential for describing an in vitro-in vivo relationship which cannot be described using the currently available models.

Functional domains of Tat required for efficient human immunodeficiency virus type 1 reverse transcription

Tat expression is required for efficient human immunodeficiency virus type 1 (HIV-1) reverse transcription. In the present study, we generated a series of 293 cell lines that contained a provirus with a tat gene deletion (Deltatat). Cell lines that contained Deltatat and stably transfected vectors containing either wild-type tat or a number of tat mutants were obtained so that the abilities of these tat genes to stimulate HIV-1 gene expression and reverse transcription could be compared. tat genes with mutations in the amino terminus did not stimulate either viral gene expression or HIV-1 reverse transcription. In contrast, tat mutants in the activation, core, and basic domains of Tat did not stimulate HIV-1 gene expression but markedly stimulated HIV-1 reverse transcription. No differences in the levels of virion genomic RNA or tRNA3Lys were seen in the HIV-1 Deltatat viruses complemented with either mutant or wild-type tat. Finally, overexpression of the Tat-associated kinases CDK7 and CDK9, which are involved in Tat activation of HIV-1 transcription, was not able to complement the reverse transcription defects associated with the lack of a functional tat gene. These results indicate that the mechanism by which tat modulates HIV-1 reverse transcription is distinct from its ability to activate HIV-1 gene expression.