Efficacy, safety, tolerability, and pharmacokinetics of long-acting injectable cabotegravir for HIV pre-exposure prophylaxis in transgender women: a secondary analysis of the HPTN 083 trial

BACKGROUND

The HIV Prevention Trials Network (HPTN) 083 trial showed that long-acting injectable cabotegravir was more effective than tenofovir disoproxil fumarate plus emtricitabine in preventing HIV in cisgender men and transgender women who have sex with men. We aimed to characterise the cohort of transgender women included in HPTN 083.

METHODS

HPTN 083 is an ongoing, phase 2b/3, randomised, multicentre, double-blind, double-dummy clinical trial done at 43 sites in seven countries (Argentina, Brazil, Peru, the USA, South Africa, Thailand, and Viet Nam). HIV-negative participants were randomly assigned (1:1) to receive injectable cabotegravir or tenofovir disoproxil fumarate plus emtricitabine. The study design and primary outcomes of the blinded phase of HPTN 083 have already been reported. An enrolment minimum of 10% transgender women was set for the trial. Here we characterise the cohort of transgender women enrolled from Dec 6, 2016, to May 14, 2020, when the study was unblinded. We report sociodemographic characteristics, use of gender affirming hormone therapy, and behavioural assessments of the transgender women participants. Laboratory testing and safety evaluations are also reported. The trial is registered at ClinicalTrials.gov, NCT02720094.

FINDINGS

HPTN 083 enrolled 570 transgender women (304 tenofovir disoproxil fumarate plus emtricitabine; 266 injectable cabotegravir). Transgender women were primarily from Asia (225 [39%]) and Latin America (205 [36%]); 330 (58%) reported using gender affirming hormone therapy. Intimate partner violence was common (270 [47%] reported emotional abuse and 172 [30%] reported physical abuse) and 323 (57%) reported a history of childhood sexual abuse. 159 (28%) transgender women disagreed that they were at risk for HIV, and 142 (25%) screened positive for depressive symptoms. During study follow-up, incidence of syphilis was 16·25% (95% CI 13·28-19·69), rectal gonorrhoea was 11·66% (9·14-14·66), and chlamydia was 20·61% (17·20-24·49). Frequency of adverse events was similar between the treatment groups. Nine seroconversions occurred among transgender women during the blinded phase of the study (seven in the tenofovir disoproxil fumarate plus emtricitabine group and two in the injectable cabotegravir group); overall incidence was 1·19 per 100 person-years (95% CI 0·54-2·25): 1·80 per 100 person-years (0·73-3·72) in the tenofovir disoproxil fumarate plus emtricitabine group and 0·54 per 100 person-years (0·07-1·95) in the injectable cabotegravir group (hazard ratio 0·34 [95% CI 0·08-1·56]). Cabotegravir concentrations did not differ by gender affirming hormone therapy use.

INTERPRETATION

HIV prevention strategies for transgender women cannot be addressed separately from social and structural vulnerabilities. Transgender women were well represented in HPTN 083 and should continue to be prioritised in HIV prevention studies. Our results suggest that injectable cabotegravir is a safe and effective pre-exposure prophylaxis option for transgender women.

FUNDING

National Institute of Allergy and Infectious Diseases and ViiV Healthcare.

Cabotegravir for HIV Prevention in Cisgender Men and Transgender Women

BACKGROUND

Safe and effective long-acting injectable agents for preexposure prophylaxis (PrEP) for human immunodeficiency virus (HIV) infection are needed to increase the options for preventing HIV infection.

METHODS

We conducted a randomized, double-blind, double-dummy, noninferiority trial to compare long-acting injectable cabotegravir (CAB-LA, an integrase strand-transfer inhibitor [INSTI]) at a dose of 600 mg, given intramuscularly every 8 weeks, with daily oral tenofovir disoproxil fumarate-emtricitabine (TDF-FTC) for the prevention of HIV infection in at-risk cisgender men who have sex with men (MSM) and in at-risk transgender women who have sex with men. Participants were randomly assigned (1:1) to receive one of the two regimens and were followed for 153 weeks. HIV testing and safety evaluations were performed. The primary end point was incident HIV infection.

RESULTS

The intention-to-treat population included 4566 participants who underwent randomization; 570 (12.5%) identified as transgender women, and the median age was 26 years (interquartile range, 22 to 32). The trial was stopped early for efficacy on review of the results of the first preplanned interim end-point analysis. Among 1698 participants from the United States, 845 (49.8%) identified as Black. Incident HIV infection occurred in 52 participants: 13 in the cabotegravir group (incidence, 0.41 per 100 person-years) and 39 in the TDF-FTC group (incidence, 1.22 per 100 person-years) (hazard ratio, 0.34; 95% confidence interval, 0.18 to 0.62). The effect was consistent across prespecified subgroups. Injection-site reactions were reported in 81.4% of the participants in the cabotegravir group and in 31.3% of those in the TDF-FTC group. In the participants in whom HIV infection was diagnosed after exposure to CAB-LA, INSTI resistance and delays in the detection of HIV infection were noted. No safety concerns were identified.

CONCLUSIONS

CAB-LA was superior to daily oral TDF-FTC in preventing HIV infection among MSM and transgender women. Strategies are needed to prevent INSTI resistance in cases of CAB-LA PrEP failure. (Funded by the National Institute of Allergy and Infectious Diseases and others; HPTN 083 ClinicalTrials.gov number, NCT02720094.).

Fundamental dissipation due to bound fermions in the zero-temperature limit

The ground state of a fermionic condensate is well protected against perturbations in the presence of an isotropic gap. Regions of gap suppression, surfaces and vortex cores which host Andreev-bound states, seemingly lift that strict protection. Here we show that in superfluid 3He the role of bound states is more subtle: when a macroscopic object moves in the superfluid at velocities exceeding the Landau critical velocity, little to no bulk pair breaking takes place, while the damping observed originates from the bound states covering the moving object. We identify two separate timescales that govern the bound state dynamics, one of them much longer than theoretically anticipated, and show that the bound states do not interact with bulk excitations.

Comparison of thermal imaging and rectal temperature in the diagnosis of pyrexia in pre-weaned calves using on farm conditions

Measuring core body temperature is used as part of the diagnostic process in assessing the health of animals. Typically in calves, this is carried out using a rectal thermometer which can be time consuming, stressful to the calf and is invasive by nature. A non-invasive technique that is gaining recognition is thermal imaging. This study investigated the use of thermal imaging as a technique to assess core body temperature in pre-weaned artificially reared calves. A total of 125 male and female calves had rectal temperatures measured daily from day 7 until day 40 of life, and at the same time had a thermal image taken of the area around the medial canthus of the eye. A weak correlation (r = 0.28) was found between calf rectal temperature and thermal image temperature. A multivariable predictive model for core body temperature increased the correlation (r = 0.32) when including the environmental parameters of air temperature (p < .001) and wind speed (p < .001) as well as reconstituted milk replacer consumption (p < .01). The effectiveness of a predictive model including these parameters for the detection of calves with a core body temperature ≥ 39.5 °C was examined and found to have a sensitivity of 0% and a specificity of 100%. The results of this study demonstrate the need to take thermal environmental parameters into consideration when using thermal imaging to assess body temperature. However, the results suggest that accurate measures of core body temperature using thermal imaging cannot be achieved under commercial farm conditions. Further research is needed to determine what other factors could be measured to increase predictive ability.

Goodbye SIRS? Innate, trained and adaptive immunity and pathogenesis of organ dysfunction

The novel concepts within Sepsis‑3 criteria include a focus on dysregulated host responses, removal of the systemic inflammation response syndrome (SIRS) criteria from sepsis diagnosis, the use of Sepsis-related (Sequential) Organ Failure Assessment (SOFA) scores to define organ dysfunction, and the explicit recognition of the septic shock as a subset of sepsis. Protection against infection requires a surveillance system, an effector response against "perceived" pathogens, a method for regaining immune homeostasis following an immune response, and generation of immunological memory. In comparison to normally regulated responses to infection, the innate immune system shows profoundly abnormal neutrophil and macrophage function. Similarly, the adaptive immune system is typically depleted numerically of lymphocytes and functionally with T and B cell exhaustion. Although there are numerous proposed mechanisms by which these dysregulated immune responses may be associated with organ failure, it is unclear what the unifying organ failure mechanisms in sepsis are. Furthermore, in sepsis survivors, the epigenetic changes on immune cells and widespread changes to lymphocyte populations may increase the risk of adverse events such as rehospitalisation and mortality. Finally, our current gaps in understanding of the immune response trajectory and the associated modifiable mechanisms in sepsis leave us a long way from successful immunomodulation for these patients. This article is freely available.

Cross-Sectional Associations Between Dietary Antioxidant Vitamins C, E and Carotenoid Intakes and Sarcopenic Indices in Women Aged 18-79 Years

The prevalence of sarcopenia is increasing in aging populations, so prevention is critical. Vitamins (A, C, E and carotenoids) modify skeletal muscle via protein and collagen synthesis and anti-inflammatory activities. Previous studies have not investigated intake of these vitamins in relation to sarcopenic indices in both younger and older-aged women. Indices of skeletal muscle mass (as fat-free mass (FFM) relative to body size) were measured using DXA and leg explosive power (LEP) using the Nottingham Power Rig in 2570 women aged 18-79 years. Adjusted measures of skeletal muscle were calculated according to quintiles of vitamin C, E, retinol and carotenoid intake, derived from Food Frequency Questionnaires, after stratification by age. Higher vitamin C intake was associated with significantly higher indices of FFM and LEP, (Q5-Q1 = 2.0-12.8%, P < 0.01-0.02). Intakes of total and individual carotenoids were significantly associated with indices of FFM and LEP (Q5-Q1 = 1.0-7.5%). Vitamin E was significantly associated with FFM% and FFM_BMI only. In mutually adjusted analysis with vitamin C, total carotene, vitamin E and protein in the model, the strongest associations were with vitamin C. These associations were stronger in younger women (< 65 years). For the first time, our research shows higher dietary intakes of antioxidant vitamins, particularly vitamin C, is associated with higher skeletal muscle mass and power in free-living women. These findings have relevance for the treatment and prevention of frailty and sarcopenia throughout adulthood.

Untangling the relationship between diet and visceral fat mass through blood metabolomics and gut microbiome profiling

BACKGROUND/OBJECTIVES

Higher visceral fat mass (VFM) is associated with an increased risk for developing cardio-metabolic diseases. The mechanisms by which an unhealthy diet pattern may influence visceral fat (VF) development has yet to be examined through cutting-edge multi-omic methods. Therefore, our objective was to examine the dietary influences on VFM and identify gut microbiome and metabolite profiles that link food intakes to VFM.

SUBJECTS/METHODS

In 2218 twins with VFM, food intake and metabolomics data available we identified food intakes most strongly associated with VFM in 50% of the sample, then constructed and tested the 'VFM diet score' in the remainder of the sample. Using linear regression (adjusted for covariates, including body mass index and total fat mass), we investigated associations between the VFM diet score, the blood metabolomics profile and the fecal microbiome (n=889), and confirmed these associations with VFM. We replicated top findings in monozygotic (MZ) twins discordant (⩾1 s.d. apart) for VFM, matched for age, sex and the baseline genetic sequence.

RESULTS

Four metabolites were associated with the VFM diet score and VFM: hippurate, alpha-hydroxyisovalerate, bilirubin (Z,Z) and butyrylcarnitine. We replicated associations between VFM and the diet score (beta (s.e.): 0.281 (0.091); P=0.002), butyrylcarnitine (0.199 (0.087); P=0.023) and hippurate (-0.297 (0.095); P=0.002) in VFM-discordant MZ twins. We identified a single species, Eubacterium dolichum to be associated with the VFM diet score (0.042 (0.011), P=8.47 × 10^-5), VFM (0.057 (0.019), P=2.73 × 10^-3) and hippurate (-0.075 (0.032), P=0.021). Moreover, higher blood hippurate was associated with elevated adipose tissue expression neuroglobin, with roles in cellular oxygen homeostasis (0.016 (0.004), P=9.82x10^-6).

CONCLUSIONS

We linked a dietary VFM score and VFM to E. dolichum and four metabolites in the blood. In particular, the relationship between hippurate, a metabolite derived from microbial metabolism of dietary polyphenols, and reduced VFM, the microbiome and increased adipose tissue expression of neuroglobin provides potential mechanistic insight into the influence of diet on VFM.

Simulation Training, Coaching, and Cue Cards Improve Delirium Care

A quality improvement study supports the use of multimodal education to enhance clinical practice for care of patients with delirium.

Measurements of skeletal muscle mass and power are positively related to a Mediterranean dietary pattern in women

The age-related loss of skeletal muscle and function are risk factors for osteoporosis and fractures. We found that higher adherence to the Mediterranean diet score was significantly associated with greater fat-free mass and leg explosive power suggesting a role for the Mediterranean Diet in prevention of loss of muscle outcomes.

INTRODUCTION

The loss of skeletal muscle mass, strength, and function with age are contributing risk factors for the onset of sarcopenia, frailty, osteoporosis, fractures, and mortality. Nutrition may affect the progression and trajectory of these changes in skeletal muscle but the role of the micronutrient-rich Mediterranean diet (MD) has hardly been investigated in relation to these muscle outcomes.

METHODS

We examined associations between the MD score (MDS) and FFM% (fat-free mass / weight × 100), FFMI (fat-free mass/height2), hand grip strength, and leg explosive power (LEP, watts/kg) in a cross-sectional study in 2570 women aged 18-79 years from the TwinsUK study. Measurements of body composition were made using dual-energy X-ray absorptiometry and dietary intake assessed by a food frequency questionnaire. FFM%, FFMI, grip strength, and LEP were compared across quartiles of the MDS after adjustment for covariates, with CRP measured in a subgroup (n = 1658).

RESULTS

Higher adherence to the MDS was positively associated with measurements of muscle outcomes, with significant differences of 1.7 % for FFM% and 9.6 % for LEP (P trend <0.001), comparing extreme quartiles of intake, but not with grip strength or CRP concentrations.

CONCLUSIONS

For the first time in a northern European population, we have observed significant positive associations between the MDS and FFM% and LEP in healthy women that are potentially clinically relevant, independent of the factors known to influence muscle outcomes. Our findings emphasize the potential role for overall diet quality based on the MD in the prevention of age-related loss of skeletal muscle outcomes.

Seroprevalence of respiratory viral pathogens of indigenous calves in Western Kenya

Most studies of infectious diseases in East African cattle have concentrated on gastro-intestinal parasites and vector-borne diseases. As a result, relatively little is known about viral diseases, except for those that are clinically symptomatic or which affect international trade such as foot and mouth disease, bluetongue and epizootic haemorrhagic disease. Here, we investigate the seroprevalence, distribution and relationship between the viruses involved in respiratory disease, infectious bovine rhinotracheitis virus (IBR), bovine parainfluenza virus Type 3 (PIV3) and bovine viral diarrhoea virus (BVDV) in East African Shorthorn Zebu calves. These viruses contribute to the bovine respiratory disease complex (BRD) which is responsible for major economic losses in cattle from intensive farming systems as a result of pneumonia. We found that calves experience similar risks of infection for IBR, PIV3, and BVDV with a seroprevalence of 20.9%, 20.1% and 19.8% respectively. We confirm that positive associations exist between IBR, PIV3 and BVDV; being seropositive for any one of these three viruses means that an individual is more likely to be seropositive for the other two viruses than expected by chance.

Assessing Oral Hygiene in Hospitalized Older Veterans

Poor oral health for all older adults can result in higher risk for heart disease, stroke, diabetes, and oral cancer. Findings from this study indicated older veterans needed to improve their oral hygiene habits but barriers to oral hygiene performance prevented them from receiving and performing oral hygiene measures.

Evaluation of a multidisciplinary Tier 3 weight management service for adults with morbid obesity, or obesity and comorbidities, based in primary care

A multidisciplinary Tier 3 weight management service in primary care recruited patients with a body mass index ≥40 kg·m(-2) , or 30 kg·m(-2) with obesity-related co-morbidity to a 1-year programme. A cohort of 230 participants was recruited and evaluated using the National Obesity Observatory Standard Evaluation Framework. The primary outcome was weight loss of at least 5% of baseline weight at 12 months. Diet was assessed using the two-item food frequency questionnaire, activity using the General Practice Physical Activity questionnaire and quality of life using the EuroQol-5D-5L questionnaire. A focus group explored the participants' experiences. Baseline mean weight was 124.4 kg and mean body mass index was 44.1 kg·m(-2) . A total of 102 participants achieved 5% weight loss at 12 months. The mean weight loss was 10.2 kg among the 117 participants who completed the 12-month programme. Baseline observation carried forward analysis gave a mean weight loss of 5.9 kg at 12 months. Fruit and vegetable intake, activity level and quality of life all improved. The dropout rate was 14.3% at 6 months and 45.1% at 1 year. Focus group participants described high levels of satisfaction. It was possible to deliver a Tier 3 weight management service for obese patients with complex co-morbidity in a primary care setting with a full multidisciplinary team, which obtained good health outcomes compared with existing services.

Rethinking unmet need: Determinants of contraceptive use in Santiago, the Dominican Republic

Inadequate access to contraceptives is often considered the primary source of unmet need among women who desire to prevent pregnancy. This study evaluates two potential determinants of contraceptive use among Dominican women: (1) perceived access to family planning and (2) perceived personal reproductive control, a measure based in psychological theories of locus of control. Sexually active women aged 18-45 who did not desire fertility were surveyed to assess influences on contraceptive use. In-depth interviews were conducted among a subset of participants to contextualise survey results. Fewer than half (49%) of the 80 survey respondents had used contraception in the last 3 months. Higher personal reproductive control was significantly related to contraceptive use (aOR 1.18, 95% CI 1.04-1.34), however, higher perceived access to contraceptives was not (aOR 1.09, 95% CI 0.97-1.23). Male partner influence was identified as a barrier to contraceptive use. In this population, high personal reproductive control is a better predictor of contraceptive use than perceived access.

A survey of environmental service workers' knowledge and opinions regarding environmental cleaning

Environmental service workers play an important role in the prevention of health care-associated infections. Environmental service workers working at a Veterans Administration Medical Center completed the Environmental Service Workers' Knowledge and Opinions Regarding Environmental Cleaning Survey. The findings from this survey suggest the need for further education of environmental service workers regarding the different types of pathogens that are spread by contaminated environmental surfaces and which of these are killed with bleach.

Association between diet and physical activity and sedentary behaviours in 9-10-year-old British White children

Objectives

To examine the association between diet and physical activity and sedentary behaviours in 9–10-year-old children.

Study design

A cross-sectional study using data from the SPEEDY (Sport, Physical activity and Eating behaviour: Environmental Determinants in Young People) study undertaken in Norfolk, UK.

Methods

Data from 4-day food diaries and 7 days of accelerometery were matched on concurrent days. Time spent in moderate-to-vigorous physical activity (MVPA), time spent in sedentary behaviour and various measures of dietary intake were collected. Covariates included age, sex, weight status, family socio-economic status, and energy intake reporting quality. Multivariable regression models, adjusted for clustering of children by school and stratified by sex, were fitted to examine the associations between dietary measures and physical activity and sedentary outcomes.

Results

In total, 1317 children (584 boys and 733 girls) provided concurrent data. Boys in the highest quartile of energy percentage from protein spent approximately 6 min [95% confidence interval (CI) 0–12] less in MVPA compared with boys in the lowest quartile. Those in the highest quartiles of fruit and vegetable intake and fruit juice intake had respective average activity counts per minute that were 56 above (95% CI 8–105) and 48 below (95% CI 2–95) those in the lowest quartiles, whilst those in the highest quartile of fizzy drink consumption spent approximately 7 min (95% CI 2–13) more in MVPA and approximately 14 min (95% CI 5–24 min) less in sedentary behaviour. Boys in the highest quartile of savoury snack consumption spent approximately 8 min (95% CI 2–13 min) more in MVPA per day, and approximately 12 min (95% CI 2–23) less in sedentary behaviour. No significant associations were apparent among girls.

Conclusions

Few associations were detected, and the directions of those that were apparent were mainly counterintuitive. The extent to which this reflects a true lack of association or is associated with the measurement methods used for diet and physical activity needs further investigation.

Gene delivery into neuronal and glial cells by using a replication-deficient adenovirus vector: prospects for neurological gene therapy

We have used a recombinant adenovirus vector (E1-) expressing β-galactosidase to explore a novel mechanism with which to transfer genes into cells of the central nervous system (CNS). The replication-deficient adenovirus vector expressing β-galactosidase (RAd35) was propagated on a permissive helper cell line (293 cells). High level protein expression from the human cytomegalovirus immediate early promoter (hCMV IE) was obtained in a target cell population of RAd35 infected cultured neuronal and glial cell lines. Light microscopy showed that over 50% of the glial cells studied expressed β-galactosidase. Following retinoic acid treatment, RAd35 infected cell lines ND7/23, NG108 and NTera2, showed β-galactosidase expression in up to 90% of the cells. In addition, these cells showed morphological evidence of differentiation into neurons. This pattern of β-galactosidase expression was also observed in primary rat cerebella granule neuron cultures. In vivo studies were performed in Balb/c mice following direct intracranial injections of RAd35 into the brain. Cell sections showed a localised staining in the brain at the site of injection of the virus. Non-replicating adenovirus vectors are therefore highly efficient systems for delivering a transgene into brain cells. However, their broad cell tropism may limit their applications for genetic disorders in which a specific cell type is to be targeted for gene therapy. To address this problem, we have constructed adenovirus vectors which contain specific neuronal promoters and are currently assessing in vitro expression.

Effect of pregnancy on emtricitabine pharmacokinetics

OBJECTIVES

The aim of the study was to describe emtricitabine pharmacokinetics during pregnancy and postpartum.

METHODS

The International Maternal Pediatric and Adolescent AIDS Clinical Trials (IMPAACT), formerly Pediatric AIDS Clinical Trials Group (PACTG), study P1026s is a prospective pharmacokinetic study of HIV-infected pregnant women taking antiretrovirals for clinical indications, including a cohort taking emtricitabine 200 mg once daily. Intensive steady-state 24-hour emtricitabine pharmacokinetic profiles were performed during the third trimester and 6-12 weeks postpartum, and on maternal and umbilical cord blood samples collected at delivery. Emtricitabine was measured by liquid chromatography-mass spectrometry with a quantification limit of 0.0118 mg/L. The target emtricitabine area under the concentration versus time curve, from time 0 to 24 hours post dose (AUC(0-24) ), was ≥7 mg h/L (≤30% reduction from the typical AUC of 10 mg h/L in nonpregnant historical controls). Third-trimester and postpartum pharmacokinetics were compared within subjects.

RESULTS

Twenty-six women had pharmacokinetics assessed during the third trimester (median 35 weeks of gestation) and 22 postpartum (median 8 weeks postpartum). Mean [90% confidence interval (CI)] emtricitabine pharmacokinetic parameters during the third trimester vs. postpartum were, respectively: AUC: 8.0 (7.1-8.9) vs. 9.7 (8.6-10.9) mg h/L (P = 0.072); apparent clearance (CL/F): 25.0 (22.6-28.3) vs. 20.6 (18.4-23.2) L/h (P = 0.025); 24 hour post dose concentration (C(24) ): 0.058 (0.037-0.063) vs. 0.085 (0.070-0.010) mg/L (P = 0.006). The mean cord:maternal ratio was 1.2 (90% CI 1.0-1.5). The viral load was <400 HIV-1 RNA copies/mL in 24 of 26 women in the third trimester, in 24 of 26 at delivery, and in 15 of 19 postpartum. Within-subject comparisons demonstrated significantly higher CL/F and significantly lower C(24) during pregnancy; however, the C(24) was well above the inhibitory concentration 50%, or drug concentration that suppresses viral replication by half (IC(50) ) in all subjects.

CONCLUSIONS

While we found higher emtricitabine CL/F and lower C(24) and AUC during pregnancy compared with postpartum, these changes were not sufficiently large to warrant dose adjustment during pregnancy. Umbilical cord blood concentrations were similar to maternal concentrations.

Nutritional practices in full-day-care pre-schools

BACKGROUND

Full-day-care pre-schools contribute significantly to the nutritional intake and acquisition of dietary habits of the pre-school child. The present study investigated nutritional practices in full-day-care pre-schools in Dublin, Ireland, aiming to determine the nutritional support that pre-school managers deem necessary, thereby facilitating the amelioration of existing pre-school nutritional training and practices.

METHODS

A telephone questionnaire completed by pre-school managers (n=54) examined pre-school dietary practices, food provision and the association between these and pre-school size, nutritional training attendance, possession of the Food and Nutrition Guidelines for Pre-school Services and having a healthy eating policy. Nutritional training needs were also investigated.

RESULTS

Twenty-five pre-schools provided all food for attending children; parents were sole providers in six. Thirty-four pre-schools had a written healthy eating policy. Attendance at nutritional training was reported by 40. Possession of the Guidelines (n=40) did not consistently result in their use. Poor parental and staff involvement in policy and menu development was cited. Although the delayed introduction of iron-containing foods and a feeding beaker in infants was clearly evident, inappropriate beverages and snacks were served to children aged 1-5 years in 43 and 37 pre-schools, respectively. Training priorities cited by managers included parental education and the provision of information regarding menu planning and healthy food choices.

CONCLUSIONS

Nutritional training should advocate whole staff familiarity with and use of current guidelines, in addition to encouraging nutritional policy development and enforcement. Parental education is warranted. Dietary education should focus specifically on appropriate weaning practices, healthy beverage and snack provision and menu planning.

To what degree is digital imaging reliable? Validation of femoral neck shaft angle measurement in the era of picture archiving and communication systems

OBJECTIVES

This study investigates the reliability of femoral neck shaft angle (NSA) measurements made with the software and images available in routine clinical practice.

METHODS

Using the Centricity Enterprise™ (GE Healthcare Pty Ltd Piscataway, NJ) picture archiving and communication system (PACS), the NSA of the proximal femur was measured from anteroposterior radiographs of adult hips. 3 independent observers, using a standardised technique, performed a total of 120 measurements.

RESULTS

The Pearson's correlation coefficient for the intraobserver agreement was 0.98 (p<0.01) and for interobserver measurements 0.86 (p<0.01). Bland-Altman plots revealed the limits of intraobserver agreement to be ±2.5°, but interobserver limits of agreement to be ±6°. The intraclass correlation coefficient (ICC) was also calculated. The interobserver ICC was 0.62 (0.42-0.78, 95% confidence interval (CI); p<0.001). The intraobserver ICC was 0.98 (0.95-0.99, 95% CI; p<0.001).

CONCLUSION

PACS software has many advantages, but when using systems that can display angle measurements to one-tenth of a degree caution must be exercised to ensure that reliability of these measurements is not overestimated. We found that in the context of measuring the NSA of the proximal femur the reliability of the measurement, even under the best conditions, is only ±6° for different observers.

Bolting and flowering control in sugar beet: relationships and effects of gibberellin, the bolting gene B and vernalization

BACKGROUND AND AIMS

Bolting, the first visible sign of reproductive transition in beets (Beta vulgaris), is controlled by the dominant bolting gene B (B allele), which allows for flowering under long days (LDs, >14 h light) without prior vernalization. The B-locus carries recessive alleles (bb) in sugar beet (Beta vulgaris L. spp. vulgaris), so that vernalization and LDs are required for bolting and flowering. Gibberellin growth hormones (GAs) control stem elongation and reproductive development, but their role during these processes in sugar beet is not defined. We aimed to investigate the involvement of GAs in bolting and flowering in sugar beet, and also its relationship with the vernalization requirement as defined by the B-gene.

METHODOLOGY

Plants segregating for the B allele were treated with exogenous GA(4) under inductive (16 h light) and non-inductive (8 h light) photoperiods, with and without prior vernalization treatment. A co-dominant polymerase chain reaction (PCR) marker was used to genotype the B-gene locus. Bolting and flowering dates were scored, and bolt heights were measured as appropriate. Analysis of variance was used to determine the effects and interactions of GAs, the B allele and vernalization on bolting and flowering. The effects of the B allele on bolting were also verified in the field.

PRINCIPAL RESULTS

Application of GAs or the B allele could initiate bolting independently. When the B allele was absent, the applied GAs promoted stem growth, but did so only in vernalized plants, irrespective of photoperiod. Under LDs, bolt height before flowering in plants carrying the B allele (BB; Bb) was not significantly influenced by GAs. The timing and frequency of flowering were influenced by the B allele without interactive effects from GAs.

CONCLUSIONS

In sugar beet, GA acts independently of the B allele and photoperiod to induce bolting. Vernalization enables GA action independently of the B allele; hence, the dominant B allele may not directly participate in vernalization-induced bolting.

Bowel habit, diet and body weight in preadolescent children

BACKGROUND

The possible influence of diet and body weight on bowel habit in children is unknown. The present study aimed to investigate the inter-relationships between bowel function, excess body weight and dietary intake in a group of preadolescent children.

METHODS

Eighty-four preadolescent children aged 7-10 years were recruited [mean (SD) age 9.7 (1.0) years]. All children completed a bowel habit diary, examining specific parameters of bowel function and a weighed food inventory concurrently for seven consecutive days. Height and weight measurements were also taken. Children were grouped according to whether they met dietary recommendations and by overweight status; differences in bowel function between the groups were then analysed.

RESULTS

Children who exceeded reference values for fat were more likely to report an incidence of straining to start (P = 0.005) and pain during defaecation (P = 0.021). Subjects who met protein recommendations were less likely to report incomplete evacuation (P = 0.000) and those who met zinc recommendations were less likely to report pain during defaecation (P = 0.044). Excess body weight (according to International Obesity Task Force cut-offs) was also associated with poor bowel habit, with overweight and obese children reporting lower defaecation frequency and a higher incidence of straining and feelings of incomplete evacuation, although these findings were not statistically significant. Defaecation frequency in healthy children was 1.4 defaecations per day compared to 1.2 defaecations for overweight and obese children.

CONCLUSION

A poor diet that fails to meet dietary recommendations as well as being overweight and obese appears to be associated with increased defaecation problems in preadolescent children.

Change of pathology request forms can reduce unwanted requests and tests

BACKGROUND

Developments in clinical and laboratory medical practice have resulted in a large increase in laboratory workload, with considerable financial implications. It has been shown that the design of laboratory request cards can influence patterns of test ordering and possibly reduce inappropriate requests.

AIMS/METHODS

To redesign pathology request cards with a view to reducing inappropriate test requesting.

RESULTS

A redesign of the request cards used by general practitioners in the Bradford area led to a significant reduction in the ordering of specific investigations.

CONCLUSIONS

The redesigning of pathology request cards can have a beneficial effect on test requesting.

Discovery Strategies in a BioPharmaceutical Startup: Maximising your Chances of Success Using Computational Filters

Small research-based pharmaceutical start-ups often lack the budget and do not have the infrastructure available to apply all possible techniques for compound selection. This review details our use of a range of techniques such as high-throughput docking and similarity searching to maximize the success rate when attempting to identify pharmaceutically relevant ligands in a resource-constrained environment.

Runway width effects in the visual approach to landing

The effect of changes in runway width on the perception of glide-slope has been the subject of extensive investigations. Despite considerable research, an explanation of this effect has been elusive. A mathematical model for glide-slope perception was published recently based on the premise that a desirable goal of perception is to form a perception with minimal uncertainty. One of the qualitative predictions of that model was that changes in the aspect ratio of the runway would affect the perceived glide-slope. In this article, the predictions of the model are quantified and are shown to be in close agreement with experimental results in the literature.

Novel (4-piperazin-1-ylquinolin-6-yl) arylsulfonamides with high affinity and selectivity for the 5-HT(6) receptor

The discovery of (4-piperazin-1-ylquinolin-6-yl) arylsulfonamides and their binding affinities for a selection of 5-HT and dopamine subreceptors is described. Many compounds show high affinity (pK(i)>8) for the 5-HT(6) receptor and >100-fold selectivity against a range of other receptors. Structure-activity relationships of these compounds are discussed.

Appropriate design of biochemistry request cards can promote the use of protocols and reduce unnecessary investigations

Attempts to control laboratory workload in the past always proved to be short-lived. We designed a request card based on clinical conditions for a gynaecology out-patient clinic to help clinical staff to adhere to agreed investigation protocols. Each request card had a tick-box associated with a clinical condition. The tests performed for each condition were advertised on a poster in the clinic. The workload was assessed for a 2-year period before and after the introduction of these cards. The numbers of all endocrine tests, except progesterone and sex hormone binding globulin, fell by 19% (P<0.0001) whereas the clinical cases seen remained steady at 227 per month. This report demonstrates that agreed protocols can be implemented but that a persistent aide-mémoire is necessary.

Evaluation of substernal goiters using computed tomography and MR imaging

Computed tomography and MR imaging are valuable techniques for determining the presence and extent of substernal goiters, their impingement on adjacent structures in the neck and chest, and whether mediastinal masses are thyroidal in origin. This article discusses the advantages and disadvantages of each technique and the radiologic characteristics of substernal goiters. Radiographic examples of both techniques are included to illustrate common clinical settings. Finally, suggestions for choosing which patients will benefit from scanning and which technique will safely provide the maximum information in various clinical settings are discussed.

Intravenous pulse methylprednisolone in the treatment of uveitis associated with multiple sclerosis

PURPOSE

To demonstrate the safety and effectiveness of intravenous methylprednisolone (IVMP) in the treatment of uveitis in association with multiple sclerosis (MS).

METHODS

Uveitis is an unusual manifestation of MS that may be severe, chronic and require systemic immunosuppression therapy. High-dose IVMP has previously been shown to be effective in the treatment of inflammatory eye disease and MS. Eight episodes of uveitis in five patients with MS were treated over a 10-year period in an open, uncontrolled trial. Two patients had chronic anterior uveitis, one patient had bilateral panuveitis and two patients had intermediate uveitis.

RESULTS

All patients responded to IVMP with evidence of a decrease in intraocular inflammatory activity and improved visual acuity (VA) within 2 weeks of commencing treatment. There were no severe ocular or systemic steroid side effects.

CONCLUSIONS

Intravenous methylprednisolone is an effective, well-tolerated form of therapy for uveitis in patients with MS.

The use of available social support networks by older blacks

Research has indicated that strong social networks positively influence the health of older Black adults. However, scales used in studies to measure social support do not reveal whether these networks are actually activated. The purpose of this descriptive study was to describe the reasons older Blacks with chronic illnesses did not utilize available support networks in their health care management. Following a community-based survey of 383 older Blacks, where each participant had a social support score completed from the Lubben Social Network Scale, a smaller group of 116 Blacks was selected to participate in a qualitative interview. It was found that 59 out of the 116 older Blacks had high social support scores on the Lubben Scale, but only 40 of these individuals reported the use of support networks for the maintenance of their health regimen. These findings illustrated that some older Blacks with strong support networks chose to function independently of their social support networks in the maintenance of their health.

Who supports elderly African Americans in adhering to their healthcare regimen?

Knowing who supports elderly African Americans in adhering to their healthcare regimen is vital information. This study found that the majority of elderly individuals discussed their chronic illnesses and problems related to managing their illnesses with family members rather than with formal providers. Additionally, family members were also significant in coordinating transportation; assisting with managing medications, diet, and exercise regimens; and monitoring symptoms of chronic illnesses. These findings provide direction on how to develop effective care plans and affect positive outcomes for elderly African American clients.

Dual pathways for regulation of root branching by nitrate

Root development is extremely sensitive to variations in nutrient supply, but the mechanisms are poorly understood. We have investigated the processes by which nitrate (NO3-), depending on its availability and distribution, can have both positive and negative effects on the development and growth of lateral roots. When Arabidopsis roots were exposed to a locally concentrated supply of NO3- there was no increase in lateral root numbers within the NO3--rich zone, but there was a localized 2-fold increase in the mean rate of lateral root elongation, which was attributable to a corresponding increase in the rate of cell production in the lateral root meristem. Localized applications of other N sources did not stimulate lateral root elongation, consistent with previous evidence that the NO3- ion is acting as a signal rather than a nutrient. The axr4 auxin-resistant mutant was insensitive to the stimulatory effect of NO3-, suggesting an overlap between the NO3- and auxin response pathways. High rates of NO3- supply to the roots had a systemic inhibitory effect on lateral root development that acted specifically at the stage when the laterals had just emerged from the primary root, apparently delaying final activation of the lateral root meristem. A nitrate reductase-deficient mutant showed increased sensitivity to this systemic inhibitory effect, suggesting that tissue NO3- levels may play a role in generating the inhibitory signal. We present a model in which root branching is modulated by opposing signals from the plant's internal N status and the external supply of NO3-.

On being invisible in the mental health system

The author provides a case study of her daughter's sexual abuse as a child and subsequent experiences as a chronically mentally ill client in the mental health system. Information from 17 years of mental health records and anecdotal accounts are used to illustrate the effects of the abuse, her attempts to reach out for help, and the system's failure to respond. There is evidence that a significant subset of psychiatric patients were severely sexually traumatized in childhood. Yet standard interview schedules consistently neglect to ask questions about such abuse, appropriate treatment is seldom available, and clients are often retraumatized by current practices. Psychiatry's historic resistance to addressing abuse as etiology is being challenged today by powerful economic, political, and professional forces leading to the emergence of a new trauma-based paradigm.