Are U.S. food and beverage companies now advertising healthy products to children on television? An evaluation of improvements in industry self-regulation, 2017-2021

BACKGROUND

Through the Children's Food and Beverage Advertising Initiative (CFBAI), U.S. food companies pledge to only advertise healthier products in children's television (TV) programming, but previous research shows that highly advertised products do not qualify as nutritious according to independent nutrition criteria. In 2020, the CFBAI implemented stricter nutrition criteria for products that may be advertised to children, but the potential impact of these changes has not been assessed. This observational study evaluates (1) improvements in energy and individual nutrient composition of products that companies indicated may be advertised to children (i.e., CFBAI-listed products) in 2020 versus 2017, (2) amount of advertising on children's TV for CFBAI-listed versus other products in 2021, and 3) the nutrition quality of advertised versus non-advertised CFBAI-listed products.

METHODS

Data include energy, saturated fat, sodium, and sugar content and overall nutrition quality (Nutrition Profile Index [NPI] scores) of CFBAI-listed products in 2017 (n = 308) and 2020 (n = 245). Nielsen data provided total ad spending and children's exposure to ads on children's TV channels for all foods and beverages in 2021.

RESULTS

From 2017 to 2021, energy, saturated fat and sugar declined for CFBAI-listed products in three of six food categories (yogurt, sweet and salty snacks). Although CFBAI-listed products accounted for 79% of food ads viewed by children on children's TV channels, just 50% of CFBAI-listed food and 36% of drink brands were advertised on children's TV. Moreover, advertised products were significantly less nutritious than non-advertised CFBAI-listed products.

CONCLUSION

Despite revised nutrition standards and improvements in nutrient content of some product categories, participating companies continued to primarily advertise nutritionally poor food and beverages on children's TV. CFBAI companies have not delivered on their promises to advertise healthier products to children.

Unhealthy food advertising on Costa Rican and Guatemalan television: a comparative study

This study aimed to exhaustively explore the characteristics of food advertising on TV in Guatemala and Costa Rica. The International Network for Food and Obesity Non-Communicable Diseases (NCDs) Research, Monitoring and Action Support (INFORMAS) methodology was applied. In 2016, we recorded 1440 h of video among 10 TV channels. We used the Pan American Health Organization (PAHO) Nutrient Profile (NP) Model to identify 'critical nutrients', whose excessive consumption is associated with NCDs. We created a nutritional quality score (0 if the product did not exceed any critical nutrient, 1 if the product exceeded one and 2 if it exceeded ≥2). We classified food ads as permitted (score = 0) and not-permitted (score 1 or 2) for marketing. Persuasive marketing techniques were classified as promotional characters (e.g. Batman), premium offers (e.g. toys), brand benefit claims (e.g. tasty) and health-related claims (e.g. nutritious). In Guatemala, foods that exceeded one critical nutrient were more likely to use persuasive marketing techniques, and in Costa Rica were those with an excess of ≥2 critical nutrients, compared with foods without any excess in critical nutrients [Guatemala: promotional characters (odds ratio, OR = 16.6, 95% confidence interval, CI: 5.8, 47.3), premium offers (OR = 3.4, 95% CI: 1.4, 8.2) and health-related claims (OR = 3.5, 95% CI: 2.2, 5.7); Costa Rica: health-related claims (OR = 4.2, 95% CI: 2.0, 8.5)]. In conclusion, Guatemalan and Costa Rican children are exposed to an overabundance of not-permitted food ads on TV. This justifies implementing national policies to reduce exposure to not-permitted food for marketing, including on TV and other media.

Caregivers' provision of sweetened fruit-flavoured drinks to young children: importance of perceived product attributes and differences by socio-demographic and behavioural characteristics

OBJECTIVE

Drinks containing added sugar and/or non-nutritive sweeteners are not recommended for children under 6 years. Yet, most young children consume these products. The current study examined factors associated with caregivers' provision of sweetened drinks to their young child.

DESIGN

Caregivers reported frequency of providing sweetened fruit-flavoured drinks (fruit drinks and flavoured water) and unsweetened juices (100 % juice and juice/water blends) to their 1- to 5-year-old child in the past month and perceived importance of product attributes (healthfulness, product claims and other characteristics), other drinks provided, reading the nutrition facts panel and socio-demographic characteristics. A partial proportional odds model measured the relationship between these factors and frequency of providing sweetened fruit-flavoured drinks.

SETTING

Online cross-sectional survey.

PARTICIPANTS

U.S. caregivers (n 1763) with a young child (ages 1-5).

RESULTS

The majority (74 %) of caregivers provided sweetened fruit-flavoured drinks to their child in the past month; 26 % provided them daily. Provision frequency was positively associated with some drink attributes, including perceived healthfulness, vitamin C claims and box/pouch packaging; child requests and serving other sweetened drinks and juice/water blends. Provision frequency was negatively associated with perceived importance of 'no/less sugar' and 'all natural' claims. Reading nutrition facts panels, serving water to their child and child's age were not significant.

CONCLUSION

Misunderstanding of product healthfulness and other marketing attributes contribute to frequent provision of sweetened drinks to young children. Public health efforts to address common misperceptions, including counter marketing, may raise awareness among caregivers about the harms of providing sweetened drinks to young children.

Television viewing and using screens while eating: Associations with dietary intake in children and adolescents

Screen time has been associated with overweight and obesity, as well as with poorer dietary quality. However, the reasons explaining these associations are not well understood. The objectives of this cross-sectional study were [1] to determine the extent of overall TV viewing as well as using screens while eating (e.g., watching TV or using a tablet), [2] to compare food and nutrient consumption of on-versus off-screen eating occasions, and [3] to determine whether TV viewing and using screens while eating is associated with overall dietary intake. Participants were from the Food Environment Chilean Cohort (n = 938, 4-6 y) and the Growth and Obesity Cohort Study (n = 752, 12-14 y). Dietary data was collected via one 24-h food recall. For each eating occasion, activity performed during consumption (e.g., watching TV, playing sports) was reported. Weekly TV viewing time was collected via an additional survey instrument. Analyses included multivariable linear and logistic regression. Post-hoc pairwise comparisons examined differences in outcomes by tertiles. Our sample reported a median of 9-13.5 weekly hours of TV viewing and 87.5% reported consuming at least one meal or snack per day while using screens. The median kilocalories contributed by eating during screen use was 387 kcal/d in children and 848 kcal/day in adolescents, which represents 34.7% and 42.3% of daily energy intake, respectively. There were no consistent differences when comparing eating occasions consumed on-screen versus off-screen. Higher weekly TV viewing was associated with elements of a less healthy diet including more sweets and desserts in children, and more sugar sweetened beverages in adolescents. A large percentage of Chilean children and adolescents' daily energy is consumed while using screens. In depth, longitudinal work is needed to understand how screen time eating affects diet quality and nutritional status.

Caregivers' Understanding of Ingredients in Drinks Served to Young Children: Opportunities for Nutrition Education and Improved Labeling

BACKGROUND

Against expert recommendations, sugar-sweetened beverages, especially fruit drinks, are consumed by young children. Misperceptions about drink ingredients and healthfulness can contribute to caregivers' provision.

OBJECTIVES

To assess caregivers' reasons for serving sweetened fruit-flavored drinks and unsweetened juices to their young children (1-5 y) and perceptions of product healthfulness and drink ingredients.

METHODS

A cross-sectional online survey assessed participants' (n = 1614) perceptions of sweetened fruit-flavored drinks (fruit drinks and flavored water) and unsweetened juices (100% juice and water/juice blends) provided to their child in the past month, including product healthfulness, reasons for providing, and knowledge of product ingredients [added sugar, nonnutritive sweeteners (NNSs), percentage juice]. One-factor ANOVA compared perceived healthfulness of drink categories and types of sugar and NNSs, and differences between participants who could compared with those who could not accurately identify drink ingredients.

RESULTS

Participants' top reasons for providing sweetened drinks included child liking it, being inexpensive, child asking for it, and being a special treat. Participants perceived 100% juice as healthiest, followed by juice/water blends, flavored waters, and, lastly, fruit drinks (P < 0.05). Many participants inaccurately believed the fruit drink or flavored water they served their child most often did not contain NNSs (59.0% and 64.9%) and/or added sugars (20.1% and 42.2%), when in fact they did, and 81.3-91.1% overestimated the percentage juice in the drink. Perceived healthfulness of fruit drinks was associated with caregivers' belief that the drink contained added sugar (P < 0.05), but not with their belief that it contained NNS; increased accuracy was associated with decreased perceived healthfulness (P < 0.05).

CONCLUSIONS

Inaccurate understanding of added sugar, NNSs, and percentage juice in drinks served to young children was common and could contribute to sugary drink provision. Public health efforts should seek to improve labeling practices and revise nutrition education messages.

Examining Chile's unique food marketing policy: TV advertising and dietary intake in preschool children, a pre- and post- policy study

BACKGROUND

The Chilean government implemented the first phase of a comprehensive marketing policy in 2016, restricting child-directed marketing of products high in energy, total sugars, sodium or saturated fat (hereafter "high-in").

OBJECTIVES

To examine the role that high-in TV food advertising had in the effect of the policy on consumption of high-in products between 2016 and 2017.

METHODS

Dietary data were obtained from 24-hour diet recall measured in 2016 (n = 940) and 2017 (n = 853), pre- and post-policy, from a cohort of 4 to 6 years children. Television use was linked to analyses of food advertisements to derive individual-level estimates of exposure to advertising. A multilevel mediation analysis examined direct and indirect effects of the policy through advertising exposure.

RESULTS

Children's high-in food consumption and advertising exposure declined significantly from 2016 to 2017 (P < .01). Consumption changes were not significantly mediated by changes in advertising exposure, which might suggest other elements of the Chilean Law potentially driving decreases in consumption to a greater extent than TV ads.

CONCLUSIONS

Preschoolers' exposure to high-in advertising and consumption of high-in products decreased post-policy. Further research is needed to understand how marketing changes will relate to dietary changes after full implementation of the law and in the long term.

Global benchmarking of children's exposure to television advertising of unhealthy foods and beverages across 22 countries

Restricting children's exposures to marketing of unhealthy foods and beverages is a global obesity prevention priority. Monitoring marketing exposures supports informed policymaking. This study presents a global overview of children's television advertising exposure to healthy and unhealthy products. Twenty-two countries contributed data, captured between 2008 and 2017. Advertisements were coded for the nature of foods and beverages, using the 2015 World Health Organization (WHO) Europe Nutrient Profile Model (should be permitted/not-permitted to be advertised). Peak viewing times were defined as the top five hour timeslots for children. On average, there were four times more advertisements for foods/beverages that should not be permitted than for permitted foods/beverages. The frequency of food/beverages advertisements that should not be permitted per hour was higher during peak viewing times compared with other times (P < 0.001). During peak viewing times, food and beverage advertisements that should not be permitted were higher in countries with industry self-regulatory programmes for responsible advertising compared with countries with no policies. Globally, children are exposed to a large volume of television advertisements for unhealthy foods and beverages, despite the implementation of food industry programmes. Governments should enact regulation to protect children from television advertising of unhealthy products that undermine their health.

Participating in a Food-Assisted Maternal and Child Nutrition and Health Program in Rural Guatemala Alters Household Dietary Choices

BACKGROUND

Food assistance programs may alter food choices, but factors determining households' decisions regarding food acquisition, preparation, and consumption in the context of food aid are not well understood.

OBJECTIVE

This study aimed to understand how the Programa Comunitario Materno Infantil de Diversificación Alimentaria (Mother-Child Community Food Diversification Program; PROCOMIDA), a food-assisted maternal and child health and nutrition program in rural Alta Verapaz, Guatemala, altered household food choices.

METHODS

We conducted semistructured interviews and focus groups with 63 households in 3 participating (n = 32 households) and 3 control (n = 31) villages. A last-day food recall (without estimating quantities) and food-frequency questionnaire that used food cards assessed dietary choices. Qualitative analysis used thematic a priori and emergent coding; food group consumption frequencies were analyzed by using 2-level, logistic, mixed modeling, and chi-square testing while accounting for community clustering.

RESULTS

Compared with control households, PROCOMIDA changed household food choices through a combination of providing food resources (with monthly food rations) and new knowledge and skills related to health and food (in the program's behavior change communication component) while reinforcing existing knowledge and beliefs. PROCOMIDA families consumed rice, red beans, and oil more frequently than did control families (differences of 2.20 (P < 0.001), 2.68 (P < 0.001), and 1.64 (P = 0.038) times/wk, respectively); these foods were in the rations. PROCOMIDA families also ate chicken, local plants, and some vegetables more frequently. The importance of these foods was emphasized in the behavioral change communication component; these foods may have been more accessible because provision of food rations freed resources.

CONCLUSION

Our findings suggest that if a program provides food free of cost to rural indigenous families in the context of a maternal and child nutrition and health program, it may be important to include a well-designed behavioral change communication component to improve household food choices.

A study of subunit selectivity, mechanism and site of action of the delta selective compound 2 (DS2) at human recombinant and rodent native GABA(A) receptors

BACKGROUND AND PURPOSE

Most GABA(A) receptor subtypes comprise 2α, 2β and 1γ subunit, although for some isoforms, a δ replaces a γ-subunit. Extrasynaptic δ-GABA(A) receptors are important therapeutic targets, but there are few suitable pharmacological tools. We profiled DS2, the purported positive allosteric modulator (PAM) of δ-GABA(A) receptors to better understand subtype selectivity, mechanism/site of action and activity at native δ-GABA(A) receptors.

EXPERIMENTAL APPROACH

Subunit specificity of DS2 was determined using electrophysiological recordings of Xenopus laevis oocytes expressing human recombinant GABA(A) receptor isoforms. Effects of DS2 on GABA concentration-response curves were assessed to define mechanisms of action. Radioligand binding and electrophysiology utilising mutant receptors and pharmacology were used to define site of action. Using brain-slice electrophysiology, we assessed the influence of DS2 on thalamic inhibition in wild-type and δ(0/0) mice.

KEY RESULTS

Actions of DS2 were primarily determined by the δ-subunit but were additionally influenced by the α, but not the β, subunit (α4/6βxδ > α1βxδ >> γ2-GABA(A) receptors > α4β3). For δ-GABA(A) receptors, DS2 enhanced maximum responses to GABA, with minimal influence on GABA potency. (iii) DS2 did not act via the orthosteric, or known modulatory sites on GABA(A) receptors. (iv) DS2 enhanced tonic currents of thalamocortical neurones from wild-type but not δ(0/0) mice.

CONCLUSIONS AND IMPLICATIONS

DS2 is the first PAM selective for α4/6βxδ receptors, providing a novel tool to investigate extrasynaptic δ-GABA(A) receptors. The effects of DS2 are mediated by an unknown site leading to GABA(A) receptor isoform selectivity.

Causes of death among diabetic patients in Denmark

AIMS/HYPOTHESIS

To study the distribution of causes of death in the Danish population, and its variation by diabetes status, sex, age and calendar year as well as the years of life lost from the specific causes of death.

METHODS

Persons aged 30-98 years were followed from 1995 to 2008 by linkage of Danish registers. Poisson regression was used to model cause-specific mortality rates by age and calendar time for each specific cause of death, according to sex and diabetes status. The mortality rates were also modelled as a function of age and birth cohort. We computed the distribution of causes of death and years of life lost from specific causes of death due to diabetes.

RESULTS

During the 14-year study period, patients with diabetes contributed 2.3 million person-years of follow-up and 124,210 deaths, whereas persons without diabetes contributed 45.1 million person-years and 648,020 deaths. The mortality was higher among individuals with diabetes, and the mortality ratio (diabetes vs no diabetes) decreased with age and for all causes and cardiovascular diseases also by calendar time. The effect of sex on the association between diabetes and mortality varied with age and cause of death. About 9 years of life were lost to diabetes at age 30 years, and 3 years at age 70 years.

CONCLUSIONS/INTERPRETATION

Age-specific mortality is higher among people with diabetes, and rate ratios vary with age, sex, calendar period and cause of death. The distribution of causes of death was similar for persons with and without diabetes.

The testing effect on skills learning might last 6 months

In a recent study we found that testing as a final activity in a skills course increases the learning outcome compared to spending an equal amount of time practicing. Whether this testing effect measured as skills performance can be demonstrated on long-term basis is not known. The research question was: does testing as a final activity in a cardio-pulmonary resuscitation (CPR) skills course increase learning outcome when assessed after half a year, compared to spending an equal amount of time practicing? The study was an assessor-blinded randomised controlled trial. A convenient sample of 7th semester medical students attending a mandatory CPR course was randomised to intervention course or control course. Participants were taught in small groups. The intervention course included 3.5 h skills training plus 30 min of skills testing. The practice-only control course lasted 4 h. Both groups were invited to a retention assessment of CPR skills half a year later. Participants included 89/180 (50%) of those invited to participate in the study. Mean performance score was 75.9 (SD 11.0) in the intervention group (N = 48) and 70.3 (SD 17.1) in the control group, effect size 0.4. The difference between groups was not statistically significant, P = 0.06. This study suggests that testing as a final activity in a CPR skills course might have an effect on long-term learning outcome compared to spending an equal amount of time practicing the skills. Although this difference was not statistically significant, the identified effect size of 0.4 can have important clinical and educational implications.

Sources and Isotopic Composition of Atmospheric Sulfur

In nonindustrial areas the prime source of SO(--)(4) in rain and snow is atmospherically oxidized H(2)S that is produced predominately along coastal belts by anaerobic bacteria. The delta S(34) analyses of atmospheric SO(--)(4) vary from +3.2 to +15.6 per mil in contrast to +20.7 per mil for sea water SO(--)(4). Contrary to previous studies based on Cl(-)/SO(--)(4) ratios, sea spray SO(--)(4) is a minor source.

Comparison of cerebral pharmacokinetics of buprenorphine and norbuprenorphine in anin vivosheep model

The pharmacokinetics and time course of blood-brain equilibration of buprenorphine (BUP) and norbuprenorphine (norBUP) in sheep were characterized. Sheep were administered 0.04 mg kg(-1) BUP or 0.6 mg kg(-1) norBUP as 4-min i.v. infusions. The cerebral kinetics were inferred from arterio-sagittal sinus concentration gradients and changes in cerebral blood flow. These data were fitted to physiologically based pharmacokinetic models. BUP cerebral kinetics were best described by a membrane-limited model with a large equilibration delay (half-life of 20 min) between brain and blood due to intermediate permeability (47 ml min(-1)) and a large cerebral distribution volume (595 ml). Significant limitation in permeability (6 ml min(-1)) characterized the cerebral kinetics of norBUP with a cerebral distribution volume (157 ml) giving a blood-brain equilibration half-life (21 min) similar to that for BUP. The logD of BUP and norBUP were 3.93 +/- 0.08 and 1.18 +/- 0.04 (mean +/- SD), respectively. Both compounds revealed slow cerebral equilibration with variations in degree of permeability and distribution volume reflecting the difference in lipophilicity. It is possible that norBUP contributes to the central effects seen after chronic BUP administration as this study demonstrated its entry into the brain.

Assessment of Advanced Life Support competence when combining different test methods—Reliability and validity

Robust assessment of Advanced Life Support (ALS) competence is paramount to the credibility of ALS-provider certification and for estimating the learning outcome and retention of ALS competence following the courses. The European Resuscitation Council (ERC) provides two sets of MCQs and four Cardiac Arrest Simulation Test (CASTest) scenarios for the assessments according to guidelines 2005.

AIMS

To analyse the reliability and validity of the individual sub-tests provided by ERC and to find a combination of MCQ and CASTest that provides a reliable and valid single effect measure of ALS competence.

METHODS

Two groups of participants were included in this randomised, controlled experimental study: a group of newly graduated doctors, who had not taken the ALS course (N=17) and a group of students, who had passed the ALS course 9 months before the study (N=16). Reliability in terms of inter-rater agreement and generalisability across skills scenarios were estimated. Validity was studied in terms of equality of test difficulty and ability to discriminate performance between the groups.

RESULTS

Inter-rater agreement on checklist scores were generally high, Intraclass Correlation Coefficients between 0.766 and 0.977. Inter-rater agreements on pass/fail decisions were not perfect. The one MCQ test was significantly more difficult than the other. There were no significant differences between CASTests. Generalisability theory was use to identify a composite of MCQ and CASTest scenarios that possessed high reliability, equality of test sets, and ability to discriminate between the two groups of supposedly different ALS competence.

CONCLUSIONS

ERC sub-tests of ALS competence possess sufficient reliability and validity. A combined ALS score with equal weighting of one MCQ and one CASTest can be used as a single measurement of ALS competence.

Leisure time physical exercise during pregnancy and the risk of miscarriage: a study within the Danish National Birth Cohort

OBJECTIVE

To examine the association between leisure time physical exercise during pregnancy and the risk of miscarriage.

DESIGN

Prospective study with elements of retrospective data collection.

SETTING

Denmark 1996-2002.

POPULATION

A total of 92,671 pregnant women enrolled in the Danish National Birth Cohort and interviewed subsequently.

METHODS

Data on exercise during pregnancy and potential confounders were obtained through computer-assisted telephone interviews either during pregnancy or after an early miscarriage. Outcome of pregnancy was identified by register linkage. Using Cox regression analysis, we estimated the hazard ratio (HR) of miscarriage according to weekly amount of exercise and the type of exercise. The HR was estimated for <11, 11-14, 15-18, and 19-22 weeks of gestation, respectively.

MAIN OUTCOME MEASURES

Miscarriage, defined as fetal loss before 22 completed weeks of gestation.

RESULTS

A stepwise increasing relation was found between amount of exercise and risk of miscarriage, where risk of miscarriage increased by amount of exercise up to HR = 3.7 (95% CI 2.9-4.7) for women who exercised more than 7 hours per week compared with nonexercisers. Particularly 'high-impact exercise' was associated with an increased risk of miscarriage. No association was seen between exercise and risk of miscarriage after 18 weeks of gestation.

CONCLUSIONS

This study suggests that exercise early in pregnancy is associated with an increased risk of miscarriage. The results should, however, be interpreted cautiously as potential bias arising from retrospective data collection may explain part of the association.

Transvaginal sonography combined with saline contrast sonohysterography in evaluating the uterine cavity in premenopausal patients with abnormal uterine bleeding

OBJECTIVES

To evaluate whether saline contrast sonohysterography (SCSH) adds additional information to that obtained by transvaginal sonography (TVS) for predicting endometrial abnormality in premenopausal patients with abnormal uterine bleeding.

PATIENTS AND METHODS

This was a two-center prospective study at a university clinic and a central hospital in Denmark. The uterine cavity was evaluated with TVS and SCSH in 470 premenopausal patients with abnormal uterine bleeding. One hundred and eighty-nine of the patients had operative hysteroscopy or hysterectomy within 4 months which provided a detailed description of the uterine cavity and was used as the true value for exclusion of polyps and submucous myomas.

RESULTS

Based on normal endometrial morphology alone, the results for detection of an abnormal uterine cavity were as follows: sensitivities of TVS 0.92, SCSH 0.99; specificities of TVS 0.62, SCSH 0.72; positive predictive values of TVS 0.80, SCSH 0.85; negative predictive values of TVS 0.82, SCSH 0.98. Transvaginal sonography combined with SCSH was superior to TVS for detection of intracavitary abnormalities (McNemar test, P = 0.008). The post-test probability of there being an abnormal cavity after normal findings on TVS alone was 0.18 (0.10-0.32) and after TVS and SCSH it was 0.02 (0.01-0.11). When normal endometrial morphology was combined with an endometrial thickness of < 12 mm for evaluation of all abnormalities including hyperplasia, the diagnostic potential of TVS or SCSH was almost unchanged except for specificities, which were markedly lower (TVS 0.54; SCSH 0.57). In all the patients referred, TVS had a negative predictive value of 0.94 for identification of polyps and myomas when findings at subsequent SCSH were accepted as the true value. Transvaginal sonography reduced the pretest probability of polyps or submucous myomas from 0.35 to a post-test probability of 0.06, but missed 21% of the polyps.

CONCLUSIONS

Sonohysterography was a sensitive tool and was superior to TVS used alone for evaluation of the uterine cavity in patients who underwent operative surgery for abnormal uterine bleeding. All abnormalities except one were found at SCSH, while TVS alone missed polyps and had almost one in four equivocal findings. The use of TVS, without saline contrast, left one in five of the polyps undiagnosed in referred patients with abnormal bleeding.

Can the endometrial thickness as measured by trans-vaginal sonography be used to exclude polyps or hyperplasia in pre-menopausal patients with abnormal uterine bleeding?

BACKGROUND

To combine findings of normal mid-line echoes from TVS (trans-vaginal sonography) with cut-off levels for endometrial thickness, in order to examine the associated risk of abnormalities in the uterine cavity.

DESIGN AND SETTING

Two center prospective study at a university clinic and a central hospital in Denmark.

PARTICIPANTS

Three hundred and fifty-five pre-menopausal patients with abnormal uterine bleeding, and indications for endometrial sampling or surgery.

INTERVENTIONS

The thickness of the endometrium was measured, and the mid-line echoes were evaluated using TVS. The findings from the endometrial sampling, combined with the evaluation of the uterine cavity using operative hysteroscopy (115), hysterectomy (74) or HSE (hysterosonographic examination) (166), were used as the true values.

RESULTS

The mean (+/-s.d.) endometrial thickness was significantly different in patients with hyperplasia 11.5 mm (+/-5.0), polyps 11.8 mm (+/-5.1), sub-mucous myomas 7.1 mm (+/-3.4) and in patients without these abnormalities 8.37 (+/-3.9) (p<0.001). Hyperplasia and/or polyps were present in 20% of all patients, and in 8% of 143 patients with an endometrial thickness of < or =7 mm. This proportion did not decrease with lower cut-off levels for endometrial thickness. Receiver operating characteristic (ROC) curves were not optimal for excluding hyperplasia or polyps by endometrial thickness. In 173 cases with a distinct, regular midline echo without echo-dense foci in TVS the proportion of patients with abnormalities was 16% (11-23). This proportion did not decrease with cut-off levels for endometrial thickness.

CONCLUSIONS

Using TVS, low levels of endometrial thickness reduced the possibility of abnormalities such as polyps and hyperplasia, but did not exclude them. Low cut-off levels for endometrial thickness did not increase the diagnostic performance in cases with normal sonograms.

Effect of oral drenching with zinc oxide or synthetic zeolite A on total blood calcium in dairy cows

Danish Holstein dairy cows in late lactation and milked in the morning only were used as a model for dry pregnant cows to determine the effect of oral drenching with zeolite A and zinc oxide, respectively, on total serum calcium. Ten cows were assigned randomly to two groups of five cows each, given either synthetic zeolite A (group A) or zinc oxide (group B). Blood samples were drawn daily at 10 a.m. and 10 p.m. during the whole experiment, and total serum calcium was determined. Daily fluctuations in blood calcium were recorded, with morning values being consistently lower than evening values. Oral drenching with a single dose of zinc oxide of 100 mg/kg of body weight as well as with zeolite in doses of 500 g of zeolite/cow twice a day for 2.5 d was reflected in serum calcium levels. In the group given zeolite A, there was a depression in evening values of total serum calcium although the difference did not reach statistical significance. It was followed by an increase above baseline level ("overshooting"). This was interpreted as a response from the calcium homeostatic mechanisms. In the group given a single dose of zinc oxide, a decrease in total serum calcium occurred. This decrease was not followed by overshooting, indicating that the single treatment with zinc oxide did not stimulate the calcium homeostatic mechanisms. The perspective of this first attempt to reduce dry cow ration calcium availability may be seen in relation to difficulties in formulating dry cows rations from home grown forage sufficiently low in calcium to elicit a hypocalcemia protective response at calving.

[Comparison of monolayer specimens and conventional smears]

INTRODUCTION

Monolayer specimens were compared with conventional smears in a split sample study. The quality of the specimens, sensitivity, time consumption, and costs were elucidated.

METHOD

Conventional smears and fixated residual material from 1701 women were available.

RESULTS

The number of inadequate/less adequate specimens was reduced significantly (p < 0.001). Diagnostic agreement was found in 1531 (90%) of the 1701 cases (kappa = 0.52, SE (kappa) = 0.026). Dysplasia (NOS) was diagnosed in seven monolayer specimens (0.4%) versus 33 smears (1.9%) and ratio atypia/low grade was reduced by 33%, which indicates greater accuracy in diagnosis in monolayers. Histological follow-up showed sensitivities of 95% (monolayers) and 94% (smears). The time consumed (laboratory work, screening) on a smear versus a monolayer specimen was 11.5 minutes versus 9.3 minutes. Utensil costs of a smear are kr. 10.69. compared to kr. 26.50 for a monolayer specimen.

CONCLUSION

The higher costs should be set against the saving in significantly improved specimen quality, improved diagnostic accuracy, and shorter time consumption. The use of the monolayer technique (direct to vial) is recommended to replace the conventional smear.

[Partial re-screening of all negative smears. A method of quality control of pathology department concerning smear screening against cervix cancer]

Partial rescreening of all negative smears is recommended as the most cost-effective method of internal quality control. The method was tested by eight cytotechnologists and the average diagnostic sensitivity, assessed upon their answering of 200 test-smears (150 negative and 50 positive) was 80%, while specificity vas calculated to 95%. Partial rescreening has here-upon been used in daily routine. After one year 21,000 smears have been re-screened. Twenty-nine cases of false negatives, 16 with atypia, eight with koilocytosis, and five cases with dysplasia have been detected, which corresponds to an overall false negative rate on 3%. In five of the 29 false negative cases with dysplasia histological follow-up has shown three cases of CIN III (two carcinoma in situ, one severe dysplasia), one case with CIN II (moderate dysplasia) and one case with CIN I (mild dysplasia). Conclusively, partial rescreening of all negative smears implies an improved quality with reduction of the number of false negative specimens.

MIB-1 expression in breast carcinomas with medullary features. An immunohistological study including correlations with p53 and bcl-2

Typical medullary carcinoma (TMC) is usually considered to have a more favourable prognosis than other types of infiltrating breast carcinomas. This is a biological paradox, since its clinical behaviour is not in agreement with its anaplastic morphology and high mitotic rate. It should be remembered that neoplastic growth reflects cell production minus cell loss, the latter being achieved by apoptosis. At present, bcl-2 oncogene (apoptosis inhibitor) and p53 gene are assumed to be involved in the regulation of cell death and tumour proliferation. Sixty breast carcinomas, initially indexed as medullary carcinomas, were re-classified using the diagnostic criteria given by Ridolfi. This review yielded 13 typical (TMC), 24 atypical (AMC), and 23 non-medullary carcinomas (NMC). Following antigen retrieval by microwave treatment, immunohistochemical analyses, using MIB-1, p53 and bcl-2 monoclonal antibodies were performed on serial sections from formalin-fixed, paraffin-embedded specimens. TMC revealed the highest incidence of intense p53 positivity, and the highest mean MIB-1 index, and absence of the apoptosis-inhibitor protein bcl-2. These results suggest the presence of a higher overall cell turnover in TMC than in AMC and NMC. Increased apoptosis balancing the increased cell proliferation might be among the possible explanations for the more favourable prognosis in TMC.

Prognostic comparison of three classifications for medullary carcinomas of the breast

The aim of this study was to make prognostic comparisons between the modified scheme of Pedersen et al. the definitions of Tavassoli and the Ridolfi criteria for medullary carcinomas. Sixty breast carcinomas primarily diagnosed as medullary carcinomas were reclassified into typical medullary carcinoma (TMC), atypical medullary carcinoma (AMC) and non-medullary carcinoma (NMC) according to the three classifications. The Ridolfi classification proved to be superior to the two other schemes in discriminating survival differences between the three groups TMC, AMC and NMC. All 13 patients with TMC are still alive indicating an excellent prognosis, while 29% and 39% of the 47 patients in the AMC and NMC category, respectively, have died of their disease. In the simplified system of Pedersen et al. the survival at 10 years for TMC patients decreased to 75% and no significant survival difference between the three groups could be demonstrated. As the prognosis for AMC proved to be worse compared to TMC and in fact was similar to NMC with values of 43% at 10 years in the Ridolfi classification, we find no reasons to maintain this category. We conclude that as long as no alternative and more easily applicable diagnostic method exists, pathologists should still apply the Ridolfi criteria on these tumours with medullary features leaving two diagnostic possibilities: TMC or NMC (i.e. poorly differentiated ductal carcinoma). Only lesions that fulfil all six criteria without any doubt should be diagnosed as TMC, thus avoiding overdiagnosis and a resulting risk of undertreatment.

Inclusion body myositis and transitional cell carcinoma of the bladder: significant resolution of symptoms after tumor excision

Inclusion body myositis (IBM) is a separate class of the inflammatory myopathies with recently proposed clinical and pathological diagnostic criteria. An association between inflammatory myopathies and malignancy has been questioned in the literature. Recent reviews of the inflammatory myopathies suggest that only dermatomyositis is associated with malignancy. The largest study to date of patients with IBM found that 15% had a malignancy (6 of 40). We report the first documented case of IBM and concurrent transitional cell carcinoma of the bladder. We suggest that a causal relationship between IBM and malignancy may exist because of significantly improved functional strength gained after tumor removal.

Intradermal and subcutaneous leiomyosarcoma: a clinicopathological and immunohistochemical study of 41 cases

Superficial leiomyosarcomas are rare tumours. The lesions confined to the dermis, contrary to those involving the subcutis, have been reported to carry a favourable prognosis. A retrospective study of 41 consecutive cases of surgically treated intradermal and subcutaneous leiomyosarcomas was undertaken in order to determine the prognostic factors that may influence the survival of these patients. Seven tumours were predominantly intradermal and 34 involved the subcutaneous tissue. Fifty-four percent of the tumours were located in the lower extremities. All cases stained positively for smooth muscle antigen and 66% for desmin. The tumours were classified with regard to tumour grade I (low grade, 3%), II (intermediate, 12%), IIIA (high grade, 46%) and IIIB (high grade, 39%). In all patients, follow-up information was available. Mean follow-up time was 5 years. The patients with intradermal tumours were all alive without signs of recurrence, whereas 14 of those with leiomyosarcomas involving the subcutis have died with pulmonary metastases. Our study confirms that "pure" intradermal leiomyosarcomas independent of tumour grade behave in a benign fashion, probably due to small tumour size. Tumour size > or = 5 cm, deep localization with fascia involvement, and high malignancy grade (IIIB) were found to deteriorate survival based on a univariate analysis. However, in a multivariate analysis only tumour size was found to be an independent prognostic factor.

Medullary breast carcinoma vs. poorly differentiated ductal carcinoma: an immunohistochemical study with keratin 19 and oestrogen receptor staining

Sixty breast carcinomas previously indexed as medullary carcinomas over a 24-year-period were reviewed and reclassified according to definitions suggested by Ridolfi et al. as typical medullary carcinoma, atypical medullary carcinoma, and non-medullary carcinoma. Paraffin sections of tumour tissue were examined by an avidin-biotin complex method using two keratin 19-specific monoclonal antibodies (BA17, DAKO and clone 170-2-14, Boehringer) and a monoclonal oestrogen receptor antibody (DAKO). For comparison 52 ductal carcinomas of grade II and grade III were immunostained as well. The results showed that all 60 tumours with medullary features and all 52 ductal carcinomas reacted moderately to strongly positive with anti-keratin 19 (Boehringer). The staining was diffuse in all cases, except one case of ductal carcinoma (grade III), which stained focally. Immunostaining with the second keratin 19 antibody (BA17) revealed similar results with positive staining in 59 (95%) cases of carcinomas with medullary features and 51 (98%) cases of ductal carcinomas. Only one case in each group did not express keratin 19 (BA17), one re-classified case of non-medullary carcinoma with neuroendocrine features and one case of ductal carcinoma of grade III. None of the 13 cases of typical medullary carcinoma were oestrogen receptor positive and only seven (12%) of the carcinomas with medullary features (2 atypical, 5 non-medullary) were oestrogen receptor positive with quantitative values from 20 to 100%. The 52 ductal carcinomas of grade II and III were oestrogen receptor positive in 56% and 47% of cases. It is concluded that keratin 19 staining is of no particular value in differentiating medullary from poorly differentiated ductal carcinoma. A carcinoma with positive oestrogen receptor staining is not likely to be a typical medullary carcinoma.

Immunocytochemical staining of smears and corresponding cell blocks from serous effusions: a follow-up and comparative investigation

Recently, we have recommended immunocytochemistry on serous effusions with the monoclonal antibodies Ber-EP4 and EMA to be used as a routine procedure. In this study, our earlier defined immunocytochemical profiles were tested in daily diagnostic work for a period and the profiles were applicated on the corresponding cell blocks from the effusions, too. It is concluded that routine use of the benign, malignant epithelial, and malignant mesothelial immunocytochemical profiles is valuable and superior to cytomorphology alone. Additionally, immunocytochemical staining of smears proved slightly more sensitive than immunohistochemistry performed on sections from the cell blocks.

Ductal adenoma of the breast: the cytological features of six cases

Ductal adenoma of the breast may simulate malignancy by both clinical, histological, and cytological examination. Fine-needle aspirations from breast lesions are now daily routine and preoperative recognition of this benign lesion is desirable. This study describes the cytologic features of six additional cases of ductal adenoma. The smears from all the lesions were highly cellular with epithelial cells in sheets. Numerous large fragments of purple stroma in tight connection with epithelial cells often making finger-like hyaline structures or globules between cells were seen. Naked oval nuclei in the background were observed in all cases indicating benignancy. We find the cytologic picture in fine-needle aspirations from ductal adenomas sufficiently characteristic for preoperative diagnosis. The differential diagnoses toward other benign and malignant conditions are discussed.

Intraventricular infusion of the selective sigma-agonist 1,3-di-ortho-tolylguanidine (DTG) mitigates ischaemic brain damage in the hippocampus

Experimental evidence suggests that neuronal pharmacologic sites termed sigma (sigma) may be related, but not identical to PCP sites in the ion channel linked to NMDA excitatory receptors. These receptors may play a role in schizophreniform psychoses, and clinical trials of putative sigma-ligands have begun. Because of this, and because of the relationship of sigma-ligands to NMDA receptors, we studied the effect of the most selective presently available sigma-ligand on ischaemic neuronal death throughout the rat brain after transient forebrain ischaemia. Ventricular delivery of DTG at 0.5 mumol/h via an osmotic minipump was chosen to allow continuous access of the drug to brain tissue, control animals receiving artificial CSF. After one week survival, selective neuronal necrosis was reduced in the hippocampus, but not in the neocortex or striatum, contrasting with our previous findings in this model with pure NMDA antagonists. The results indicate that ischaemic neuronal necrosis in the hippocampus may be mitigated by sigma-agonists, possibly via an interaction with NMDA receptors.

Small cell carcinoma of the ovary diagnosed in early pregnancy

Small cell carcinoma of the ovary is a rare malignancy affecting young women. We report the first case of small cell carcinoma of the ovary and coincident pregnancy. The patient died of the disease 23 months after the initial diagnosis.

Extraocular sebaceous carcinoma of the skin with visceral metastases: case report

Extraocular sebaceous gland carcinomas of the skin are uncommon neoplasms that may recur locally, but in contrast to their ocular counterparts infrequently metastasize. A case is reported in which a 62-year-old woman had a 1 cm scalp tumor incompletely excised. Microscopic examination revealed a sebaceous carcinoma. No further surgical treatment was performed and 31 months after diagnosis the patient presented with regional and distant metastases resulting in death. It is emphasized that extraocular sebaceous carcinoma may behave in a biologically aggressive manner, just as their counterparts arising in the ocular adnexae, and the necessity to ensure complete tumor excision is stressed.

Neurobehavioral deficit due to ischemic brain damage limited to half of the CA1 sector of the hippocampus

It is well known that ischemia causes neuronal necrosis in selectively vulnerable sectors of the hippocampus. Since the hippocampus is involved in spatial navigation, learning, and memory, selective deficits in these areas may arise from ischemic brain damage. The objective of this study was to test whether a minimal ischemic insult, producing selective neuronal necrosis restricted to only a portion of the CA1 pyramidal cells of the hippocampus, could produce a detectable spatial navigation deficit. Male Wistar rats received 9 min of forebrain ischemia induced by carotid clamping and hypotension or sham operation with exposure of the carotid arteries. The rats were allowed to recover and were tested on a simple place task, a place learning-set task, and a pattern discrimination task in swimming pools paradigms. Subsequently, the rats were perfusion-fixed and their entire brains subjected to quantitative histopathologic analysis. Although both ischemic and sham-operated groups learned the simple place task, the learning-set task revealed defects in spatial navigation, reflected as increased errors and latency in the performance of the ischemic rats. In the subsequent pattern discrimination task, the ischemic group was superior to the control group, which perseverated by attempting to use a place strategy to solve the discrimination. Quantitative neuropathology revealed neuronal necrosis in the ischemia group limited to 50% of the CA1 zone of the hippocampus. Extrahippocampal damage consisted of rare cortical neuronal necrosis in 2 of 6 animals.(ABSTRACT TRUNCATED AT 250 WORDS)

Intraventricular infusion of 2-amino-7-phosphonoheptanoate (APH) mitigates ischaemic brain damage

Intracerebroventricular infusion of the competitive N-methyl-D-aspartate (NMDA) antagonist 2-amino-7-phosphonoheptanoate (APH) was evaluated as a neuroprotective regimen in a rat transient cerebral ischaemia model allowing long-term recovery. Ventricular delivery of APH via an osmotic minipump was chosen to allow continuous and direct access to brain tissue of this polar molecule, and because of the potential applicability of such a regimen in clinical situations where the brain is at risk from cerebral ischaemia and a ventricular catheter is in place. The highest tolerable concentration of APH, 50 mM, was given at 1 microliter/h. Selective neuronal necrosis was significantly reduced in the cerebral cortex and the incidence of infarction in the substantia nigra pars reticulata (SNPR) was decreased. A borderline protective effect was seen in the hippocampal CA1 pyramidal neurons, and no significant protection was seen in the caudate nucleus. The results suggest a limited usefulness for APH as a cerebral protective agent.

Broad ligament mucinous and serous cystadenomas of borderline malignancy

The clinical and pathological findings including light microscopic and ultrastructural features of two cases of borderline mucinous and serous cystadenomas that originated in the broad ligament are reported. The tumors did not involve the oviduct or ovary. They probably arose in pre-existing cysts of mesothelial and paramesonephric (primary Müllerian) origin. These rare tumors bear a close resemblance to the borderline epithelial tumors of the ovary and the same prognostic criteria may be applicable to the lesions presented here.

Mesotheliomas of the tunica vaginalis testis and hernial sacs

Three histologically and immunohistochemically well-documented cases of mesothelioma of the tunica vaginalis testis and hernial sac are presented. Analysis and follow-up data on our three patients and a review of 30 previously reported cases have revealed a varied and often unpredictable clinical course. A classification into high- and lowgrade malignant tumours is suggested, based on clinical and pathological findings.

Ketamine fails to protect against ischaemic neuronal necrosis in the rat

Ketamine is a dissociative anaesthetic known to be an N-methyl-D-aspartate receptor blocker. Since the NMDA excitatory receptor on neurones is implicated in ischaemic neuronal necrosis, ketamine might be expected to have a beneficial effect in cerebral hypoxia-ischaemia. Ketamine was tested in a rat model of forebrain ischaemia allowing 7 days recovery. Ketamine 6 mg kg-1 i.v. was administered 5-10 min before ischaemia in one group of rats, and ketamine 60 mg kg-1 day-1 i.m. for 3 days and 7 continuous days after ischaemia in two other groups. An additional group received ketamine 24 mg kg-1 i.v. before ischaemia and 120 mg kg-1 day-1 i.m. after ischaemia for 7 days continuously. Control rats received ischaemia but no treatment. The results were compared with untreated controls by neuropathological examination of the entire brain, sectioned subserially. There was no significant difference in necrosis between treated and untreated groups after any of the ketamine regimens. The findings demonstrate that systemically administered ketamine fails to protect the brain against hypoxic-ischaemic injury in the rat.

Bacteriogenic sulfur in air pollution

On a yearly basis, the major source of atmospheric sulfur compounds in and near Salt Lake City, Utah, is industrial. Isotopic studies suggest that the next most important source is bacteriogenic sulfur released by anaerobes from muds. On a seasonal basis, the bacteriogenic source of sulfur compounds may rival the industrial source in importance.