A quality appraisal of economic evaluations of community water fluoridation: A systematic review

OBJECTIVES

To critically appraise the methodological conduct and reporting quality of economic evaluations (EE) of community water fluoridation (CWF).

METHODS

A systematic literature search was conducted in general databases and specialist directories of the economic literature. The Consensus on Health Economic Criteria list (CHEC) appraised the methodological quality while the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) assessed the reporting quality of included studies.

RESULTS

A total of 1,138 records were identified, of which 18 met the inclusion criteria. Cost analysis emerged as the most prevalent type of EE, though a growing trend towards conducting full EEs is observed. CHEC revealed the items most frequently unfulfilled were the study design, measurement and valuation of costs and outcomes, while CHEERS also identified reporting deficiencies in these aspects. Furthermore, the review highlights subtleties in methodological aspects that may not be discerned by CHEC, such as the estimation of the impact of fluoridation and the inclusion of treatment savings within cost estimates.

CONCLUSIONS

While numerous studies were conducted before publication of these assessment instruments, this review reveals that a noteworthy subset of studies exhibited good methodological conduct and reporting quality. There has been a steady improvement in the methodological and reporting quality over time, with recently published EEs largely adhering to best practice guidelines. The evidence presented will assist policymakers in leveraging the available evidence effectively to inform resource allocation decisions. It may also serve as a resource for researchers to enhance the methodological and reporting standards of future EEs of CWF.

Ultrasonic testing of thick and thin Inconel 625 alloys manufactured by laser powder bed fusion

Additive manufacturing of alloys enables low-volume production of functional metallic components with complex geometries. Ultrasonic testing can ensure the quality of these components and detect typical defects generated during laser powder bed fusion (LPBF). However, it is difficult to find a single ultrasonic inspection technique that can detect defects in the large variety of geometries generated using LPBF. In this work, phased array ultrasonic testing (PAUT) is suggested to inspect thick LPBF components, while guided waves are explored for thin curved ones. PAUT is used to detect cylindrical lack of fusion defects in thick LPBF rectangular parts. Practical defects are generated by reducing the laser power at prespecified locations in the samples. The defects' shape and density are verified using optical microscopy and X-ray computed tomography. Partially fused defects down to 0.25 mm in diameter are experimentally detected using a 10 MHz PAUT probe with the total focusing method post-processing. The experimental results are compared to defect images predicted by finite element simulations. For thin components with curved geometry, guided waves are used to detect powder-filled cylindrical defects. The waves are generated using piezoelectric transducers, and the spatiotemporal wavefield is measured using a scanning laser Doppler vibrometer. Using root-mean-square imaging of the wavefield, defects down to 1 mm are clearly detected despite the complex internal features in the samples.

Characteristics of wastewater originating from dental practices using predominantly mercury-free dental materials

Dental materials are currently undergoing a revolution. Mercury use, including traditional amalgam (mercury-containing) material used in dental fillings, is now being widely regulated under the Minamata convention, and dental amalgam is currently being replaced by resin formulations in dentistry. These resin-based materials can be tuned to offer varying material properties by incorporation of a range of nano- and micro-particle based 'fillers' for different dental properties and applications. However, these innovations may have a concomitant effect on the waste streams associated with common dental applications, in particular the potential for higher concentrations of novel micro- and nanomaterials within wastewater streams, and a potential route for novel nanomaterials into the wider Environment. These new materials may also mean that wastewater filtering apparatus commonly deployed at present, such as amalgam separators, may be less efficient or insufficient to capture these new filler materials in dental facility wastewater. In this work, we analyse dental wastewater streams from three dental facilities in Ireland with differing amalgam separators in place. The potential overall toxicity, particulate load and physicochemical properties are analysed. The overall risk posed by these new materials is also discussed.

850. Reasons for not Using PrEP and Actions that May Facilitate PrEP Uptake in Ontario and British Columbia, Canada

Background

HIV Pre-exposure prophylaxis (PrEP) is an underutilized intervention to prevent HIV infection in Canada. Known barriers to PrEP uptake include lack of awareness, low HIV risk perception, side effects, PrEP not being publicly funded (which is the case in Ontario) and stigma. We aimed to identify barriers to PrEP use and actions that may facilitate PrEP uptake in Ontario and British Columbia.

Methods

Gay, bisexual and other men who have sex with men 19 years or older living in Ontario and British Columbia, Canada, answered a survey between July 2019 and August 2020. Participants who met Canadian PrEP guideline criteria for PrEP and not already using PrEP indicated which barriers were relevant to them and which actions would make them more likely to start PrEP. We used descriptive statistics and tested differences between Ontario and British Columbia using Chi-square tests for proportions and t-tests or Wilcoxon rank-sum tests for continuous variables.

Results

Of 1527 survey responses, 260 (184 in Ontario and 76 in British Columbia) who were never PrEP users and met criteria for PrEP were included. In Ontario, the most common barriers were affordability (43%) and concern about side effects (42%). In British Columbia, the most common reasons were concern about side effects (41%) and not feeling at high enough risk (36%). In Ontario, the actions that would most likely encourage the respondent to start PrEP were short waiting time (63%), the healthcare provider informing about their HIV risk being higher than perceived (62%) and a written step-by-step guide (60%). In British Columbia, the actions that would most likely encourage the respondent to start PrEP were short waiting time (68%), people speaking publicly about PrEP (68%) and their healthcare provider counselling about: their HIV risk being higher than perceived (64%), side effects of PrEP (64%) and about how PrEP works (62%).

Table. Top reasons for not using PrEP and top actions that might influence the decision to start PrEP stratified by province. (n= 184 in Ontario, n= 76 in British Columbia).

Conclusion

Concern about side effects and not feeling at high enough risk were common barriers. Short waiting times may increase PrEP uptake. In Ontario, the findings suggested lack of affordability. In British Columbia, actions involving healthcare providers were valued.

Disclosures

Kevin Woodward, MD FRCPC, Gilead (Independent Contractor) Darrell Tan, MD PhD, Abbvie (Grant/Research Support)Gilead (Grant/Research Support)GlaxoSmithKline (Scientific Research Study Investigator)ViiV Healthcare (Grant/Research Support)

Catecholamines in neuroblastoma: Driver of hypertension, or solely a marker of disease?

Background

Neuroblastoma is a common solid tumor of childhood and is often associated with hypertension. Potential etiologies contributing to hypertension include renal compression, pain, volume overload, and catecholamine secretion.

Cases

We completed a single center retrospective review of children with neuroblastoma and ≥stage II hypertension (per Hypertension Canada guidelines) over a 2‐year period. All patients (n = 10) had elevated urine normetanephrine levels and eight had intra‐abdominal tumors. Four patients had refractory hypertension requiring > three agents, of which three required alpha/beta blockade.

Conclusion

Although multifactorial, hypertension in neuroblastoma often has a neuroendocrine component. Excess normetanephrine production in neuroblastoma may be a more common hypertensive mechanism than previously appreciated. Urinary normetanephrine elevation could suggest potential neuroendocrine‐mediated hypertension.

Impact of Reducing Water Fluoride on Dental Caries and Fluorosis

Guidance intended to reduce fluoride toothpaste ingestion in early childhood was introduced in Ireland in 2002. In 2007, water fluoride concentration was adjusted from 0.8-1.0 to 0.6-0.8 ppm. The objective of this study was to determine the difference in caries and fluorosis levels following introduction of these 2 policy measures. A before-and-after study compared caries and fluorosis in random samples of 8-y-olds in Dublin (n = 707) and Cork-Kerry (n = 1148) in 2017 with 8-y-olds in Dublin (n = 679) and Cork-Kerry (n = 565) in 2002. Dentinal caries experience (primary teeth, d_3vcmft(cde)) and fluorosis (permanent teeth, Dean's index of very mild or higher) were clinically measured. Lifetime exposure to community water fluoridation (CWF) was classified as "full CWF"/"no CWF." Effect of examination year on caries prevalence and severity and fluorosis prevalence was assessed using multivariate regression adjusting for other explanatory variables. There was little change in commencement of fluoride toothpaste use at ≤24 mo following introduction of toothbrushing guidance. Among children with full CWF, there was no statistically significant difference in caries prevalence or severity between 2017 and 2002. In 2017, caries prevalence was 55% in Dublin (full CWF) and 56% in Cork-Kerry (full CWF), and mean d_3vcmft(cde) among children with caries was 3.4 and 3.7, respectively. Caries severity was less in 2017 (mean 4.2) than 2002 (mean 4.9) among children with no CWF (P = 0.039). The difference in caries severity between children with full CWF and no CWF was less in 2017 than in 2002 (interaction P = 0.013), suggesting a reduced benefit for CWF in 2017. In 2017, fluorosis prevalence was 18% in Dublin (full CWF) and 12% in Cork-Kerry (full CWF). Fluorosis was predominantly "very mild" with no statistically significant difference between 2017 and 2002. CWF at 0.6 to 0.8 ppm is an effective caries-preventive measure. Results suggested low uptake of toothbrushing guidance, a reduced caries-preventive effect for CWF in primary teeth, and no reduction in fluorosis following introduction of the policy measures.

Heterogeneity in the Effects of Food Vouchers on Nutrition Among Low-Income Adults: A Quantile Regression Analysis

PURPOSE

To determine whether baseline fruit and vegetable (FV) intake or other predictors are associated with response to food vouchers (change in FV intake) among low-income adults.

DESIGN

Secondary analysis of a randomized, 2 x 2-factorial, community-based trial.

SETTING

San Francisco, California.

SUBJECTS

359 low-income adults aged ≥21 years old.

INTERVENTION

Participants were mailed $20 of food vouchers monthly for 6 months, and randomized to 1 of 4 arms according to: eligible foods (FV only or any foods) and redemption schedule (weekly or monthly).

MEASURES

Change in FV intake measured in cup equivalents between baseline and month 6 of the trial, based on 24-hour dietary recalls.

ANALYSIS

Quantile multivariate regressions were employed to measure associations between key predictors and change in FV intake across study arms.

RESULTS

FV-only weekly vouchers were associated with increased FV intake at the 25th percentile (0.24 cups/day, p = 0.048) and 50th percentile (0.37 cups/day, p = 0.02) of the distribution, but not at lower and higher quantiles. Response to the vouchers diminished 0.10 cups/day for each additional household member (p = 0.02).

CONCLUSION

Response to food vouchers varied along the FV intake distribution, pointing to some more responsive groups and others potentially needing additional support to increase FV intake. Larger households likely need vouchers of higher dollar value to result in similar changes in dietary intake as that observed in smaller households.

Sustainable treatment systems for removal of pharmaceutical residues and other priority persistent substances

Pharmaceutical residues and other emerging substances commonly summarised as micropollutants pass through wastewater treatment plants (WWTPs) and end up in the receiving waters and sludge. Many studies have investigated the removal efficiency of various techniques but a holistic evaluation of various relevant treatment alternatives regarding both the removal efficiency for various micropollutants, investment and operating costs, environmental impacts and future comprehensiveness is still lacking. This paper provides the results from a large 3-year project about the evaluation of sustainable treatment systems for removal of various micropollutants or disruptive effects at Swedish WWTPs and their environmental, economic and future sustainability. The presented results are based on our own pilot tests and related assessment and modelling efforts and provide a holistic view on advanced treatment of wastewater for removal of micropollutants.

The intergenerational transmission of obesity: The role of time preferences and self-control

Previous research has found that impatient time preferences and self-control problems (present bias) are related to increased obesity risk. However, scant evidence exists pertaining to whether parents' impatience and self-control problems impact the obesity status of their children, too. Accordingly, we explore this study question among a large national sample of US adults and their children. Study results confirm previous findings indicating that intertemporal preferences are related to adults' obesity status. Moreover, these results extend the literature by finding that children of impatient or present-biased parents have a significantly higher likelihood of being obese, too. Specifically, parents' low levels of patience and present bias were each independently related to a five-percentage point increase in the likelihood of obesity of their children. These findings were more pronounced when all children were combined in analyses and for the first child; however, they varied for the second and third child. Thus, findings suggest that parents' time preferences and self-control problems likely affect not only their own weight status but that of their children.

Deal or no deal? The prevalence and nutritional quality of price promotions among U.S. food and beverage purchases

OBJECTIVE

This study examines trends in the prevalence of price promotions among packaged food and beverage purchases, differences in prevalence by household race/ethnicity or income, and the association between price promotions and the nutritional profile of purchases.

DESIGN

This cross-sectional study utilizes a dataset of 90 million purchases from 38,744 (2008) to 45,042 (2012) US households in 2008-2012. Chi-square tests were used to examine whether the proportion of purchases with price promotions changed over time or differed by household race/ethnicity or income. T-tests were used to compare purchased products' nutritional profiles.

RESULTS

Prevalence of price promotions among packaged food and beverage purchases increased by 8% and 6%, respectively, from 2008 to 2012, with both reaching 34% by 2012. Higher-income households had greater proportions of purchases with price promotions than lower-income households. Asian households had the highest proportion of purchases with any price promotion, followed by non-Hispanic whites. While total price-promoted packaged food purchases had higher mean energy, total sugar, and saturated fat densities than purchases with no price promotions, absolute differences were small.

CONCLUSIONS

Prevalence of price promotions among US household purchases increased from 2008 to 2012 and was greater for higher-income households. No clear associations emerged between presence of price promotions and nutritional quality of purchases.

Does breastfeeding duration decrease child obesity? An instrumental variables analysis

BACKGROUND

Many studies have documented that breastfeeding is associated with a significant reduction in child obesity risk. However, a persistent problem in this literature is that unobservable confounders may drive the correlations between breastfeeding behaviors and child weight outcomes.

OBJECTIVE

This study examines the effect of breastfeeding practices on child weight outcomes at age 2.

METHODS

This study relied on population-based data for all births in Oregon in 2009 followed for two years. We used instrumental variables methods to exploit variations in breastfeeding by mothers immediately after delivery and the degree to which hospitals encouraged mothers to breastfeed in order to isolate the effect of breastfeeding practices on child weight outcomes.

RESULTS

We found that for every extra week that the child was breastfed, the likelihood of the child being obese at age 2 declined by 0.82% [95% CI -1.8% to 0.1%]. Likewise, for every extra week that the child was exclusively breastfed, the likelihood of being obese declined by 0.66% [95% CI -1.4 to 0.06%]. While the magnitudes of effects were modest and marginally significant, the results were robust in a variety of specifications.

CONCLUSION

The results suggest that hospital practices that support breastfeeding may influence childhood weight outcomes.

The effect of prices on nutrition: Comparing the impact of product- and nutrient-specific taxes

This paper provides an analysis of the role of prices in determining food purchases and nutrition using very detailed transaction-level observations for a large, nationally-representative sample of US consumers over the period 2002-2007. Using product-specific nutritional information, we develop a new method of partitioning the product space into relevant nutritional clusters that define a set of nutritionally-bundled goods, which parsimoniously characterize consumer choice sets. We then estimate a large utility-derived demand system over this joint product-nutrient space that allows us to calculate price and expenditure elasticities. Using our structural demand estimates, we simulate the role of product taxes on soda, sugar-sweetened beverages, packaged meals, and snacks, and nutrient taxes on fat, salt, and sugar. We find that a 20% nutrient tax has a significantly larger impact on nutrition than an equivalent product tax, due to the fact that these are broader-based taxes. However, the costs of these taxes in terms of consumer utility are only about 70 cents per household per day. A sugar tax in particular is a powerful tool to induce healthier nutritive bundles among consumers.

No Fat, No Sugar, No Salt . . . No Problem? Prevalence of "Low-Content" Nutrient Claims and Their Associations with the Nutritional Profile of Food and Beverage Purchases in the United States

BACKGROUND

Nutrient claims are a commonly used marketing tactic, but the association between claims and nutritional quality of products is unknown. The objective of this study was to examine trends in the proportion of packaged food and beverage purchases with a nutrient claim, whether claims are associated with improved nutritional profile, and whether the proportion of purchases with claims differs by race/ethnicity or socioeconomic status.

METHODS

This cross-sectional study examined nutrient claims on more than 80 million food and beverage purchases from a transaction-level database of 40,000 US households from 2008 to 2012. χ² Tests were used to examine whether the proportion of purchases with a low/no-content claim changed over time or differed by race/ethnicity or household socioeconomic status. Pooled transactions were examined using t-tests to compare products' nutritional profiles overall and by food and beverage group.

RESULTS

Thirteen percent of food and 35% of beverage purchases had a low-content claim. Prevalence of claims among purchases did not change over time. Low-fat claims were most prevalent for both foods and beverages (10% and 19%, respectively), followed by low-calorie (3% and 9%), low-sugar (2% and 8%), and low-sodium (2% for both) claims. Compared to purchases with no claim, purchases with any low-content claim had lower mean energy, total sugar, total fat, and sodium densities. However, the association between particular claim types and specific nutrient densities varied substantially, and purchases featuring a given low-content claim did not necessarily offer better overall nutritional profiles or better profiles for the claimed nutrient, relative to products without claims. In addition, there was substantial heterogeneity in associations between claims and nutrient densities within food and beverage groups.

CONCLUSIONS

Variations in nutrient density by claim type and food and beverage group suggests that claims may have differential utility for certain foods or nutrients and, in some cases, may mislead about the overall nutritional quality of the food.

Economic preferences and fast food consumption in US adults: Insights from behavioral economics

OBJECTIVE

To examine the relationship between economic time preferences and frequency of fast food and full-service restaurant consumption among U.S. adults.

METHODS

Participants included 5871U.S. adults who responded to a survey conducted in 2011 pertaining to the lifestyle behaviors of families and the social context of these behaviors. The primary independent variable was a measure of time preferences, an intertemporal choice assessing delay discounting. This was elicited via responses to preferences for an immediate dollar amount or a larger sum in 30 (30-day time horizon) or 60days (60-day time horizon). Outcomes were the frequency of fast food and full-service restaurant consumption. Ordered logistic regression was performed to examine the relationship between time preferences and food consumption while adjusting for covariates (e.g. socio-demographics).

RESULTS

Multivariable analysis revealed that higher future time preferences were significantly related to less frequent fast food intake for both the 30- and 60-day time horizon variables (P for linear trend <0.05; both). Notably, participants with the highest future time preference were significantly less likely to consume fast food than those with very low future time preferences (30-day: OR=0.74, 95%CI: 0.62-0.89; and 60-day: OR=0.86, 95%CI: 0.74-1.00). In comparison, higher future time preferences were not significantly associated with full-service restaurant intake (30-day: p for linear trend=0.73; 60-day: p for linear trend=0.83).

CONCLUSIONS

Higher future time preferences were related to a lower frequency of fast food consumption. Utilizing concepts from behavioral economics (e.g. pre-commitment contracts) to facilitate more healthful eating is warranted using experimental studies.

Within-family obesity associations: evaluation of parent, child, and sibling relationships

BACKGROUND

How parent and sibling obesity status comparatively shape a child's obesity is unknown.

PURPOSE

To investigate how the obesity status of different children within the same family is related to a parent or sibling's obesity.

METHODS

A national sample of adults in 10,244 American households was surveyed during 2011; data were analyzed in 2012-2013. Of these households, 1,948 adults had one or two children; provided sociodemographic information; and reported on adult and child height and weight, physical activity, and food environment. Logistic regression models were estimated in which the outcome of interest was child obesity status, with parent and sibling obesity as key predictors, adjusting for a range of both adult and child social and demographic confounders.

RESULTS

In one-child households, it was 2.2 times more likely (SE=0.5) that the child would be obese if a parent was obese. In households with two children, having an obese younger sibling was more strongly associated with elder-child obesity (OR=5.4, SE=1.9) than parent's obesity status (OR=2.3, SE=0.8). Having an obese elder sibling was associated with younger-child obesity (OR=5.6, SE=1.9), and parent obesity status was no longer significant. Within-family sibling obesity was more strongly patterned between siblings of the same gender than between different genders, and child physical activity was significantly associated with obesity status.

CONCLUSIONS

Considering offspring composition and sibling gender may be beneficial in childhood obesity prevention and intervention.

Milestones in oral health services in the Republic of Ireland

With the many changes occurring in Ireland it would seem an opportune time to review the body of research conducted and policy enacted in the Republic of Ireland on oral health services and oral health. The dental health of the nation prior to water fluoridation, the legislation and policy decisions impacting on oral health up to budgetary changes, and the production of evidence-based guidelines will be discussed. The first national survey of dental health was conducted in Ireland in 1952 - 'Dental Caries in Ireland'. In the intervening 60 years, further surveys of the oral health of people in Ireland have been carried out. Legislation, surveys and policy documents that have shaped dentistry and the oral health of the population are set out in Tables 1 and 2. A more comprehensive description of the policies can be found in the thesis submitted in fulfilment of Masters in Dental Public Health (MDPH) by the lead author.

A new index to measure tooth wear--methodolgy and practical advice

A new tooth wear index, designed to measure stages of tooth wear in enamel and dentine is presented. The index measures the lateral spread of wear in enamel and the depth of tooth wear in dentine. The index scores enamel loss at 5 levels and 6 levels in dentine and provides a more sensitive index for monitoring the progression of wear than older indices. The protocols and methods of the index are described and incorporate refinements based on the combined experiences of two independent studies conducted on adults and children. The findings of both studies are summarised and recommendations are made for future studies which investigate the prevalence of tooth wear in adults or children.

Merimepodib, pegylated interferon, and ribavirin in genotype 1 chronic hepatitis C pegylated interferon and ribavirin nonresponders

Merimepodib (MMPD) is an orally administered, inosine monophosphate dehydrogenase inhibitor that has shown antiviral activity in nonresponders with chronic hepatitis C (CHC) when combined with pegylated interferon alfa 2a (Peg-IFN-alfa-2a) and ribavirin (RBV). We conducted a randomized, double-blind, multicenter, phase 2b study to evaluate the antiviral activity, safety, and tolerability of MMPD in combination with Peg-IFN-alfa-2a and RBV in patients with genotype 1 CHC who were nonresponders to prior therapy with Peg-IFN and RBV. Patients received 50 mg MMPD, 100 mg MMPD, or placebo every 12 hours, in addition to Peg-IFN-alfa-2a and RBV, for 24 weeks. Patients with a 2-log or more decrease from baseline or undetectable hepatitis C virus (HCV) RNA levels at week 24 were then eligible to continue Peg-IFN-alfa-2a and RBV for a further 24 weeks, followed by 24 weeks of follow-up. The primary efficacy endpoint was sustained virological response (SVR) rate at week 72 in all randomized patients who received at least one dose of study drug and had a history of nonresponse to standard therapy. A total of 354 patients were randomized to treatment (117 to placebo; 119 to 50 mg MMPD; 118 to 100 mg MMPD), and 286 completed the core study. The proportion of patients who achieved SVR was similar among the treatment groups: 6% (6/107) for 50 mg MMPD, 4% (5/112) for 100 mg MMPD, and 5% (5/104) for placebo (P = 0.8431). Adverse-event profiles for the MMPD combination groups were similar to that for Peg-IFN-alfa and RBV alone. Nausea, arthralgia, cough, dyspnea, neutropenia, and anemia were more common in patients taking MMPD.

CONCLUSION

The addition of MMPD to Peg-IFN-alfa-2a and RBV combination therapy did not increase the proportion of nonresponder patients with genotype 1 CHC achieving an SVR.

Contributions of the kinase cross-reactivity profile of MK-0457 to clinical activity

7050

Background: MK-0457 was designed as a small-molecule inhibitor of the Aurora kinases, AUR A, B, and C (Ki,app = 0.66–18 nM). Kinase screens indicate high selectivity of MK-0457 over other Ser/Thr kinases, but nM potency against a small set of wild type and mutant Tyr kinases, including BCR-ABL, JAK-2, and FLT-3. Consistent with this biochemical profile, MK-0457 has clinical activity in patients with chronic myeloid leukemia (CML) and acute lymphocytic leukemia (ALL) with the T315I BCR-ABL mutation and in patients with JAK-2 positive myeloproliferative diseases (MPD). This study compared the enzyme inhibitory profile of MK0457 with kinase inhibition profiles in cell models to further associate biological and clinical activity. Methods: MK-0457 was tested against a panel of ∼200 kinases (at Km for ATP). Viability of BaF3 cells transfected with wild type or mutant BCR-ABL or FLT3 (D845Y and FLT3-ITD mutants) was measured in MTS assays (72 hrs). Cell cycle profiles were determined by FACS analyses. Cellular inhibition of kinase activities was measured by Western Blots using phospho-substrate specific antibodies. Results: In enzyme profiling, MK-0457 (200 nM) shows = 50% inhibition of ABL, T315I ABL, ABL2, FLT-3, FLT-3 D835Y, BMX, JAK2, YES, LYN, and LCK kinases. Western blot analyses indicate nM IC50s for inhibition of phosphorylation of AUR B, Histone H3 (AUR B substrate), FLT-3, BCR-ABL, and STAT5 (substrate of BCR-ABL and FLT-3 mutants). In addition to AUR kinase inhibition, the Tyr kinases are expected to be inhibited at clinical doses of 24–32 mg/m2/hr (achieving plasma exposures of >1 μM in patients). Depsite its multi-kinase profile, MK-0457 induces similar cytotoxicity (IC50 ∼300 nM) and shows an AUR B-like inhibitory phenotype of G2/M arrest, endoreduplication and apoptosis in BaF3 cells transfected with ABL or FLT-3 (mutant and wild type) kinases. Conclusions: MK-0457 is a potent Aurora kinase inhibitor with cross-reactivity against a small set of Tyr kinases. Although MK-0457 displays an AUR inhibition phenotype in cells, inhibition of these Tyr kinases may contribute to its observed clinical activity in T315I mutant CML and ALL and in JAK-2 positive MPD.

No significant financial relationships to disclose.

Human Milk Vacuolating Cytotoxin A Immunoglobulin A Antibodies ModifyHelicobacter pyloriInfection in Gambian Children

We collected data, including the weights, urea breath test results, and presence of maternal milk cytotoxin-associated gene-specific and vacuolating cytotoxin A-specific immunoglobulin A monthly from 48 mothers and infants (to 44 weeks of age) in The Gambia. In all, 11 children (23%) had negative urea breath test results, and 37 (77%) had positive results. Weight loss associated with Helicobacter pylori colonization was restricted to children whose mothers did not produce anti-vacuolating cytotoxin A antibodies in their milk (P=.028, by t test).

A phase II study of the safety and efficacy of the MDR inhibitor VX-710 combined with doxorubicin and vincristine in small cell lung cancer

17001

Background: Tumors with multidrug resistance (MDR) frequently show upregulation of efflux proteins MDR protein (MRP-1) and P-glycoprotein (Pgp). MDR represents a major obstacle to successful chemotherapy treatment and can be reversed in Pgp or MRP1-expressing cells by the MDR inhibitor VX-710. A phase II study was designed to evaluate the safety/tolerability and efficacy of VX-710 combined with doxorubicin (D) and vincristine (V) in patients (pts) with relapsed SCLC. Methods: Eligible pts had progressive, measurable disease and a PS <2 after response to 1st-line chemotherapy. Stage I safety evaluation was done with planned expansion to a second stage if 9 responses were confirmed in the first 35 pts. Pts were treated with VX-710 (120 mg/m2/h) for 72 hours with D (45 mg/m2) and V (1.4 mg/m2) given 4 hours after the start of VX-710. Pts were treated q 21 days until progression or intolerable adverse events (AEs). Severe neutropenia was noted in the first 15 pts, so the protocol was amended to include prophylactic G-CSF or ciprofloxacin. Interim analysis was performed after 36 pts were treated. Results: 36 pts were enrolled from 12/98 to 12/00. Neutropenia was the major toxicity, occurring in 25/36 (69%) pts. This was more severe (30% vs. 20% grade 4) and occurred earlier (58% vs. 38% in cycle 1) among the 15 pts enrolled prior to an amendment requiring neutropenia prophylaxis vs. those enrolled afterward. Other common treatment-related AE’s: asthenia (53%), nausea (50%), constipation (44%), alopecia (42%), dyspnea (42%), anemia (42%). 67% were grade 1 or 2 in severity. Four pts died on study or within 30 days of termination: 2 from infections likely related to therapy and 2 from disease progression. Among 32 evaluable pts, 7 (22%) had partial responses; 6 of these sustained responses through 6 cycles (with one response lasting 3 years). Three additional pts had unconfirmed responses. Median survival was 6 months (95% CI 4–7 months). Conclusions: The addition of VX-710 to D and V therapy did not improve anti-tumor activity or survival. Hematologic toxicity was severe, causing 2 pt deaths from neutopenic fever. Although there were some durable responses, response criteria were not met to proceed with stage 2. Further development with VX-710 has since stopped.

[Table: see text]

Early Helicobacter pylori colonisation: the association with growth faltering in The Gambia

BACKGROUND

Helicobacter pylori is one of the commonest causes of chronic infection of mankind, yet the natural history of acute infection is poorly understood. Some studies suggest that gastric colonisation with H pylori is associated with suboptimal nutrition and growth in childhood.

AIMS

To describe the clinical features of early H pylori colonisation and assess its role in the development of infant malnutrition and growth faltering.

METHODS

Two consecutive prospective longitudinal cohort studies were conducted at the Medical Research Council Laboratories in a rural community in The Gambia, West Africa. The first birth cohort of 125 infants was followed by a second of 65 children from the same community. H pylori colonisation was detected by sequential 13C urea breath tests, and infant growth was monitored by serial measurements.

RESULTS

Children with early H pylori colonisation became significantly lighter, shorter, and thinner than their peers in late infancy. The association was found in both cohorts. No socioeconomic or demographic confounding variables were identified to explain this, and the weight deficit was no longer detectable when the children were aged 5-8 years.

CONCLUSIONS

Results suggest that H pylori colonisation in early infancy predisposes to the development of malnutrition and growth faltering, although the effect did not persist into later childhood.

Identification and reconstitution of the yeast mitochondrial transporter for thiamine pyrophosphate

The genome of Saccharomyces cerevisiae contains 35 members of a family of transport proteins that, with a single exception, are found in the inner membranes of mitochondria. The transport functions of the 15 biochemically identified mitochondrial carriers are concerned with shuttling substrates, biosynthetic intermediates and cofactors across the inner membrane. Here the identification of the mitochondrial carrier for the essential cofactor thiamine pyrophosphate (ThPP) is described. The protein has been overexpressed in bacteria, reconstituted into phospholipid vesicles and identified by its transport properties. In confirmation of its identity, cells lacking the gene for this carrier had reduced levels of ThPP in their mitochondria, and decreased activity of acetolactate synthase, a ThPP-requiring enzyme found in the organellar matrix. They also required thiamine for growth on fermentative carbon sources.

De novo lipogenesis during controlled overfeeding with sucrose or glucose in lean and obese women

BACKGROUND

The results of previous studies suggest that de novo lipogenesis may play an important role in the etiology of obesity, particularly during overconsumption of different carbohydrates.

OBJECTIVE

We hypothesized that de novo lipogenesis would increase during overfeeding, would vary depending on the type of carbohydrate consumed, and would be greater in obese than in lean women.

DESIGN

De novo lipogenesis was measured during 96 h of overfeeding by 50% with either sucrose or glucose and during an energy balance treatment (control) in 8 lean and 5 obese women. De novo lipogenesis was determined by measuring the amount of deuterium incorporation into plasma triacylglycerols. Fat and carbohydrate balance were measured simultaneously by continuous whole-body calorimetry.

RESULTS

De novo lipogenesis did not differ significantly between lean and obese subjects, except with the control treatment, for which de novo lipogenesis was greater in the obese subjects. De novo lipogenesis was 2- to 3-fold higher after overfeeding by 50% than after the control treatment in all subjects. The type of carbohydrate overfeeding (sucrose or glucose) had no significant effect on de novo lipogenesis in either subject group. Estimated amounts of absolute VLDL production ranged from a minimum of 2 g/d (control) to a maximum of 10 g/d after overfeeding. This compares with a mean fat balance of approximately 275 g after 96 h of overfeeding. Individual subjects showed characteristic amounts of de novo lipogenesis, suggesting constitutive (possibly genetic) differences.

CONCLUSION

De novo lipogenesis increases after overfeeding with glucose and sucrose to the same extent in lean and obese women but does not contribute greatly to total fat balance.

Extrapancreatic pseudoaneurysm after pancreas transplantation

Pseudoaneurysms after pancreatic transplantation are an infrequent event. Repair usually involves removal of the transplant. We describe a patient with a pseudoaneurysm associated with pancreatic transplantation. The pseudoaneurysm originated from the external iliac artery distal to the donor Y-graft anastomosis. Diagnosis was made by duplex ultrasound. Surgical repair was effected through a retroperitoneal incision enabling vascular control. The patient has done well postoperatively, and with 1-year follow-up, continues to have normal renal and pancreatic allograft function.

Comparison of recoveries in breath carbon dioxide of H13CO-3 and H14CO-3 administered simultaneously by single 6 h constant unprimed intravenous infusion

The aim of this study was to assess the bioequivalence of H13CO-3 and H14CO-3, by administering both labels simultaneously by single infusion and comparing their recovery in breath CO2 and urinary urea. Six healthy male subjects (age range 24-41 years; weight 76.7 (sd, 18.6) kg; height 1.79 (sd 0.05) m) were infused with unprimed solutions of HCO3- (110.0 mmol/kg) labelled with 13C (0.76 mmol 13C/h) and 14C (48 Bq/h) at a constant rate for 6 h, in a whole-body calorimeter (1400 litres) for measurement of CO2 production. Samples of breath were collected hourly in a Douglas bag and all urine was collected into two batches (0-4 h and 4-6 h) for estimating recovery of infused label by measurement of enrichment or specific activity. Recovery in breath CO2 of both labels increased from about 25 % for the first hour to 88 % and above for hours 3-4 onwards. Mean recovery of 13C in breath CO2 was slightly higher than that of 14C for all periods (mean difference always less than 1 % of infused label) but was significant only for the first 3 h (P < 0.05). Recovery of 14C in urea was significantly higher (P < 0.01) than 13C, but was confounded by substantial variability and uncertainties concerning 13CO2 background enrichments. These results suggest that there is no compelling need to alter factors currently used for recovery of 14C in breath when using 13C instead, and vice versa.

13C and H2 breath tests to study extent and site of starch digestion in children with cystic fibrosis

BACKGROUND

Starch is an important source of energy for children with cystic fibrosis, but little is known about their capacity to digest it.

METHODS

A 13C breath test was used to measure starch digestion and oxidation in 16 children with cystic fibrosis (median [range] age, 7.9 [4-15] years; 7 girls, 9 boys) and 5 normal healthy control subjects (median age, 8.3 [7-13] years; 3 girls, 2 boys). A test meal of 13C flour and lactulose was consumed and breath samples were obtained half-hourly thereafter for 6 hours to measure 13C enrichment by isotope ratio mass spectrometry and H2 by electrochemistry. The test was repeated on 10 children with cystic fibrosis when they were taking pancreatic supplements.

RESULTS

The median (range) cumulative percentage 13C dose recovery (cPDR), was 35% (18-52%) in control subjects, 18% (9-33%) in children with cystic fibrosis without enzymes, and 29% (22-51%) in those with pancreatic supplements. cPDR differed significantly between healthy control subjects and children with cystic fibrosis without enzymes (p = 0.01) and between children with cystic fibrosis with and without enzymes (p < 0.0001), but there was no difference between control subjects and children with cystic fibrosis taking enzymes (p = 0.5). Eight children with cystic fibrosis had a cPDR within control range, and in six there was a second peak in 13CO2 enrichment coincident with an increase in H2.

CONCLUSIONS

Starch digestion and oxidation are diminished in children with cystic fibrosis, but pancreatic enzymes restored them to near normal levels. A second peak in 13CO2 enrichment, suggestive of colonic starch fermentation was absent in healthy children, but present in some children with cystic fibrosis and abolished by pancreatic enzymes.

Interpreting the 13C-urea breath test among a large population of young children from a developing country

The 13C-urea breath test is a noninvasive tool for the diagnosis of gastric Helicobacter pylori infection. However, it has not been validated in young children from the developing world, where infection is very common. 13C urea breath tests were performed on 1532 occasions on 247 Gambian infants and children aged from 3 to 48 mo. The means and variances of the separate sub-populations of 13C enrichment results contained within the overall dataset were estimated by a Genstat procedure using the EM algorithm, thereby identifying a cut-off value to discriminate positive from negative results. To illustrate the appropriateness of this calculated cut-off value, 13C urea breath tests were performed upon a small group of 14 patients aged 6 to 28 mo undergoing diagnostic upper endoscopy. Fixed gastric antral biopsies were examined to identify H. pylori. Two subpopulations were identified within the large dataset. A cut-off value of 5.47 delta per thousand relative to Pee Dee Belemnite limestone above baseline at 30 min identified 95% of the normally distributed negative sub-population and 99.4% of the log normal distributed positive sub-population. Comparison with endoscopic data confirmed that this cut-off value was appropriate for this population, as 7/7 children without H. pylori on their gastric biopsies had negative urea breath tests, and 6/7 children with gastric H. pylori colonization had positive urea breath tests. These findings confirm the value of the urea breath test as a diagnostic tool in young children from developing countries. They also offer a way to calculate the most appropriate cut-off value for use in different populations and the likelihood that it will correctly assign any value into the appropriate sub-population, without the need for endoscopy.

Development of fat digestion in infancy

AIM

To measure the development of fat digestion in early life, using a stable isotope breath test.

METHODS

A combined longitudinal and cross sectional study was performed on 30 term and preterm infants using 13C-labelled mixed triglyceride (MTG). Seventy six tests were performed in all. Results were expressed as cumulative percentage dose recovered over 6 hours (cPDR).

RESULTS

Eighteen of 34 tests performed on infants under 30 days of age showed cPDRs below the normal range for adults and older children. The remainder of tests, performed on infants over 57 days of age, all showed cPDRs within the normal range. Peak PDR correlated significantly (r = 0. 928, p<0.01) with cPDR.

CONCLUSION

The capacity to digest fat is incomplete at birth, but quickly develops to normal levels during the first months of life. The MTG breath test is a useful non-invasive method to measure the development of fat digestion in early life.

Helicobacter pylori colonization in early life

Helicobacter pylori infection is a major cause of upper gastrointestinal disease throughout the world. Colonization begins in childhood, although little is known about its age of onset, rate, or mode of colonization. Our aim was to identify the age of acquisition of H. pylori colonization in Gambian children. A cohort of 248 Gambian children aged 3 to 45 months was studied at intervals of 3 months for 2 years, using the 13C-urea breath test, specific IgM and specific IgG serology. The prevalence of positive breath tests rose from 19% at 3 months of age to 84% by age 30 months. Elevated specific IgG and IgM antibody levels were associated with positive breath tests, although there was discrepancy between breath test results and serology, particularly IgG serology, during the 1st year of life. Neither IgG nor IgM serology could be validated as reliable diagnostic tools for infant H. pylori colonization compared with the 13C-urea breath test. Reversion to negative breath test, in association with declining specific antibody levels, occurred in 48/248 (20%) of children. On the assumption that the 13C-urea breath test is a reliable index of H. pylori colonization, we conclude that the infection is extremely common from an early age in Gambian children. Transient colonization may occur. Previous studies relying on serodiagnosis may have significantly underestimated the true early prevalence of colonization in the developing world, where the target age for intervention studies is probably early infancy.

New purchasing measures for stellar performance

According to this article, many manufacturing companies evaluate their purchasing departments using inappropriate measures. One reason is that the measures chosen are easy to use. Another is that the companies tend to favor predictability, and they thus prefer numbers that they can try to achieve. But predictability is not always a virtue. In fact, an obsession with predictability can prevent the kind of flexibility that is often necessary to respond to changes in the market. The article suggests that the best measures to use in evaluating purchasing departments are behavior measures, not price, delivery, or quality measures.

Disentangling the overlap between Tourette's disorder and ADHD

OBJECTIVE

To identify similarities and differences in neuropsychiatric correlates in children with Tourette's syndrome (TS) and those with ADHD.

METHOD

The sample consisted of children with Tourette's syndrome with ADHD (N = 79), children with Tourette's syndrome without ADHD (N = 18), children with ADHD (N = 563), psychiatrically referred children (N = 212), and healthy controls (N = 140).

RESULTS

Disorders specifically associated with Tourette's syndrome were obsessive compulsive disorder (OCD) and simple phobias. Rates of other disorders, including other disruptive behavioral, mood, and anxiety disorders, neuropsychologic correlates, and social and school functioning were indistinguishable in children with Tourette's and ADHD. However, children with Tourette's syndrome plus ADHD had more additional comorbid disorders overall and lower psychosocial function than children with ADHD.

CONCLUSIONS

These findings confirm previously noted associations between Tourette's syndrome and OCD but suggest that disruptive behavioral, mood, and anxiety disorders as well as cognitive dysfunctions may be accounted for by comorbidity with ADHD. However, Tourette's syndrome plus ADHD appears to be a more severe condition than ADHD alone.

Importance of measuring CO2-production rate when using 13C-breath tests to measure fat digestion

Stable isotope breath tests offer a safe, repeatable non-invasive method of measuring fat digestion. They involve the ingestion of a substrate labelled with 13C followed by serial measurements of the 13C:12C ratio in expired CO2, from which the percentage of the 13C dose recovered (PDR) can be calculated. However PDR depends on the CO2-production rate. Our aim was to compare results obtained using directly measured CO2-production rates with those calculated from two predicted values. Twelve normal healthy children and twenty-four children with cystic fibrosis (CF) (without or with the normal dose of enzyme supplementation) were studied with 1,3-distearyl, 2[carboxyl-13C] octanoyl glycerol. The volume of CO2 produced (litres/min) was measured at rest for 30 min approximately 3 h after substrate ingestion, and the results were converted to mmol/min. For each subject the expected BMR was calculated from the equation of Schofield (1985), based on sex, age, weight and height, and from these values, CO2-production rate was derived. Surface area was calculated and an estimated value of 5 mmol/m2 per min (Shreeve et al. 1970) was used. Using these three CO2-production rates, three different PDR were calculated and compared. In healthy children there was a close concordance between measured and predicted CO2-production rates, but children with CF had a mean measured CO2-production rate 39% higher than normal children. This use of normal data for predicted CO2-production rates in children with CF underestimates cumulative PDR. If direct measurements of CO2-production rate are not available or impossible to perform the VCO2 obtained from the BMR calculated using the equations of Schofield (1985) or Shreeve et al. (1970) can be used in normal children. However, if accurate results for PDR are to be obtained, CO2-production rates should be measured when performing breath tests in conditions where energy expenditure and/or CO2-production rate are not expected to be normal.

Effectiveness and tolerability of tomoxetine in adults with attention deficit hyperactivity disorder

OBJECTIVE

The authors assessed the experimental noradrenergic compound tomoxetine as an alternative treatment for adult attention deficit hyperactivity disorder (ADHD).

METHOD

They conducted a double-blind, placebo-controlled, crossover study of tomoxetine in 22 adults with well-characterized ADHD.

RESULTS

Treatment with tomoxetine at an average oral dose of 76 mg/day was well tolerated. Drug-specific improvement in ADHD symptom was highly significant overall and sufficiently robust to be detectable in a parallel-groups comparison restricted to the first 3 weeks of the protocol. Eleven of 21 patients showed improvement after receiving tomoxetine, compared with only two of 21 patients who improved after receiving placebo. Significant tomoxetine-associated improvement was noted on neuropsychological measures of inhibitory capacity from Stroop tests.

CONCLUSIONS

This preliminary study showed that tomoxetine was effective in treating adult ADHD and was well tolerated. These promising results provide support for further studies of tomoxetine over an extended period of treatment.