COVID-19 outcomes in haemopoietic stem cell transplant recipients in Western Australia: the value of vaccination and antiviral therapy

Coronavirus-19 (COVID-19) mortality rates among haemopoietic stem cell transplant (HSCT) patients are high, ranging between 20% and 40%. We prospectively evaluated the mortality outcomes of COVID-19 in Western Australian HSCT patients. A total of 32/492 (6.5%) HSCT recipients contracted COVID-19 during the study, of whom 30/32 (94%) developed mild or asymptomatic disease. Two allogeneic HSCT patients were hospitalised for severe COVID-19; one patient died. Stringent healthcare, social isolation practices, aggressive vaccination programmes and rapid access to COVID-19 antivirals may have promoted mild COVID-19 illness in Western Australian HSCT patients, resulting in one of the lowest COVID-19 mortality rates in HSCT recipients worldwide.

Follow-up of the re-evaluation of quillaia extract (E 999) as a food additive and safety of the proposed extension of uses

Quillaia extract (E 999) was re-evaluated in 2019 by the EFSA Panel on Food Additives and Flavourings (FAF). EFSA derived an acceptable daily intake (ADI) of 3 mg saponins/kg bw per day for E 999. Following a European Commission call for data to submit data to fill the data gaps, the present follow-up opinion assesses data provided by interested business operators (IBOs) to support an amendment of the EU specifications for E 999. Additionally, this opinion deals with the assessment of the proposed extension of use for E 999 in food supplements supplied in a solid and liquid form, excluding food supplements for infants and young children and, as a carrier in botanical nutrients. The Panel concluded that the proposed extension of use, if authorised, could result in an exceedance of the ADI at the maximum of the ranges of the mean for children, adolescents and the elderly, and for all populations at the 95th percentile. An additional proposed extension of use for E 999 to be used as a carrier for glazing agents on entire fresh fruits and vegetables has been received. Since no information on the proposed use levels of E 999 on a saponins content basis has been provided by this applicant, the Panel was not able to evaluate the safety of this extension of use. Considering the technical data submitted, the Panel recommended some modifications of the existing EU specifications for E 999, mainly to lower the limits for lead, mercury and arsenic and to include a maximum limit for cadmium and for calcium oxalate. The Panel also recommended that the limits would be expressed on a saponins basis. The Panel proposed to revise the definition of E 999 to better describe the composition in a qualitative way.

Re-evaluation of erythritol (E 968) as a food additive

This opinion addresses the re-evaluation of erythritol (E 968) as food additive and an application for its exemption from the laxative warning label requirement as established under Regulation (EU) No 1169/2011. Erythritol is a polyol obtained by fermentation with Moniliella pollinis BC or Moniliella megachiliensis KW3-6, followed by purifications and drying. Erythritol is readily and dose-dependently absorbed in humans and can be metabolised to erythronate to a small extent. Erythritol is then excreted unchanged in the urine. It does not raise concerns regarding genotoxicity. The dataset evaluated consisted of human interventional studies. The Panel considered that erythritol has the potential to cause diarrhoea in humans, which was considered adverse because its potential association with electrolyte and water imbalance. The lower bound of the range of no observed adverse effect levels (NOAELs) for diarrhoea of 0.5 g/kg body weight (bw) was identified as reference point. The Panel considered appropriate to set a numerical acceptable daily intake (ADI) at the level of the reference point. An ADI of 0.5 g/kg bw per day was considered by the Panel to be protective for the immediate laxative effect as well as potential chronic effects, secondary to diarrhoea. The highest mean and 95th percentile chronic exposure was in children (742 mg/kg bw per day) and adolescents (1532 mg/kg bw per day). Acute exposure was maximally 3531 mg/kg bw per meal for children at the 99th percentile. Overall, the Panel considered both dietary exposure assessments an overestimation. The Panel concluded that the exposure estimates for both acute and chronic dietary exposure to erythritol (E 968) were above the ADI, indicating that individuals with high intake may be at risk of experiencing adverse effects after single and repeated exposure. Concerning the new application, the Panel concluded that the available data do not support the proposal for exemption.

Safety evaluation of the food additive steviol glycosides, predominantly Rebaudioside M, produced by fermentation using Yarrowia lipolyticaVRM

The EFSA Panel on Food Additive and Flavourings (FAF Panel) provides a scientific opinion on the safety of a new process to produce steviol glycosides by fermentation of simple sugars using a genetically modified strain of Yarrowia lipolytica (named Y. lipolytica VRM). The manufacturing process may result in impurities different from those that may be present in the other steviol glycosides E 960a-d, therefore the Panel concluded that separate specifications are required for the food additive produced as described in the current application. Viable cells and DNA from the production strain are not present in the final product. The Panel considered that the demonstration of the absence of kaurenoic acid in the proposed food additive, using a method with a limit of detection (LOD) of 0.3 mg/kg, is adequate to dispel the concerns for potential genotoxicity. Given that all steviol glycosides follow the same metabolic pathways, the Panel considered that the current steviol glycosides would fall within the same group of substances. Therefore, the Panel considered that the already existing data on rebaudioside M and structurally related steviol glycosides are sufficient, and a similar metabolic fate and toxicity is expected for the food additive. The results from the bacterial reverse mutation assay and the in vitro micronucleus assay were negative and indicated absence of genotoxicity from the food additive. The existing acceptable daily intake (ADI) of 4 mg/kg body weight (bw) per day, expressed as steviol equivalents, was considered to be applicable to the proposed food additive. The Panel concluded that there is no safety concern for steviol glycosides, predominantly Rebaudioside M, produced by fermentation using Y. lipolytica VRM, to be used as a food additive at the proposed uses and use levels.

Safety evaluation of synthesised DNA oligonucleotides as a food additive

The EFSA Panel on Food Additives and Flavourings (FAF) was requested to evaluate the safety of synthesised DNA oligonucleotides as a new food additive, in accordance with Regulation (EC) No 1331/2008. Considering that the additional information requested by the Panel during the risk assessment was not provided by the applicant, the assessment was concluded on the basis of the sole information available in the application. The proposed food additive consists of purified synthetic DNA sequences intended to be used for traceability purposes, alone or combined with carriers. Information provided by the applicant on the identity, characterisation and production process of the proposed food additive was considered insufficient. The Panel considered that the product specifications as proposed by the applicant do not adequately define and characterise the proposed food additive. The applicant proposed for the food additive the maximum use levels of 0.001 mg/kg for a variety of food categories. The food additive was also proposed as a Group I additive at a specific maximum level of quantum satis. The applicant did not provide exposure estimates according to the EFSA ANS Panel guidance (2012). No biological or toxicological data were provided by the applicant for the proposed food additive. Considering the inadequate information available and the uncertainty introduced by the proposal at quantum satis, along with the insufficient specifications, the Panel could not conclude on the safety of the food additive as proposed and described by the applicant.

Physician Assistant Student Attitudes About People With Serious Mental Illness

PURPOSE

This study explored the attitudes of physician assistant (PA) students toward the future care of individuals with serious mental illness (SMI). Physician assistant student education offers a unique opportunity to confront and reduce bias toward individuals with SMI. However, no previous literature has documented PA student attitudes toward SMI.

METHODS

Preclinical students (n = 7) from a single PA program were invited to participate in 2 focus groups exploring attitudes toward the future care of patients with SMI. The focus groups lasted approximately 60 minutes and were conducted by non-PA faculty using a question guide.

RESULTS

Four themes emerged from interviews: perceptions about the population, knowledge of mental health conditions, approach to care, and program curriculum input.

CONCLUSION

Several themes aligned with the participant's level of training. Participants demonstrated didactic knowledge yet lacked clinical exposure to provide context. Future studies should focus on developing interactive learning techniques to prepare students for patients with SMI.

Scientific opinion on the renewal of the authorisation of Fumokomp (SF-009) as a smoke flavouring Primary Product

The EFSA Panel on Food Additives and Flavourings (FAF) was requested to evaluate the safety of the smoke flavouring Primary Product Fumokomp (SF-009), for which a renewal application was submitted in accordance with Article 12(1) of Regulation (EC) No 2065/2003 (in the renewal application the Primary Product is reported as 'Fumokomp Conc.'). This opinion refers to an assessment of data submitted on chemical characterisation, dietary exposure and genotoxicity of the Primary Product. Fumokomp Conc. is produced by pyrolysis of beech and hornbeam woods. Gas chromatography-mass spectrometry (GC-MS) was applied for both identification and quantification of the volatile constituents of the Primary Product. Given the limitations of the method, the Panel cannot judge with confidence whether the applied method meets the legal quality criterion that at least 80% of the volatile fraction shall be identified and quantified. Moreover, the Panel concluded that the absence of furan-2(5H)-one from the Primary Product was not convincingly demonstrated. At the maximum proposed use levels, dietary exposure estimates calculated with FAIM ranged from 0.04 to 0.9 mg/kg body weight (bw) per day at the mean and from 0.1 to 1.5 mg/kg bw per day at the 95th percentile. The information available on the 32 identified components of the Primary Product, although limited, did not indicate a concern for genotoxicity for any of these substances. However, whole mixture testing in an in vitro mouse lymphoma assay gave positive results which would require an adequate in vivo follow-up study. In addition, the potential for aneugenicity of the Primary Product has not been adequately investigated. Accordingly, the potential safety concern for genotoxicity of the Primary Product cannot be ruled out.

Scientific opinion on the renewal of the authorisation of SmokEz Enviro-23 (SF-006) as a smoke flavouring Primary Product

The EFSA Panel on Food Additives and Flavourings (FAF) was requested to evaluate the safety of the smoke flavouring Primary Product SmokEz Enviro-23 (SF-006), for which a renewal application was submitted in accordance with Article 12(1) of Regulation (EC) No 2065/2003. This opinion refers to the assessment of data submitted on chemical characterisation, dietary exposure and genotoxicity of the Primary Product. SmokEz Enviro-23 is obtained by pyrolysis of oak, maple, hickory, ash, birch, beech and cherry woods. Given the limitations of the quantification approach employed by the applicant, the Panel could not judge whether the applied methods meet the legal quality criterion that at least 80% of the volatile fraction shall be identified and quantified. At the maximum proposed use levels, dietary exposure estimates calculated with DietEx ranged from 0.01 to 3.2 mg/kg body weight (bw) per day at the mean and from no dietary exposure to 9.5 mg/kg bw per day at the 95th percentile. The Panel concluded that four components in the Primary Product raise a potential concern for genotoxicity. In addition, a potential concern for genotoxicity was identified for the unidentified part of the mixture. The Primary Product contains furan-2(5H)-one and benzene-1,2-diol, for which a concern for genotoxicity was identified in vivo upon oral administration. Considering that the exposure estimates for these two components are above the threshold of toxicological concern (TTC) of 0.0025 μg/kg bw per day for DNA-reactive mutagens and/or carcinogens, the Panel concluded that the Primary Product raises concern with respect to genotoxicity.

Scientific opinion on the renewal of the authorisation of Zesti Smoke Code 10 (SF-002) as a smoke flavouring Primary Product

The EFSA Panel on Food Additives and Flavourings (FAF) was requested to evaluate the safety of the smoke flavouring Primary Product Zesti Smoke Code 10 (SF-002), for which a renewal application was submitted in accordance with Article 12(1) of Regulation (EC) No 2065/2003. This opinion refers to the assessment of data submitted on chemical characterisation, dietary exposure and genotoxicity of the Primary Product. Zesti Smoke Code 10 is obtained by pyrolysis of hickory and oak woods. Given the limitations of the quantification approach employed by the applicant, the Panel could not judge whether the applied methods meet the legal quality criterion that at least 80% of the volatile fraction shall be identified and quantified. At the maximum proposed use levels, dietary exposure estimates calculated with DietEx ranged from 0.02 to 4.6 mg/kg body weight (bw) per day at the mean and from no dietary exposure to 13.0 mg/kg bw per day at the 95th percentile. The Panel concluded that four components in the Primary Product raise a potential concern for genotoxicity. In addition, a potential concern for genotoxicity was identified for the unidentified part of the mixture. The Primary Product contains furan-2(5H)-one and benzene-1,2-diol, for which a concern for genotoxicity was identified in vivo upon oral administration. Considering that the exposure estimates for these two components are above the threshold of toxicological concern (TTC) of 0.0025 μg/kg bw per day for DNA-reactive mutagens and/or carcinogens, the Panel concluded that the Primary Product raises concern with respect to genotoxicity.

Scientific opinion on the renewal of the authorisation of proFagus Smoke R709 (SF-008) as a smoke flavouring Primary Product

The EFSA Panel on Food Additives and Flavourings (FAF) was requested to evaluate the safety of the smoke flavouring Primary Product proFagus Smoke R709 (SF-008), for which a renewal application was submitted in accordance with Article 12(1) of Regulation (EC) No 2065/2003. This opinion refers to the assessment of data submitted on chemical characterisation, dietary exposure and genotoxicity of the Primary Product. ProFagus Smoke R709 is obtained by pyrolysis of beech and oak wood as main source materials. The panel concluded that the compositional data provided on the Primary Product are adequate. At the maximum proposed use levels, dietary exposure estimates calculated with DietEx ranged from 0.8 to 12.2 mg/kg body weight (bw) per day at the mean and from 2.3 to 51.4 mg/kg bw per day at the 95th percentile. The Panel concluded that three components in the Primary Product raise a potential concern for genotoxicity. In addition, a potential concern for genotoxicity was identified for the unidentified part of the mixture. The Primary Product contains furan-2(5H)-one, for which a concern for genotoxicity was identified in vivo upon oral administration. Considering that the exposure estimates for this component are above the TTC of 0.0025 μg/kg bw per day for DNA-reactive mutagens and/or carcinogens, the panel concluded that the Primary Product raises concern with respect to genotoxicity.

Training Volume and High-Speed Loads Vary Within Microcycle in Elite North American Soccer Players

ABSTRACT

Ishida, A, Draper, G, Wright, M, Emerson, J, and Stone, MH. Training volume and high-speed loads vary within microcycle in elite North American soccer players. J Strength Cond Res 37(11): 2229-2234, 2023-The purposes of this study were to reduce dimensionality of external training load variables and examine how the selected variables varied within microcycle in elite North American soccer players. Data were collected from 18 players during 2018-2020 in-seasons. Microcycle was categorized as 1, 2, 3, 4, 5 days before match day (MD-1, MD-2, MD-3, MD-4, and MD-5, respectively). Training load variables included total distance, average speed, maximum velocity, high-speed running distance (HSR), average HSR, HSR efforts, average HSR efforts, sprint distance, average sprint distance, sprint efforts, average sprint efforts, total PlayerLoad, and average PlayerLoad. The first principal component (PC) can explain 66.0% of the variances and be represented by "high-speed load" (e.g., HSR and sprint-related variables) with the second PC relating to "volume" (e.g., total distance and PlayerLoad) accounting for 17.9% of the variance. Average sprint distance and total distance were selected for further analysis. Average sprint distance was significantly higher at MD-3 than at MD-2 (p = 0.01, mean difference = 0.36 m•minute-1, 95% confidence intervals [CIs] = 0.07-0.65 m•minute-1) and MD-4 (p = 0.012, mean difference = 0.26 m•minute-1, 95% CIs = 0.10-0.41 m•minute-1). Total distance was significantly higher at MD-3 than at MD-1 (p < 0.001, mean difference = 1,465 m, 95% CIs = 1,003-1926 m), and MD-2 (p < 0.001, mean difference = 941 m, 95% CIs = 523-1,360 m). Principal component analysis may simplify reporting process of external training loads. Practitioners may need to choose "volume" and "high-speed load" variables. Elite North American Soccer players may accumulate higher average sprint distance at MD-3 than at other training days.

Scientific opinion on the renewal of the authorisation of proFagus Smoke R714 (SF-001) as a smoke flavouring Primary Product

The EFSA Panel on Food Additives and Flavourings (FAF) was requested to evaluate the safety of the smoke flavouring Primary Product proFagus Smoke R714 (SF-001), for which a renewal application was submitted in accordance with Article 12(1) of Regulation (EC) No 2065/2003. This opinion refers to the assessment of data submitted on chemical characterisation, dietary exposure and genotoxicity of the Primary Product. ProFagus Smoke R714 is obtained by pyrolysis of beech and oak woods as main source materials. Based on the compositional data, the Panel noted that the identified and quantified proportion of the solvent-free fraction amounts to 39 weight (wt)%, thus the applied method does not meet the legal quality criterion that at least 50% of the solvent-free fraction shall be identified and quantified. At the maximum proposed use levels, dietary exposure estimates calculated with DietEx ranged from 0.7 to 10.9 mg/kg body weight (bw) per day at the mean and from 2.2 to 42.5 mg/kg bw per day at the 95th percentile. The Panel concluded that three components in the Primary Product raise a potential concern for genotoxicity. In addition, a potential concern for genotoxicity was identified for the unidentified part of the mixture. The Primary Product contains furan-2(5H)-one, for which a concern for genotoxicity was identified in vivo upon oral administration. Considering that the exposure estimates for this component are above the threshold of toxicological concern (TTC) of 0.0025 μg/kg bw per day for DNA-reactive mutagens and/or carcinogens, the Panel concluded that the Primary Product raises concern with respect to genotoxicity.

Scientific opinion on the renewal of the authorisation of Scansmoke SEF7525 (SF-004) as a smoke flavouring Primary Product

The EFSA Panel on Food Additives and Flavourings (FAF) was requested to evaluate the safety of the smoke flavouring Primary Product Scansmoke SEF7525 (SF-004), for which a renewal application was submitted in accordance with Article 12(1) of Regulation (EC) No 2065/2003. This opinion refers to the assessment of data submitted on chemical characterisation, dietary exposure and genotoxicity of the Primary Product. Scansmoke SEF7525 is obtained from a tar produced from a mixture of red oak, white oak, maple, beech and hickory. Based on the compositional data, the Panel noted that the identified and quantified proportion of the solvent-free fraction amounts to 32.6 weight (wt)%, thus the applied method does not meet the legal quality criterion that at least 50% of the solvent-free fraction shall be identified and quantified. At the maximum proposed use levels, dietary exposure estimates calculated with Food Additive Intake Model (FAIM) ranged from 0.6 to 3.8 mg/kg body weight (bw) per day at the mean and from 1.1 to 10.1 mg/kg bw per day at the 95th percentile. Based on the available information on genotoxicity on 44 identified components, the Panel concluded that two substances in the Primary Product, styrene and benzofuran, raise a potential concern for genotoxicity. In addition, a potential concern for genotoxicity was identified for the unidentified part of the mixture. Considering that the exposure estimates for styrene and benzofuran are above the threshold of toxicological concern (TTC) value of 0.0025 kg/kg bw per day for DNA-reactive mutagens and/or carcinogens and since further data are needed to clarify their potential genotoxicity, the Panel concluded that the potential safety concern for genotoxicity of the Primary Product cannot be ruled out.

Scientific opinion on the renewal of the authorisation of Smoke Concentrate 809045 (SF-003) as a smoke flavouring Primary Product

The EFSA Panel on Food Additives and Flavourings (FAF) was requested to evaluate the safety of the smoke flavouring Primary Product Smoke Concentrate 809045 (SF-003), for which a renewal application was submitted in accordance with Article 12(1) of Regulation (EC) No 2065/2003. This opinion refers to the assessment of data submitted on chemical characterisation, dietary exposure and genotoxicity of the Primary Product. Product Smoke Concentrate 809045 is obtained by pyrolysis of beech wood. The Panel concluded that the compositional data provided on the Primary Product are adequate. At the maximum proposed use levels, dietary exposure estimates calculated with DietEx ranged from 0.1 to 1.5 mg/kg body weight (bw) per day at the mean and from 0.2 to 5.2 mg/kg bw per day at the 95th percentile. The Panel concluded that eleven components in the Primary Product raise a potential concern for genotoxicity. In addition, a potential concern for genotoxicity was identified for the unidentified part of the mixture. The Primary Product contains furan-2(5H)-one and benzene-1,2-diol, for which a concern for genotoxicity was identified in vivo upon oral administration. Considering that the exposure estimates for these two components are above the threshold of toxicological concern (TTC) of 0.0025 μg/kg bw per day for DNA-reactive mutagens and/or carcinogens, the Panel concluded that the Primary Product raises concern with respect to genotoxicity.

Letermovir for pre-emptive cytomegalovirus therapy after allogeneic hematopoietic cell transplantation

BACKGROUND

Cytomegalovirus (CMV) is a common cause of morbidity after allogeneic haematopoietic cell transplantation (alloHCT). Pre-emptive therapy (PET) with valganciclovir (VGC) is associated with haematological toxicity.

METHODS

We included alloHCT patients from 2018 to 2021 where letermovir (LTV) was used for CMV PET because of cytopenias.

RESULTS

Ten patients were included. Six received VGC prior to LTV. VGC was commenced at median d42, given for median 40 days. LTV was commenced at median d90, given for median 54 days. At commencement of antiviral, CMV viral load was higher for VGC at 3.7 log10 IU/mL, compared to LTV at 2.9 log10 IU/mL. Viral load reduction occurred at 0.18 log10 IU/mL per week for VGC, compared to 0.17 log10 IU/mL per week for LTV. There was no clinically significant CMV viremia after stopping LTV. Cytopenias improved on LTV.

CONCLUSION

LTV was effective in controlling CMV viremia when it was given at a lower starting CMV viral load and later post alloHCT than VGC. Further study is required of LTV as upfront PET following alloHCT.

Scientific opinion on the renewal of the authorisation of SmokEz C-10 (SF-005) as a smoke flavouring Primary Product

The EFSA Panel on Food Additives and Flavourings (FAF) was requested to evaluate the safety of the smoke flavouring Primary Product SmoKEz C-10 (SF-005), for which a renewal application was submitted in accordance with Article 12(1) of Regulation (EC) No 2065/2003. This opinion refers to the assessment of data submitted on chemical characterisation, dietary exposure and genotoxicity of the Primary Product. SmoKEz C-10 is obtained by pyrolysis of maple, oak, hickory, ash, birch, beech and cherry woods. Given the limitations of the quantification approach employed by the applicant, the Panel could not judge whether the applied methods meet the legal quality criterion that at least 80% of the volatile fraction shall be identified and quantified. At the maximum proposed use levels, dietary exposure estimates calculated with DietEx ranged from 0.01 to 5.1 mg/kg body weight (bw) per day at the mean and from no dietary exposure to 18.1 mg/kg bw per day at the 95th percentile. The Panel concluded that five components in the Primary Product raise a potential concern for genotoxicity. In addition, a potential concern for genotoxicity was identified for the unidentified part of the mixture. The Primary Product contains furan-2(5H)-one and benzene-1,2-diol, for which a concern for genotoxicity was identified in vivo upon oral administration. Considering that the exposure estimates for these two components are above the threshold of toxicological concern (TTC) of 0.0025 μg/kg bw per day for DNA-reactive mutagens and/or carcinogens, the Panel concluded that the Primary Product raises concern with respect to genotoxicity.

A - 61 The Impact of Metacognition on Everyday Functioning in Mild Cognitive Impairment and Dementia

OBJECTIVE

The purpose of this study was to evaluate the role of metacognition on everyday functioning in mild cognitive impairment and dementia.

METHOD

Participants included 44 healthy older controls, 57 individuals with mild cognitive impairment (MCI), and 26 individuals with Alzheimer's disease (ad). Participants were administered verbal and nonverbal memory tests and a visuospatial test. They made predictions about their performances before taking each test and then made postdictions about their performances after each test. Prediction and postdiction accuracy scores were calculated. Additionally, all participants took the Everyday Cognition (ECog) Scale.

RESULTS

Regression analyses were conducted, separately for each diagnostic group, to determine the roles of prediction and postdiction accuracy on everyday functioning. For healthy older controls, prediction and postdiction accuracy on a visuospatial test significantly impacted overall everyday functioning. In MCI, prediction accuracy on a nonverbal memory test significantly impacted everyday functioning. Finally, in ad, postdiction accuracy on a nonverbal memory test significantly predicted everyday memory.

CONCLUSION(S)

Overall, metacognition predicts everyday functioning in healthy aging, MCI, and ad. For healthy aging and MCI, the ability to both accurately predict and retrospectively evaluate their own cognition impacts overall everyday functioning. With the increased cognitive impairment of ad, only the ability to retrospectively evaluate performances impacts everyday memory.

A - 25 The Role of Prospective Memory in Instrumental Activities of Daily Living and the Use of Compensatory Aids in Mild Cognitive Impairment

OBJECTIVE

Prospective memory (PM), which involves remembering to execute a future action, is impacted by Alzheimer's disease. This study examined the role of PM in instrumental activities of daily living (IADLs) and the use of compensatory aids in mild cognitive impairment (MCI) and healthy aging.

METHODS

Participants included 44 healthy older controls and 49 persons with MCI. Simple PM was measured by asking participants to remember to execute a single action- to request a pill after completing each of a series of neuropsychological tests. Complex PM was then measured by asking participants to request a specific number of pills depending on whether a memory test was just completed or a non-memory test was completed. The Instrumental Activities of Daily Living- Compensation (IADL-C) scale was used to assess IADLs and the use of compensatory aids for completing these activities.

RESULTS

Regression analyses revealed that both types of PM together predicted the IADLs of money/self-management skills and home/daily living skills in healthy older controls. Both types of PM also predicted total IADLs in controls. PM did not predict IADLs in MCI or the use of compensatory aids in either group.

CONCLUSION

Results indicated that PM was predictive of IADLs in healthy older adults. When PM skills are poorer, as in MCI, they are not predictive of IADLs.

The KINETIC phase 2 randomized controlled trial of oral pamapimod-pioglitazone in non-critically ill COVID-19 inpatients

The combination of pamapimod and pioglitazone (KIN001) has a synergetic antiviral, anti-inflammatory, and antifibrotic activity, which may prevent evolution toward COVID-19-associated severe respiratory failure. In a randomized, placebo-controlled, double-blind, phase 2, multicenter trial, 128 non-critically ill hospitalized patients with confirmed COVID-19 were treated with KIN001 or a placebo for 28 days. The proportion of patients alive and free of oxygen or respiratory support at the end of the therapy was lower than anticipated but not different in the two groups (KIN001 n = 19, 29%, placebo n = 21, 33%). 85 participants had at least one adverse event, with no difference in the number and distribution of events between the two groups. The clinical trial was stopped for futility, mainly due to a lower-than-expected incidence of the primary endpoint. KIN001 was safe and well-tolerated but had no significant effect on clinical outcome.

A - 52 Self-Reports and Informant-Reports of Everyday Functioning as Predictors of Objective Cognition in Mild Cognitive Impairment and Dementia

OBJECTIVE

The objective of the current study was to investigate self- and informant-reports of everyday functioning and whether they predicted objective cognitive functioning.

METHOD

Participants included 65 persons with mild cognitive impairment (MCI), 18 individuals with dementia, and 58 healthy older controls. Self-reports and informant-reports were taken on the Everyday Cognition Scales (E-Cog), which included seven subscales: everyday language, memory, executive functioning (EF) planning, EF organization, EF divided attention, visual-spatial/perceptual abilities, and attention. Participants also completed a neuropsychological battery, and composite scores were calculated for each cognitive domain.

RESULTS

Regression analyses revealed that in healthy older controls, self-reported EF organization significantly predicted objective executive functions. Additionally, informant-reported language significantly predicted objective language. In the MCI group, self- and informant-reports on the E-Cog did not predict objective cognition. For the dementia group, informant-reported EF planning, EF organization, and EF divided attention significantly predicted objective executive functions. Furthermore, informant-reported language significantly predicted objective language.

CONCLUSIONS

Overall, informant-reports of everyday language predicted objective language in healthy aging and dementia. Self-reports were only predictive of objective cognition in healthy older controls, with self-reported everyday executive functions predicting objective executive functions. Interestingly, in MCI, self- and informant-reports were not predictive of any domain of objective cognitive skill. These results indicate that when the cognitive impairment is more subtle than in dementia, objective neuropsychological assessment will be even more important, as self- and informant-reports are not associated with actual cognitive functioning.

Pre-pregnancy gene expression signatures are associated with subsequent improvement/worsening of rheumatoid arthritis during pregnancy

BACKGROUND

While many women with rheumatoid arthritis (RA) improve during pregnancy and others worsen, there are no biomarkers to predict this improvement or worsening. In our unique RA pregnancy cohort that includes a pre-pregnancy baseline, we have examined pre-pregnancy gene co-expression networks to identify differences between women with RA who subsequently improve during pregnancy and those who worsen.

METHODS

Blood samples were collected before pregnancy (T0) from 19 women with RA and 13 healthy women enrolled in our prospective pregnancy cohort. RA improvement/worsening between T0 and 3rd trimester was assessed by changes in the Clinical Disease Activity Index (CDAI). Pre-pregnancy expression profiles were examined by RNA sequencing and differential gene expression analysis. Weighted gene co-expression network analysis (WGCNA) was used to identify co-expression modules correlated with the improvement/worsening of RA during pregnancy and to assess their functional relevance.

RESULTS

Of the 19 women with RA, 14 improved during pregnancy (RAimproved) while 5 worsened (RAworsened). At the T0 baseline, however, the mean CDAI was similar between the two groups. WGCNA identified one co-expression module related to B cell function that was significantly correlated with the worsening of RA during pregnancy and was significantly enriched in genes differentially expressed between the RAimproved and RAworsened groups. A neutrophil-related expression signature was also identified in the RAimproved group at the T0 baseline.

CONCLUSION

The pre-pregnancy gene expression signatures identified represent potential biomarkers to predict the subsequent improvement/worsening of RA during pregnancy, which has important implications for the personalized treatment of RA during pregnancy.

Competency Assessment of General Surgery Trainees: A Perspective From the Global South, in a CBME-Naive Context

OBJECTIVE

Before proceeding with local implementation of competency-based medical education-related assessment practices designed and evaluated in the Global North, we sought to challenge the assumption that this would be perceived as both necessary and acceptable in our context where training and assessment is based on a traditional, knowledge-focused approach. The aim of this study was to determine the perspectives of general surgery trainees and consultants towards the assessment of competence, how this has been achieved previously, and how it should be performed in the future at the University of Cape Town (UCT), South Africa.

DESIGN

Semi-structured interviews were conducted with consultants and trainees. Interviews were transcribed and then analyzed using a Reflexive Thematic Analysis approach.

SETTING AND PARTICIPANTS

Ten consultants (5 senior and 5 junior) and 10 trainees (5 South African and 5 international) from the Division of General Surgery at UCT in August 2022.

RESULTS

Five unique themes were developed: (1) Assessment of competence is essential, (2) competence includes multiple domains of practice, (3) a surgeon must be able to operate, (4) previously used methods were inadequate to assess competence, and (5) frequent assessment with feedback is desired. The themes were considered in the context of Situated Learning Theory, particularly Communities of Practice and their role in the training for, and authentic assessment of, competence in general surgery trainees.

CONCLUSIONS

Participants described a need to develop and implement a new competency assessment program for general surgery training in this context, which is aligned with described competency-based medical education principles. Thoughtful integration of the formative and summative use of direct observation in the workplace, with a clear emphasis on procedural ability and the provision of high-quality feedback, may enhance the successful implementation of a strategy for competency-based assessment in general surgery training programs.

Comparison of a Pre-Trained AI Contouring Model to Unseen Institutional Data

PURPOSE/OBJECTIVE(S)

To compare contours generated by a pre-trained, commercial AI model to those manually drawn in house.

MATERIALS/METHODS

Previously treated radiotherapy patients (N = 20 per site) for several sites (brain, head & neck, thorax, abdomen, pelvis) with approved structure sets were selected for this retrospective analysis. For the planning CT of each patient, a pre-trained AI model auto-contoured several OARS: bladder, brain, eyes, femurs, kidneys, lenses, mandible, and parotids, etc. A two-step rejection method filtered the results based on unmatched structure names (i.e., contours existing in only one of the two structure sets causing incorrect auto-matching of structure names by the comparison algorithm), and structures with different superior and/or inferior extents. From the remaining contours, DSC (Dice Similarity Coefficient) and HD95% (95th percentile of Hausdorff Distance) were calculated between auto and manually generated contours using vendor-supplied software; median values were then calculated.

RESULTS

The entire data set contained 592 structures at the on-set of analysis. After applying the rejection filters, the remaining data had 294 structures; a large portion of filtering was due to unmatched names. Out of these, OARs with contours from at least 10 patients (N>9) were further analyzed to include the 25th and 75th percentile for DSC and HD95%. Results from this analysis (structures with N>9) are presented in the table below, where results of left-right paired structures are combined into one row. The submandibular glands, larynx, and optical nerves (5 < N < 10) all had median DSC < 0.77 while lungs had median DSC > 0.98 (N = 6). Parotids and lenses had poor DSC and HD95% scores and may require significant contour editing to achieve agreement with our clinical conventions. This study highlights the difficulty with retrospective analysis of contours with an external trained model due to variations in the superior/inferior extent of tubular structures such as rectum, cord, esophagus, etc. CONCLUSION: Results are encouraging, given that the pre-trained commercial model has not seen our institutional data. The pre-trained AI contouring model matched very well to manual contours for large volume, higher contrast structures but did not match well for parotids and lenses. Variability in conventions regarding the superior/inferior extent of some structures hinders retrospective comparison with a pre-trained AI model.

Follow-up of the re-evaluation of glycerol esters of wood rosins (E 445) as a food additive

Glycerol esters of wood rosin (GEWR) (E 445) were re-evaluated in 2018. On the toxicity database and given the absence of reproductive and developmental toxicity data, the acceptable daily intake (ADI) of 12.5 mg/kg body weight (bw) per day for GEWR (E 445) established by the Scientific Committee on Food (SCF) in 1994 was considered temporary. The conclusions of the assessment were restricted to GEWR derived from Pinus palustris and Pinus elliottii and with a chemical composition in compliance with GEWR used in the toxicological testing. Following a European Commission call for data to submit data to fill the data gaps, the present follow-up opinion assesses data provided by interested business operators (IBOs). Considering the technical data submitted by IBOs, the EFSA Panel on Food Additives and Flavourings (FAF Panel) recommended some modifications of the existing EU specifications for E 445, mainly a revision of the definition of the food additive and lowering the limits for toxic elements. Considering the available toxicological database evaluated during the re-evaluation of E 445 by the ANS Panel in 2018, and the toxicological studies submitted by the IBOs, the Panel established an ADI of 10 mg/kg bw per day based on the no observed adverse effect level (NOAEL) of 976 mg/kg bw per day from the newly available dietary reproduction/developmental toxicity screening study in rats and applying an uncertainty factor of 100. Since GEWR from P. palustris and P. elliottii were tested in the toxicity studies considered to establish the ADI and in the absence of detailed information on the chemical composition (major constituents) in GEWR generated from other Pinus species, thus not allowing read across, the ADI is restricted to the GEWR (E 445) manufactured from P. palustris and P. elliottii. The Panel concluded that there was no safety concern for the use of GEWR (E 445), at either the maximum permitted levels or at the reported uses and use levels.

Follow-up of the re-evaluation of indigo carmine (E 132) as a food additive

Indigo carmine (E 312) was re-evaluated in 2014 by the EFSA Panel on Food Additives and Nutrient sources added to Food (ANS). The ANS Panel confirmed the acceptable daily intake (ADI) of 5 mg/kg body weight (bw) per day for indigo carmine allocated by JECFA (1975). The ANS Panel indicated that the ADI was applicable to a material with a purity of 93% pure colouring and manufactured using processes resulting in comparable residuals as material used in the Borzelleca et al. studies (1985, 1986) and Borzelleca and Hogan (1985) which were the basis for deriving the ADI. The ANS Panel considered that any extension of the ADI to indigo carmine of lower purity and/or manufactured using a different process would require new data to address the adverse effects on the testes observed in the Dixit and Goyal (2013) study. Following a European Commission call for data to submit data to fill the data gaps, an IBO submitted technical and toxicological data. Considering the technical data, the EFSA Panel on Food Additives and Flavourings (FAF Panel) recommended some modifications of the existing EU specifications for E 132, mainly to lower the limits for toxic elements. Considering the toxicological data, an IBO has submitted a 56-day dietary study to address the adverse effects on testes using a material with 88% purity. The results of this study submitted did not confirm the severe adverse effects observed in the Dixit and Goyal study. Considering all the available information, the Panel confirmed the ADI of 5 mg/kg bw per day for indigo carmine (E 132) disodium salts, meeting the proposed revisions of the specifications (85% minimum for the colouring matter). The Panel concluded that there is no safety concern for the use of indigo carmine (E 132) disodium salts at the reported use levels and submitted analytical data.

Re-evaluation of calcium carbonate (E 170) as a food additive in foods for infants below 16 weeks of age and follow-up of its re-evaluation as food additive for uses in foods for all population groups

Calcium carbonate (E 170) was re-evaluated in 2011 by the former EFSA Panel on Food Additives and Nutrient sources added to Food (ANS). As a follow-up to this assessment, the Panel on Food Additives and Flavourings (FAF) was requested to assess the safety of calcium carbonate (E 170) for its uses as a food additive in food for infants below 16 weeks of age belonging to food category 13.1.5.1 (Dietary foods for infants for special medical purposes and special formulae for infants) and as carry over in line with Annex III, Part 5 Section B to Regulation (EC) No 1333/2008. In addition, the FAF Panel was requested to address the issues already identified during the re-evaluation of the food additive when used in food for the general population. The process involved the publication of a call for data to allow the interested business operators (IBOs) to provide the requested information to complete the risk assessment. The Panel concluded that there is no need for a numerical acceptable daily intake (ADI) for calcium carbonate and that, in principle, there are no safety concern with respect to the exposure to calcium carbonate per se at the currently reported uses and use levels in all age groups of the population, including infants below 16 weeks of age. With respect to the calcium intake resulting from the use of E 170 in food for the general population and infants < 16 weeks of age, the Panel concluded that it contributes only to a small part to the overall calcium dietary exposure. However, the unavoidable presence of aluminium in E 170 is of concern and should be addressed. In addition, the Panel concluded that the technical data provided by the IBO support further amendments of the specifications for E 170 laid down in Commission Regulation (EU) No 231/2012.

Elite North American soccer performance in thermally challenging environments: An explorative approach to tracking outcomes

AIMS

The physiologic challenges related to performances in hot conditions calls for dedicated consideration when planning athlete training, although complete amelioration of the effects of heat may not be possible. We aimed to quantify within-subject correlations between different measures of environmental temperature and performance changes over multiple elite soccer competitions.

METHODS

Thirty-seven elite male soccer players (age: 26 ± 3.4 years, height: 171 ± 2 cm, body mass: 78 ± 7.1 kg) competed in North America over four seasons (range: 3 to 98 matches). Players wore global positioning system devices during games and reported differential-RPE immediately post game. Temperatures at kick-off, week average temperature, the difference between game-day and week average (DiffTemp), and heat index at kick-off were obtained. Within-player correlations were calculated using general linear models to quantify associations between fluctuations in temperature measures and physical and perceived outputs.

RESULTS

Correlations between total distance and the various temperature measures were trivial to small (range: -0.08 to 0.13, p=<0.001-0.02). Small negative correlations were found between all temperature measures except DiffTemp and high-speed running (HSR) (range: -0.17 to -0.14, p=<0.001). Most correlations between differential-RPE and temperature measures were trivial to small and not significant (r = 0.06 to 0.18 p = 0.03-0.92) although breathlessness-RPE and heat index showed a small significant association (P = 0.018).

CONCLUSION

Decrements in HSR appear to be associated with increased environmental temperature, however, these associations are small in magnitude.

Interatrial Septal Mass Secondary to Rosai-Dorfman Disease: A Rare Cause of Complete Heart Block

Varying degrees of atrioventricular block can be associated with old age or a manifestation of an ischemic, metabolic, or infective pathology. In patients with no clear explanation, it is important to investigate secondary causes. Our case describes the first case of an adult with Rosai-Dorfman histiocytosis presenting with complete heart block. (Level of Difficulty: Advanced.).

Re-evaluation of xanthan gum (E 415) as a food additive in foods for infants below 16 weeks of age and follow-up of its re-evaluation as a food additive for uses in foods for all population groups

Xanthan gum (E 415) was re-evaluated in 2017 by the former EFSA Panel on Food Additives and Nutrient sources added to Food. As a follow-up to that assessment, the Panel on Food Additives and Flavourings (FAF) was requested to assess the safety of xanthan gum (E 415) for its uses as a food additive in food for infants below 16 weeks of age belonging to food category (FC) 13.1.5.1 (Dietary foods for infants for special medical purposes and special formulae for infants). In addition, the FAF Panel was requested to address the issues already identified during the re-evaluation of the food additive when used in food for the general population. The process involved the publication of a call for data to allow the interested business operators to provide the requested information to complete the risk assessment. The Panel concluded that the technical data provided by the interested business operators support an amendment of the specifications for E 415 laid down in Commission Regulation (EU) No 231/2012. Due to the low validity of the available clinical studies, the Panel concluded that a reference point could not be derived from them but the results of the available studies on neonatal piglets could serve to derive a reference point. The Panel calculated the margin of exposure for infants below 16 weeks of age consuming food for special medical purposes (FC 13.1.5.1) for the highest xanthan gum exposure and concluded that there are no safety concerns for the use of xanthan gum (E 415) as a food additive in FC 13.1.5.1.

Filling a nick in NIK: extending the half-life of a NIK inhibitor through structure-based drug design

Inhibition of NF-κB inducing kinase (NIK) has been pursued as a promising therapeutic target for autoimmune disorders due to its highly regulated role in key steps of the NF-κB signaling pathway. Previously reported NIK inhibitors from our group were shown to be potent, selective, and efficacious, but had higher human dose projections than desirable for immunology indications. Herein we report the clearance-driven optimization of a NIK inhibitor guided by metabolite identification studies and structure-based drug design. This led to the identification of an azabicyclo[3.1.0]hexanone motif that attenuated in vitro and in vivo clearance while maintaining NIK potency and increasing selectivity over other kinases, resulting in a greater than ten-fold reduction in predicted human dose.

Flavouring Group Evaluation 217 Revision 3 (FGE.217Rev3): consideration of genotoxic potential for α,β-unsaturated ketones and precursors from chemical subgroup 4.1 of FGE.19: lactones

The Panel on Food Additives and Flavourings of the European Food Safety Authority was requested to evaluate the genotoxic potential of four flavouring substances [FL-no: 10.023, 10.030, 10.057 and 13.012] from subgroup 4.1 of FGE.19. For three of these substances [FL-no: 10.023, 10.030 and 13.012], the concern for genotoxicity has been ruled out in previous revisions of Flavouring Group Evaluation 217 (FGE.217). However, in FGE.217Rev2, a concern for genotoxicity could not be ruled out for 3a,4,5,7a-tetrahydro-3,6-dimethylbenzofuran-2(3H)-one [FL-no: 10.057]. After publication of FGE.217Rev2, industry provided additional genotoxicity studies for [FL-no: 10.057], which are evaluated in the present opinion FGE.217Rev3. The flavouring substance [FL-no: 10.057] did not induce gene mutations or numerical or structural chromosomal aberrations in vitro. Based on these data, the Panel concluded that the concern for genotoxicity is ruled out for [FL-no: 10.057]. Consequently, it can be evaluated through the Procedure.

Re-evaluation of sucrose esters of fatty acids (E 473) as a food additive in foods for infants below 16 weeks of age and follow-up of its previous evaluations as food additive for uses in foods for all population groups

Sucrose esters of fatty acids (E 473) was re-evaluated in 2004 by the former EFSA Panel on Food Additives, Flavourings, Processing Aids and Materials in Contact with Food (AFC Panel). In addition, the former EFSA Panel on Food Additives and Nutrient Sources added to Food (ANS Panel) issued scientific opinions on the safety of sucrose esters of fatty acids (E 473) in 2010, 2012 and 2018. As a follow-up to these assessments, the Panel on Food Additives and Flavourings (FAF) was requested to assess the safety of sucrose esters of fatty acids (E 473) for its uses as food additive in food for infants below 16 weeks of age. In addition, the FAF Panel was requested to address the issues already identified by the EFSA AFC and ANS Panels when used in food for the general population. The process involved the publication of calls for data to allow the interested business operators to provide the requested information to complete the risk assessment. The Panel concluded that the technical data provided by the interested business operators support an amendment of the specifications for sucrose esters of fatty acids (E 473) laid down in Commission Regulation (EU) No 231/2012. According to the available information, E 473 is not used in food categories (FCs) 13.1.1 and 13.1.5.1, including all types of food for infants below 16 weeks of age, and in FC 13.1.5.2. As a consequence, an assessment of the safety for the uses of E 473 as food additive in these FCs and age group was not performed. When the updated exposure estimates considering the provided use levels for some food categories are taken into account the estimates of exposure to sucrose esters of fatty acids (E 473) exceeded the group acceptable daily intake (ADI) of 40 mg/kg body weight (bw) per day for many population groups.

New Methodology for Determining Plasma Protein Binding Kinetics Using an Enzyme Reporter Assay Coupling with High-Resolution Mass Spectrometry

Determination of drug binding kinetics in plasma is important yet extremely challenging. Accordingly, we introduce "dynamic free fraction" as a new binding parameter describing drug-protein binding kinetics. We demonstrate theoretically and experimentally that the dynamic free fraction can be determined by coupling the drug binding assay with a reporter enzyme in combination with high-resolution mass spectrometry measuring the relative initial steady-state rates of enzymatic reactions in the absence and presence of matrix proteins. This novel and simple methodology circumvents a long-standing challenge inherent in existing methods for determining binding kinetics constants, such as k_on and k_off, and enables assessment of the impact of protein binding kinetics on pharmaceutical properties of drugs. As demonstrated with nine model drugs, the predicted liver extraction ratio, a measure of efficiency of drug removal by the liver, correlates significantly better to the observed extraction ratio when using the dynamic free fraction (f_D) in place of the unbound fraction (f_u) of the drug in plasma. Similarly, the in vivo hepatic clearance of these drugs, a measure of liver drug elimination, is highly comparable to the clearance values calculated with the dynamic free fraction (f_D), which is markedly better than those calculated with the unbound fraction (f_u). In contrast to the prevailing view, these results indicate that protein binding kinetics is an important pharmacokinetic property of a drug. As plasma protein binding is one of the most important drug properties, this new methodology may represent a breakthrough and could have a real impact on the field.

Flavouring Group Evaluation 21 Revision 6 (FGE.21Rev6): thiazoles, thiophenes, thiazoline and thienyl derivatives from chemical groups 29 and 30

The Panel on Food additives and Flavourings (FAF) was requested to evaluate the flavouring substances 2,4-dimethyl-3-thiazoline [FL-no: 15.060] and 2-isobutyl-3-thiazoline [FL-no: 15.119] in Flavouring Group Evaluation 21 revision 6 (FGE.21Rev6). FGE.21Rev6 deals with 41 flavouring substances of which 39 have been already evaluated to be of no safety concern when based on the MSDI approach. For [FL-no: 15.060 and 15.119], a concern for genotoxicity was raised in FGE.21. Genotoxicity data have been submitted for the supporting substance 4,5-dimethyl-2-isobutyl-3-thiazoline [FL-no: 15.032] evaluated in FGE.76Rev2. The concerns for gene mutations and clastogenicity are ruled out for [FL-no: 15.032] and for the structurally related substances [FL-no: 15.060 and 15.119], but not for aneugenicity. Therefore, the aneugenic potential of [FL-no: 15.060 and 15.119] should be investigated in studies with the individual substances. For [FL-no: 15.054, 15.055, 15.057, 15.079 and 15.135], (more reliable) information on uses and use levels is needed to (re)calculate the mTAMDIs in order to finalise their evaluation. Provided that information is submitted for [FL-no: 15.060 and 15.119] with respect to potential aneugenicity, that would allow evaluation of these substances through the Procedure, also for these two substances, more reliable data on uses and use levels would be required. Upon submission of such data, additional data on toxicity may become necessary for all seven substances. For [FL-no: 15.054, 15.057, 15.079 and 15.135], information on the actual percentages of stereoisomers in the material of commerce based on analytical data should be provided.

Re-evaluation of locust bean gum (E 410) as a food additive in foods for infants below 16 weeks of age and follow-up of its re-evaluation as a food additive for uses in foods for all population groups

Locust bean gum (E 410) was re-evaluated in 2017 by the former EFSA Panel on Food Additives and Nutrient sources added to Food (ANS). As a follow-up to that assessment, the Panel on Food Additives and Flavourings (FAF) was requested to assess the safety of locust bean gum (E 410) for its uses as a food additive in food for infants below 16 weeks of age belonging to food category 13.1.5.1 (Dietary foods for infants for special medical purposes and special formulae for infants). In addition, the FAF Panel was requested to address the issues already identified during the re-evaluation of the food additive when used in food for the general population, including the safety assessment for FC 13.1.5.1 and 13.1.5.2 (Dietary foods for babies and young children for special medical purposes as defined in directive 1999/21/EC). The process involved the publication of a call for data. Based on the received data, the Panel concluded that the technical data provided by the interested business operators support an amendment of the specifications for locust bean gum (E 410) laid down in Commission Regulation (EU) No 231/2012. The Panel identified a reference point of 1,400 mg/kg bw per day based on reduced blood zinc levels in a piglet study. It applied the margin of exposure (MoE) for the safety assessment of locust bean gum (E 410) when used as a food additive in FC 13.1.5.1 and 13.1.5.2. The Panel concluded that a MoE above 1 would not raise a safety concern. A MoE above 1 was obtained for some of the scenarios and exposure levels for infants. For toddlers (consumers only of food for special medical purposes), the MoE was above 1 for all exposure levels.

Scientific Guidance on the data required for the risk assessment of flavourings to be used in or on foods

Following a request from the European Commission, EFSA developed a new scientific guidance to assist applicants in the preparation of applications for the authorisation of flavourings to be used in or on foods. This guidance applies to applications for a new authorisation as well as for a modification of an existing authorisation of a food flavouring, submitted under Regulation (EC) No 1331/2008. It defines the scientific data required for the evaluation of those food flavourings for which an evaluation and approval is required according to Article 9 of Regulation (EC) No 1334/2008. This applies to flavouring substances, flavouring preparations, thermal process flavourings, flavour precursors, other flavourings and source materials, as defined in Article 3 of Regulation (EC) No 1334/2008. Information to be provided in all applications relates to: (a) the characterisation of the food flavouring, including the description of its identity, manufacturing process, chemical composition, specifications, stability and reaction and fate in foods; (b) the proposed uses and use levels and the assessment of the dietary exposure and (c) the safety data, including information on the genotoxic potential of the food flavouring, toxicological data other than genotoxicity and information on the safety for the environment. For the toxicological studies, a tiered approach is applied, for which the testing requirements, key issues and triggers are described. Applicants should generate the data requested in each section to support the safety assessment of the food flavouring. Based on the submitted data, EFSA will assess the safety of the food flavouring and conclude whether or not it presents risks to human health and to the environment, if applicable, under the proposed conditions of use.

Opinion on the re-evaluation of sodium carboxy methyl cellulose (E 466) as a food additive in foods for infants below 16 weeks of age and follow-up of its re-evaluation as food additive for uses in foods for all population groups

Sodium carboxy methyl cellulose (E 466) was re-evaluated in 2018 by the former EFSA Panel on Food Additives and Nutrient sources added to Food (ANS). As a follow-up to this assessment, the Panel on Food Additives and Flavourings (FAF) was requested to assess the safety of E 466 for its uses as a food additive in food for infants below 16 weeks of age belonging to food categories (FC) 13.1.5.1 (Dietary foods for infants for special medical purposes and special formulae for infants) in line with Regulation (EC) No 1333/2008. In addition, the FAF Panel was requested to address the issues already identified during the re-evaluation of the food additive when used in food for the general population, including the safety assessment for FC 13.1.5.1 and 13.1.5.2 (Dietary foods for babies and young children for special medical purposes as defined in directive 1999/21/EC). The process involved the publication of a call for data. Based on the received data, the Panel concluded that the technical data provided by the interested business operator support an amendment of the specifications for sodium carboxy methyl cellulose (E 466) laid down in Commission Regulation (EU) No 231/2012. The interested business operators declared that E 466 is not used in food for infants below 16 weeks of age and in FC 13.1.5.1. Due to the lack of data, an assessment has not been performed for this FC and age group. The interested business operators did not provide biological and toxicological data to support the uses of E 466 in FC 13.1.5.2. Due to the almost unchanged database compared to the situation before the call for data, the FAF Panel confirmed the previous EFSA ANS Panel conclusion according to which the available data did not allow for an adequate assessment of the safety of use of sodium carboxy methyl cellulose (E 466) in infants and young children consuming foods belonging to the FC 13.1.5.2. ©2022 European Food Safety Authority. EFSA Journal published by John Wiley and Sons Ltd on behalf of European Food Safety Authority.

Cross-validation of RAVLT performance validity indicators and the RAVLT/RO discriminant function in a large known groups sample

OBJECTIVE

To cross-validate RAVLT performance validity cut-offs and the RAVLT/RO discriminant function in a large neuropsychological sample.

METHOD

RAVLT scores and the RAVLT/RO discriminant function were compared in credible (n = 100) and noncredible (n = 353) neuropsychology referrals.

RESULTS

Noncredible patients scored lower than credible patients on RAVLT scores and the RAVLT/RO discriminant function. With cut-offs set to ≥90% specificity, highest sensitivities were observed for the discriminant function (cut-off ≤.064; 55.8%), recognition total (cut-off ≤9; 53.1%), the recognition combination score (≤10; 47.7%), and total learning across trials (cut-off ≤31; 45.3%). Individuals with histories of learning difficulties were over-represented in the 10% of credible patients exceeding cut-offs. When these individuals were removed, cut-offs could be tightened while still maintaining at least 90% specificity, and thereby increasing sensitivity (e.g., recognition total cut-off ≤10, 65% sensitivity; RAVLT/RO discriminant function cut-off ≤.176, 58% sensitivity). When three of the most sensitive, non-overlapping scores were considered in combination, 17% of credible patients failed ≥1 of the three cut-offs, while 3% failed two, and only 1% failed all three. In contrast, in the noncredible sample, more than two-thirds failed one or more of the three cut-offs, nearly half failed ≥2, and nearly a quarter failed all three.

CONCLUSIONS

RAVLT PVT cut-offs and the RAVLT/RO discriminant function achieve approximately 50% sensitivity, and approach 65% sensitivity when cut-offs specific to samples without histories of learning problems are employed, confirming that RAVLT cut-offs and the RAVLT/RO discriminant function continue to be valuable techniques in the identification of performance invalidity.

Immune checkpoint inhibition in early-stage triple-negative breast cancer

INTRODUCTION

Breast cancer cells can evade immune recognition by upregulating programmed death-ligand 1 (PD-L1) leading to decreased T cell function. Anti-PD-1 agents, like pembrolizumab, and anti-PD-L1 agents, such as atezolizumab and durvalumab, in combination with chemotherapy were found to have efficacy in metastatic triple-negative breast cancer (TNBC). With sub-optimal long-term outcomes in early-stage TNBC, this combination of immune checkpoint inhibition with chemotherapy was subsequently investigated. A robust immune microenvironment and extensive tumor antigen exposure in early-stage breast cancer is believed to facilitate response to checkpoint inhibitors.

AREAS COVERED

This review focuses on studies that assess the role of neoadjuvant immune checkpoint inhibition along with chemotherapy. The results of key phase I, II and III trials using checkpoint inhibitors in early-stage breast cancer (ESBC) are reviewed along with foundational data from metastatic TNBC, including the role of biomarkers in predicting response to immunotherapy.

EXPERT OPINION

Despite a clear role for neoadjuvant immune checkpoint inhibition in TNBC, many questions remain. The benefit of these agents in the neoadjuvant versus adjuvant setting is unclear and immune-related toxicity is a major concern. Additional studies are needed to elucidate which immune checkpoint inhibitor is most efficacious and best tolerated in early-stage TNBC.

Digital health literacy and well-being of university students in Austria during the pandemic

Background

Previous findings suggest that depressive and anxiety-related symptoms have doubled among students since the beginning of the pandemic. Digital health literacy can act as a protective resource to strengthen well-being.

Objectives

This paper analyzes the relationship between digital health literacy, socioeconomic status and well-being and future-anxiety among students in Austria.

Methods

480 students from Austrian higher education institutions were surveyed via online questionnaire during the second wave of the Corona pandemic. Sociodemographic data, students’ self-assessments of well-being, fears regarding future development and perspectives, and digital health literacy were collected. Variance and regression analyses were used for the evaluation.

Results

About 50% of the students reported low scores in well-being and distinct fears about the future. A higher socioeconomic status correlated with higher well-being as well as lower fears about the future.Regarding digital health literacy, the ability to assess the relevance of information showed the highest correlation with well-being.

Conclusions

Individual factors such as gender or the study-program are relevant for the interaction between well-being and digital health literacy. The assessment of the relevance of information and its connection with one's own life reality seems to be important factors in promoting well-being.

Biokinetics and Internal Dosimetry of Tritiated Steel Particles

Decommissioning fission and fusion facilities can result in the production of airborne particles containing tritium that could inadvertently be inhaled by workers directly involved in the operations, and potentially others, resulting in internal exposures to tritium. Of particular interest in this context, given the potentially large masses of material involved, is tritiated steel. The International Commission on Radiological Protection (ICRP) has recommended committed effective dose coefficients for inhalation of some tritiated materials, but not specifically for tritiated steel. The lack of a dose coefficient for tritiated steel is a concern given the potential importance of the material. To address this knowledge gap, a "dissolution" study, in vivo biokinetic study in a rodent model (1 MBq intratracheal instillation, 3-month follow-up) and associated state-of-the-art modelling were undertaken to derive dose coefficients for model tritiated steel particles. A committed effective dose coefficient for the inhalation of 3.3 × 10^-12 Sv Bq^-1 was evaluated for the particles, reflecting an activity median aerodynamic diameter (AMAD) of 13.3 µm, with the value for a reference AMAD for workers (5 µm) of 5.6 × 10^-12 Sv Bq^-1 that may be applied to occupational inhalation exposure to tritiated steel particles.

Guidance on the use of the benchmark dose approach in risk assessment

The Scientific Committee (SC) reconfirms that the benchmark dose (BMD) approach is a scientifically more advanced method compared to the no-observed-adverse-effect-level (NOAEL) approach for deriving a Reference Point (RP). The major change compared to the previous Guidance (EFSA SC, 2017) concerns the Section 2.5, in which a change from the frequentist to the Bayesian paradigm is recommended. In the former, uncertainty about the unknown parameters is measured by confidence and significance levels, interpreted and calibrated under hypothetical repetition, while probability distributions are attached to the unknown parameters in the Bayesian approach, and the notion of probability is extended to reflect uncertainty of knowledge. In addition, the Bayesian approach can mimic a learning process and reflects the accumulation of knowledge over time. Model averaging is again recommended as the preferred method for estimating the BMD and calculating its credible interval. The set of default models to be used for BMD analysis has been reviewed and amended so that there is now a single set of models for quantal and continuous data. The flow chart guiding the reader step-by-step when performing a BMD analysis has also been updated, and a chapter comparing the frequentist to the Bayesian paradigm inserted. Also, when using Bayesian BMD modelling, the lower bound (BMDL) is to be considered as potential RP, and the upper bound (BMDU) is needed for establishing the BMDU/BMDL ratio reflecting the uncertainty in the BMD estimate. This updated guidance does not call for a general re-evaluation of previous assessments where the NOAEL approach or the BMD approach as described in the 2009 or 2017 Guidance was used, in particular when the exposure is clearly lower (e.g. more than one order of magnitude) than the health-based guidance value. Finally, the SC firmly reiterates to reconsider test guidelines given the wide application of the BMD approach.

Pestilence, Plague and Pandemics: A Troubled History

Humankind has lived with the danger of endemic, epidemic and pandemic disease for thousands of years. The effects of these outbreaks have often devastated human populations. Sixteen pandemic events causing an estimated 147 million deaths have occurred since the eighth century, The Black Death and the influenza pandemic of 1918-1920 probably having the greatest impact. Animal populations, both wild and domestic, have similarly suffered devastating outbreaks of disease which, on occasions, have translated into serious effects on human health. The deliberate or accidental introduction of animals into virgin areas has given rise to unforeseen disease events occasionally leading to extinction. Similarly, human intent or negligence and the vagaries of nature itself has resulted in ill health and loss of life. This paper describes the history of pandemics, epidemics and disasters, and the attempts to bring them under control.