Davids versus Goliaths: Pharma and academia threats to individual scientists and clinicians

Background

We previously described experiences of clinicians who published adverse drug reaction reports. We now report on threats and intimidations leveled against clinicians and scientists who received publicly documented threats after communicating safety, efficacy, or data integrity findings contrary to corporate interests.

Methods

Data on threats and intimidations were obtained from transcripts of governmental hearings or agencies, university-affiliated reports, media interviews, and investigative journalism articles. Content and timing of threats and intimidation, subsequent harms, numbers of persons seriously injured or who died from individual toxicities, financial payments from sponsors related to safety, efficacy, or data integrity concerns, and civil settlements and criminal findings were evaluated.

Findings

Twenty-six individuals who communicated safety, efficacy, or data integrity concerns were targets of threats and intimidation from corporate employees (twenty-three individuals) or regulatory personnel (three). Seventeen individuals identified instances where pharmaceutical sponsors submitted fraudulent data in support of regulatory approval of a drug or device. Scientist and clinician communications were followed by drug/device withdrawals (fourteen drugs/devices), black box warnings (six drugs), withdrawal of a sponsor’s application for regulatory approval (one device), and delay of approval of a sponsor’s application for regulatory approval (one drug). Actions mainly occurred after persons communicated with pharmaceutical employees (fourteen). Intimidation efforts by corporate personnel included threats of lawsuits (eighteen individuals), hiring private investigators (nine), and public disparagement at conferences (eleven). Related intimidation efforts carried out by academia or regulatory agency superiors included threats of: loss of positions (six), loss of grant funding (two), delays in decisions regarding tenure (two); or reassignment to a low-level position (one). Academic harms included lost: hospital or university appointments (nine and six, respectively), grant funding (two), chairperson title of an international clinical trial group (one), and journal editorial board position (one). Corporate harms included payment of $1 million to defense attorneys in three cases filed against clinicians.

Interpretation

Threats and intimidation carried out by corporate employees and/or academic supervisors followed public communication of concerns regarding patient safety, drug efficacy, or data integrity, including instances where sponsors were identified as having submitted fraudulent data to regulatory or government agencies. Consideration should be given to filing criminal charges against pharmaceutical executives who are discovered by scientists or clinicians to have knowingly submitted fraudulent data to regulatory or governmental agencies, rather than causing the scientists and clinicians who submit such reports to risk losing their reputations and occupations.

Catalytic non-thermal plasma treatment of endocrine disrupting compounds, pharmaceuticals, and personal care products in aqueous solution: A review

Contaminants of emerging concerns such as endocrine-disrupting compounds (EDCs) and pharmaceuticals/personal-care products (PPCPs) constitute a problem since they are not completely eliminated by traditional water and wastewater treatment methods. Non-thermal plasma (NTP) is considered as one of the most favorable treatment methods for the removal of organic contaminants in water and wastewater. The degradation of selected EDCs and PPCPs of various classes was reviewed, based on the recent literature, to (i) address the effect of the main NTP treatment parameters (water quality and NTP conditions: pH, initial concentration, temperature, background common ion, NOM, scavenger, gas type/flow rate, discharge/reactor type, input power, and energy efficiency/yield) on the degradation of contaminants and their intermediates, (ii) assess the influences of different catalysts and hybrid systems on degradation, (iii) describe EDC and PPCP degradation along with their properties, and (iv) evaluate mineralization, pathway, and degradation mechanism of selected EDCs and PPCPs for different cases studied. Furthermore, areas of potential research in NTP treatment for the degradation of EDCs and PPCPs in aqueous solutions are recommended. It could be reasonably predicted that this review is valid for developing our understanding of the fundamental scientific principles concerning the catalytic NTP of EDCs and PPCPs, providing helpful and practical references for researchers and designers on the effective removal of EDCs/PPCPs and the optimized operation of catalytic NTP systems.

Investigating Severe Adverse Reactions: Examples of the ANTICIPATE Methodology at Work

Severe adverse drug reactions (sADRs) are important causes of morbidity and mortality. The Southern Network on Adverse Drug Reactions (SONAR), a National Cancer Institute-funded pharmacovigilance program, has outlined a novel 9-stop methodology, termed ANTICIPATE, that has evaluated this methodology, among persons with chronic kidney disease (CKD).

Maximum Accuracy Machine Learning Statistical Analysis-A Novel Approach

Logistic regression is a statistical tool of paramount significance in the field of epidemiology¹ and ranks as one of the most frequently published multivariable analyses for designs involving a single binary dependent variable and one or more independent variables in the fields of public health^2,3 and medical⁴ research.

Systemic Barriers and Potential Concerns from Reporting Serious Adverse Drug Reactions

About 1-10% of all serious adverse drug reactions (sADRs) are reported to the Food and Drug Administration (FDA) ( Moore T, Bennett C. Underreporting of Hemorrhagic and Thrombotic Complications of Pharmaceuticals to the U.S. Food and Drug Administration: Empirical Findings for Warfarin, Clopidogrel, Ticlopidine, and Thalidomide from the Southern Network on Adverse Reactions (SONAR). Semin Thromb Hemost. 2012;38(08):905-907. https://doi.org/10.1055/s-0032-1328890 ). Prevailing opinion suggests that low reporting rates reflect time constraints.

Portrayal of Textile Based Pollutants and its Impact on Soil, Plants and Fisheries

The textile industry occupies a significant hold on the global economy. This substantial industry often generates a large volume of effluents exceeding the permissible limit of discharge in the different regions of the world. Therefore, textile effluents act as pollutants altering the natural composition of various components of the environment. This paper discusses the impact of textile-based pollutants on agriculture including plants, soil, water and fisheries. The observed result is significant because textile effluents exert a widespread negative impact on the respective respondents, though plants show few positive effects. Prior treatment of textile wastewater is necessary before applying it to the soil, as there is a possibility of affecting the plant ecosystem via soil media. Plants are benefitted in terms of germination and growth, due to irrigation by textile effluents with proper dilution. The physical and biochemical properties of water streams along with aquatic organisms are impacted by these specific discharges, leading to even severe deterioration of particular living creatures. Pollutants released from various steps of textile processing have adverse effects on the environment, disturbing the food chain, ecosystem, and overall ecological balance.

Gut-derived acetate promotes B10 cells with antiinflammatory effects

Autoimmune diseases are characterized by a breakdown of immune tolerance partly due to environmental factors. The short-chain fatty acid acetate, derived mostly from gut microbial fermentation of dietary fiber, promotes antiinflammatory Tregs and protects mice from type 1 diabetes, colitis, and allergies. Here, we show that the effects of acetate extend to another important immune subset involved in tolerance, the IL-10-producing regulatory B cells (B10 cells). Acetate directly promoted B10 cell differentiation from mouse B1a cells both in vivo and in vitro. These effects were linked to metabolic changes through the increased production of acetyl-coenzyme A, which fueled the TCA cycle and promoted posttranslational lysine acetylation. Acetate also promoted B10 cells from human blood cells through similar mechanisms. Finally, we identified that dietary fiber supplementation in healthy individuals was associated with increased blood-derived B10 cells. Direct delivery of acetate or indirect delivery via diets or bacteria that produce acetate might be a promising approach to restore B10 cells in noncommunicable diseases.

Fate and transport of enveloped viruses in indoor built spaces - through understanding vaccinia virus and surface interactions

The current coronavirus disease 2019 (COVID-19) pandemic has reinforced the necessity of understanding and establishing baseline information on the fate and transport mechanisms of viruses under indoor environmental conditions. Mechanisms governing virus interactions in built spaces have thus far been established based on our knowledge on the interaction of inorganic particles in indoor spaces and do not include characteristics specific to viruses. Studies have explored the biological and kinetic processes of microbes' attachments on surfaces in other fields but not in the built environment. There is also extensive literature on the influence of indoor architecture on air flow, temperature profiles, and forces influencing aerosol transport. Bridging the gap between these fields will lead to the generation of novel frameworks, methodologies and know-how that can identify undiscovered pathways taken by viruses and other microbes in the built environment. Our study summarizes the assessment of the influence of surface properties on the adhesion kinetics of vaccinia virus on gold, silica, glass, and stainless-steel surfaces. We found that on gold the virus layer was more viscoelastic compared to stainless-steel. There was negligible removal of the layer from the stainless-steel surface compared to the others. The results further highlight the importance of converging different fields of research to assess the fate and transport of microbes in indoor built spaces.

The First 2 Years of Biosimilar Epoetin for Cancer and Chemotherapy-Induced Anemia in the U.S.: A Review from the Southern Network on Adverse Reactions

Biosimilars are biologic drug products that are highly similar to reference products in analytic features, pharmacokinetics and pharmacodynamics, immunogenicity, safety, and efficacy. Biosimilar epoetin received Food and Drug Administration (FDA) approval in 2018. The manufacturer received an FDA nonapproval letter in 2017, despite receiving a favorable review by FDA's Oncologic Drugs Advisory Committee (ODAC) and an FDA nonapproval letter in 2015 for an earlier formulation. We discuss the 2018 FDA approval, the 2017 FDA ODAC Committee review, and the FDA complete response letters in 2015 and 2017; review concepts of litigation, naming, labeling, substitution, interchangeability, and pharmacovigilance; review European and U.S. oncology experiences with biosimilar epoetin; and review the safety of erythropoiesis-stimulating agents. In 2020, policy statements from AETNA, United Health Care, and Humana indicated that new epoetin oncology starts must be for biosimilar epoetin unless medical need for other epoetins is documented. Empirical studies report that as of 2012, reference epoetin use decreased from 40%-60% of all patients with cancer with chemotherapy-induced anemia to <5% of such patients because of safety concerns. Between 2018 and 2020, biosimilar epoetin use varied, increasing to 81% among one private insurer's patients covered by Medicare whose cancer care is administered with Oncology Analytics and to 41% with the same private insurer's patients with cancer covered by commercial health insurance and administered by the private insurer, to 0% in several Veterans Administration Hospitals, increasing to 100% in one large county hospital in California, and with yet-to-be-reported data from most oncology settings. We conclude that biosimilar epoetin appears to have overcome some barriers since 2015, although current uptake in the U.S. is variable. Pricing and safety considerations for all erythropoiesis-stimulating agents are primary determinants of biosimilar epoetin oncology uptake. IMPLICATIONS FOR PRACTICE: Few oncologists understand substitution and interchangeability of biosimilars with reference drugs. Epoetin biosimilar is new to the market, and physician and patient understanding is limited. The development of epoetin biosimilar is not familiar to oncologists.

Improving oncology biosimilar launches in the EU, the USA, and Japan: an updated Policy Review from the Southern Network on Adverse Reactions

The EU, the USA, and Japan account for the majority of biological pharmacotherapy use worldwide. Biosimilar regulatory approval pathways were authorised in the EU (2006), in Japan (2009), and in the USA (2015), to facilitate approval of biological drugs that are highly similar to reference products and to encourage market competition. Between 2007 and 2020, 33 biosimilars for oncology were approved by the European Medicines Agency (EMA), 16 by the US Food and Drug Administration (FDA), and ten by the Japan Pharmaceuticals and Medical Devices Agency (PMDA). Some of these approved applications were initially rejected because of manufacturing concerns (four of 36 [11%] with the EMA, seven of 16 [44%] with the FDA, none of ten for the PMDA). Median times from initial regulatory submission before approval of oncology biosimilars were 1·5 years (EMA), 1·3 years (FDA), and 0·9 years (PMDA). Pharmacists can substitute biosimilars for reference biologics in some EU countries, but not in the USA or Japan. US regulation prohibits substitution, unless the biosimilar has been approved as interchangeable, a designation not yet achieved for any biosimilar in the USA. Japan does not permit biosimilar substitution, as prescribers must include the product name on each prescription and that specific product must be given to the patient. Policy Reviews published in 2014 and 2016 in The Lancet Oncology focused on premarket and postmarket policies for oncology biosimilars before most of these drugs received regulatory approval. In this Policy Review from the Southern Network on Adverse Reactions, we identify factors preventing the effective launch of oncology biosimilars. Introduction to the market has been more challenging with therapeutic than for supportive care oncology biosimilars. Addressing region-specific competition barriers and educational needs would improve the regulatory approval process and market launches for these biologics, therefore expanding patient access to these products in the EU, the USA, and Japan.

Consequences to patients, clinicians, and manufacturers when very serious adverse drug reactions are identified (1997-2019): A qualitative analysis from the Southern Network on Adverse Reactions (SONAR)

BACKGROUND

Adverse drug/device reactions (ADRs) can result in severe patient harm. We define very serious ADRs as being associated with severe toxicity, as measured on the Common Toxicity Criteria Adverse Events (CTCAE)) scale, following use of drugs or devices with large sales, large financial settlements, and large numbers of injured persons. We report on impacts on patients, clinicians, and manufacturers following very serious ADR reporting.

METHODS

We reviewed clinician identified very serious ADRs published between 1997 and 2019. Drugs and devices associated with reports of very serious ADRs were identified. Included drugs or devices had market removal discussed at Food and Drug Advisory (FDA) Advisory Committee meetings, were published by clinicians, had sales > $1 billion, were associated with CTCAE Grade 4 or 5 toxicity effects, and had either >$1 billion in settlements or >1,000 injured patients. Data sources included journals, Congressional transcripts, and news reports. We reviewed data on: 1) timing of ADR reports, Boxed warnings, and product withdrawals, and 2) patient, clinician, and manufacturer impacts. Binomial analysis was used to compare sales pre- and post-FDA Advisory Committee meetings.

FINDINGS

Twenty very serious ADRs involved fifteen drugs and one device. Legal settlements totaled $38.4 billion for 753,900 injured persons. Eleven of 18 clinicians (61%) reported harms, including verbal threats from manufacturer (five) and loss of a faculty position (one). Annual sales decreased 94% from $29.1 billion pre-FDA meeting to $4.9 billion afterwards (p<0.0018). Manufacturers of four drugs paid $1.7 billion total in criminal fines for failing to inform the FDA and physicians about very serious ADRs. Following FDA approval, the median time to ADR reporting was 7.5 years (Interquartile range 3,13 years). Twelve drugs received Box warnings and one drug received a warning (median, 7.5 years following ADR reporting (IQR 5,11 years). Six drugs and 1 device were withdrawn from marketing (median, 5 years after ADR reporting (IQR 4,6 years)).

INTERPRETATION

Because very serious ADRs impacts are so large, policy makers should consider developing independently funded pharmacovigilance centers of excellence to assist with clinician investigations.

FUNDING

This work received support from the National Cancer Institute (1R01 CA102713 (CLB), https://www.nih.gov/about-nih/what-we-do/nih-almanac/national-cancer-institute-nci; and two Pilot Project grants from the American Cancer Society's Institutional Grant Award to the University of South Carolina (IRG-13-043-01) https://www.cancer.org/ (SH; BS).

End of an era of administering erythropoiesis stimulating agents among Veterans Administration cancer patients with chemotherapy-induced anemia

Erythropoisis stimulating agent (ESA) use was addressed in Food and Drug Administration (FDA) Oncology Drug Advisory Committee (ODAC) meetings between 2004 and 2008. FDA safety-focused regulatory actions occurred in 2007 and 2008. In 2007, black box warnings advised of early death and venous thromboembolism (VTE) risks with ESAs in oncology. In 2010, a Risk Evaluation Strategies (REMS) was initiated, with cancer patient consent that mortality and VTE risks were noted with ESAs. We report warnings and REMS impacts on ESA utilization among Veterans Administration (VA) cancer patients with chemotherapy-induced anemia (CIA). Data were from Veterans Affairs database (2003–2012). Epoetin and darbepoetin use were primary outcomes. Segmented linear regression was used to estimate changes in ESA use levels and trends, clinical appropriateness, and adverse events (VTEs) among chemotherapy-treated cancer patients. To estimate changes in level of drug prescription rate after policy actions, model-specific indicator variables as covariates based on specific actions were included. ESA use fell by 95% and 90% from 2005, for epoetin and darbepoetin, from 22% and 11%, respectively, to 1% and 1%, respectively, among cancer patients with CIA, respectively (p<0.01). Following REMS in 2010, mean hematocrit levels at ESA initiation decreased from 30% to 21% (p<0.01). Black box warnings preceded decreased ESA use among VA cancer patients with CIA. REMS was followed by reduced hematocrit levels at ESA initiation. Our findings contrast with privately- insured and Medicaid insured cancer patient data on chemotherapy-induced anemia where ESA use decreased to 3% to 7% by 2010–2012. By 2012, the era of ESA administration to VA to cancer patients had ended but the warnings remain relevant and significant. In 2019, oncology/hematology national guidelines (ASCO/ASH) recommend that cancer patients with chemotherapy-induced anemia should receive ESAs or red blood cell transfusions after risk-benefit evaluation.

Physician whistle-blower’s experiences in hematology-oncology safety litigation against pharmaceutical companies

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Background: Some clinicians have reported initial series of severe or fatal adverse drug reactions (ADRs) that affected large hematology-oncology patient numbers and for which pharmaceutical manufacturers subsequently paid large settlements or fines for allegedly failing to inform physicians about such ADRs. Based on their large human costs ( > 1,000 serious illnesses or deaths) and large financial costs ( > $100 million in settlements or fines), we have termed these ADRs as titanic ADRs. At a Senate hearing on one titanic, Vioxx, (a COX-2 inhibitor that was evaluated for colorectal cancer prevention), the clinician reporter was termed a “whistleblower” by a senator although this individual had not filed a formal whistleblower lawsuit. We identified physicians who would fit this characterization of whistleblowers and had published titanic hematology-oncology ADR reports in high impact journals. Methods: Hematology-oncology titanic ADRs were identified by collaborators with two NIH-funded drug safety networks (RADAR and SONAR (1998-2019)). Exclusion criteria included having also filed a whistleblower lawsuit. Qualitative research analyses evaluated content of statements made by whistleblowers to national reporters or at congressional hearings. Results: 18 physicians who reported titanic hematology/oncology-associated ADRs in peer-reviewed literature and discussed their findings in national news media outlets are included. Titanic ADRs included death, nephrogenic systemic fibrosis, coronary artery disease, and venous thromboembolism related to COX-2 inhibitors, heparin, gadolinium dye, thalidomide, lenalidomide, epoetin, and darbepoetin. Related financial settlements ranged from $100 million to $4.85 billion. Whistleblowers were from the United States, Denmark, and Germany. Primary motivations were public health and medical awareness. Whistleblowers reported having gone through lawsuits and having had executives request that the whistleblowers’ university terminate employment. One whistleblower was quoted saying “I believe that the lawsuit is an attempt to silence me.” Conclusions: Clinician whistleblowers of titanic hematology-oncology ADRs experienced reputational, financial, and personal threats. Motivations for reporting titanic ADRs were mainly public health and medical awareness focused. This differs from our previous study on clinicians publishing on non-titanic ADRs, where the primary motivation was scientific curiosity.

End of an era for erythropoiesis-stimulating agents in oncology

Erythropoiesis-stimulating agents (ESAs) are available to treat chemotherapy-induced anemia (CIA). In 2007-2008, regulatory notifications advised of venous thromboembolism and mortality risks while the Center for Medicare and Medicaid Services' restricted ESA initiation to patients with hemoglobin <10 g/dl. In 2010, a Risk Evaluation and Mitigation Strategies required consent prior to administration. We evaluated ESA utilization from 2003 to 2012 and obtained private health insurer claims data for persons with lung, colorectal, or breast cancer from 2001 to 2012. ESA use for CIA was determined by an ESA claim after chemotherapy, up to 6 months after treatment. We identified 839,948 commercially insured patients, including 24,785 patients with ESA-treated CIA (3.2%). Darbepoetin use increased 3.9-fold from 2003 to 2007 (12.3% to 48.7%) and then decreased 95% to 2.6% by 2012. Epoetin use decreased 90% from 2003 to 2012 (30.3% to 3.1%). Between 2003 and 2012, mean epoetin dosing decreased 0.8-fold (244,979 in 2003 vs. 196,216 units in 2012), but increased 1.8-fold for darbepoetin-treated CIA (262 in 2003 to 467 μg in 2012). Among CIA patients, transfusions were low (4.5%) in 2002-2007, then increased 2.2-fold between 2008 and 2012. Safety initiatives between 2007 and 2010 facilitated reductions in ESA use combined with changes in coverage. These data show the efficacy of regulatory efforts, publication of adverse events and changes in reimbursement in reducing use of ESAs. Future studies are warranted to optimize deimplementation strategies to improve patient safety.

Emission and dispersal of antibiotic resistance genes through bioaerosols generated during the treatment of municipal sewage

Wastewater treatment plants act as socio-ecological couplers through the concentration, treatment, and subsequent environmental release of sewage collected from surrounding communities and are often considered hotspots for antibiotic resistant bacteria (ARB) and antibiotic resistance genes (ARGs). While studies have identified the release of ARB/ARGs in treated liquid sewage, little is known about potential dispersal through wastewater bioaerosol emissions. The aim of this study was to better define the contribution of WWTP bioaerosols to potential environmental distribution of ARB/ARGs. Bioaerosols were collected immediately upwind and downwind from the aeration tanks of a municipal wastewater treatment plant and liquid sludge samples were obtained from the aeration tanks. From the bioaerosol and liquid samples, qPCR assays identified 44 ARGs that confer resistance to a wide range of antibiotics. Comparison of the ARG profiles across samples showed that the downwind bioaerosol profile was 68% similar to the profile found in liquid sludge samples. Community 16S rRNA gene sequencing also showed that downwind bioaerosols had similar taxonomic profiles as those generated from liquid sludge while the upwind profiles showed a distinct difference. Preliminary ARG dispersion modeling estimated an ARG emission rate of ~10,620 genes per hour from the liquid sludge and indicated that the bioaerosols have the potential to be carried kilometers away from the WWTP source based on wind speed. The overall results from this study suggest that bioaerosols generated during WWTP processes can aid in the emission and dispersal of bacteria and ARGs, resulting in a possible route of human exposure and deposition into surrounding environments.

Cross-sectional study of the prevalence, causes and management of hospital-onset diarrhoea

BACKGROUND

The National Health Service in England advises hospitals collect data on hospital-onset diarrhoea (HOD). Contemporaneous data on HOD are lacking.

AIM

To investigate prevalence, aetiology and management of HOD on medical, surgical and elderly-care wards.

METHODS

A cross-sectional study in a volunteer sample of UK hospitals, which collected data on one winter and one summer day in 2016. Patients admitted ≥72 h were screened for HOD (definition: ≥2 episodes of Bristol Stool Type 5-7 the day before the study, with diarrhoea onset >48 h after admission). Data on HOD aetiology and management were collected prospectively.

FINDINGS

Data were collected on 141 wards in 32 hospitals (16 acute, 16 teaching). Point-prevalence of HOD was 4.5% (230/5142 patients; 95% confidence interval (CI) 3.9-5.0%). Teaching hospital HOD prevalence (5.9%, 95% CI 5.1-6.9%) was twice that of acute hospitals (2.8%, 95% CI 2.1-3.5%; odds ratio 2.2, 95% CI 1.7-3.0). At least one potential cause was identified in 222/230 patients (97%): 107 (47%) had a relevant underlying condition, 125 (54%) were taking antimicrobials, and 195 (85%) other medication known to cause diarrhoea. Nine of 75 tested patients were Clostridium difficile toxin positive (4%). Eighty (35%) patients had a documented medical assessment of diarrhoea. Documentation of HOD in medical notes correlated with testing for C. difficile (78% of those tested vs 38% not tested, P<0.001). One-hundred and forty-four (63%) patients were not isolated following diarrhoea onset.

CONCLUSION

HOD is a prevalent symptom affecting thousands of patients across the UK health system each day. Most patients had multiple potential causes of HOD, mainly iatrogenic, but only a third had medical assessment. Most were not tested for C. difficile and were not isolated.

Regulatory and Clinical Experiences with Biosimilar Filgrastim in the U.S., the European Union, Japan, and Canada

Biosimilar filgrastims are primarily indicated for chemotherapy-induced neutropenia prevention. They are less expensive formulations of branded filgrastim, and biosimilar filgrastim was the first biosimilar oncology drug administered in European Union (EU) countries, Japan, and the U.S. Fourteen biosimilar filgrastims have been marketed in EU countries, Japan, the U.S., and Canada since 2008, 2012, 2015, and 2016, respectively. We reviewed experiences and policies for biosimilar filgrastim markets in EU countries and Japan, where uptake has been rapid, and in the U.S. and Canada, where experience is rapidly emerging. U.S. regulations for designating biosimilar interchangeability are under development, and such regulations have not been developed in most other countries. Pharmaceutical substitution is allowed for new filgrastim starts in some EU countries and in Canada, but not Japan and the U.S. In EU countries, biosimilar adoption is facilitated with favorable hospital tender offers. U.S. adoption is reportedly 24%, while the second filgrastim biosimilar is priced 30% lower than branded filgrastim and 20% lower than the first biosimilar filgrastim approved by the U.S. Food and Drug Administration. Utilization is about 60% in EU countries, where biosimilar filgrastim is marketed at a 30%-40% discount. In Japan, biosimilar filgrastim utilization is 45%, primarily because of 35% discounts negotiated by Central Insurance and hospital-only markets. Overall, biosimilar filgrastim adoption barriers are small in many EU countries and Japan and are diminishing in Canada in the U.S. Policies facilitating improved U.S. adoption of biosimilar filgrastim, based on positive experiences in EU countries and Japan, including favorable insurance coverage; larger price discount relative to reference filgrastim pricing; closing of the "rebate trap" with transparent pricing information; formal educational efforts of patients, physicians, caregivers, and providers; and allowance of pharmaceutical substitution of biosimilar versus reference filgrastim, should be considered. IMPLICATIONS FOR PRACTICE: We reviewed experiences and policies for biosimilar filgrastims in Europe, Japan, Canada, and the U.S. Postmarketing harmonization of regulatory policies for biosimilar filgrastims has not occurred. Acceptance of biosimilar filgrastims for branded filgrastim, increasing in the U.S. and in Canada, is commonplace in Japan and Europe. In the U.S., some factors, accepted in Europe or Japan, could improve uptake, including acceptance of biosimilars as safe and effective; larger cost savings, decreasing "rebate traps" where pharmaceutical benefit managers support branded filgrastim, decreased use of patent litigation/challenges, and allowing pharmacists to routinely substitute biosimilar for branded filgrastim.

Coupling Computational Fluid Dynamics Simulations and Statistical Moments for Designing Healthy Indoor Spaces

Cross-contamination between occupants in an indoor space may occur due to transfer of infectious aerosols. Computational fluid dynamics (CFD) provides detailed insight into particle transport in indoor spaces. However, such simulations are site-specific. This study couples CFD with statistical moments and establishes a framework that transitions site-specific results to generating guidelines for designing "healthy" indoor spaces. Eighteen cases were simulated, and three parameters were assessed: inlet/outlet location, air changes per hour, and the presence/absence of desks. Aerosol release due to a simulated "sneeze" in a two-dimensional ventilated space was applied as a test case. Mean, standard deviation, and skewness of the velocity profiles and particle locations gave an overall picture of the spread and movement of the air flow in the domain. A parameter or configuration did not dominate the values, confirming the significance of considering the combined influence of multiple parameters for determining localized air-flow characteristics. Particle clustering occurred more when the inlet was positioned above the outlet. The particle dispersion pattern could be classified into two time zones: "near time", <60 s, and "far time", >120 s. Based on dosage, the 18 cases were classified into three groups ranging from worst case scenario to best case scenario.

Quantifying the sensitivity of feedstock properties and process conditions on hydrochar yield, carbon content, and energy content

Hydrothermal carbonization (HTC) is a wet, low temperature thermal conversion process that continues to gain attention for the generation of hydrochar. The importance of specific process conditions and feedstock properties on hydrochar characteristics is not well understood. To evaluate this, linear and non-linear models were developed to describe hydrochar characteristics based on data collected from HTC-related literature. A Sobol analysis was subsequently conducted to identify parameters that most influence hydrochar characteristics. Results from this analysis indicate that for each investigated hydrochar property, the model fit and predictive capability associated with the random forest models is superior to both the linear and regression tree models. Based on results from the Sobol analysis, the feedstock properties and process conditions most influential on hydrochar yield, carbon content, and energy content were identified. In addition, a variational process parameter sensitivity analysis was conducted to determine how feedstock property importance changes with process conditions.

Sonocatalytic removal of ibuprofen and sulfamethoxazole in the presence of different fly ash sources

We examined the feasibility of using two types of fly ash (an industrial waste from thermal power plants) as a low-cost catalyst to enhance the ultrasonic (US) degradation of ibuprofen (IBP) and sulfamethoxazole (SMX). Two fly ashes, Belews Creek fly ash (BFA), from a power station in North Carolina, and Wateree Station fly ash (WFA), from a power station in South Carolina, were used. The results showed that >99% removal of IBP and SMX was achieved within 30 and 60min of sonication, respectively, at 580kHz and pH 3.5. Furthermore, the removal of IBP and SMX achieved, in terms of frequency, was in the order 580kHz>1000kHz>28kHz, and in terms of pH, was in the order of pH 3.5>pH 7>pH 9.5. WFA showed significant enhancement in the removal of IBP and SMX, which reached >99% removal within 20 and 50min, respectively, at 580kHz and pH 3.5. This was presumably because WFA contains more silicon dioxide than BFA, which can enhance the formation of OH radicals during sonication. Additionally, WFA has finer particles than BFA, which can increase the adsorption capacity in removing IBP and SMX. The sonocatalytic degradation of IBP and SMX fitted pseudo first-order rate kinetics and the synergistic indices of all the reactions were determined to compare the efficiency of the fly ashes. Overall, the findings have showed that WFA combined with US has potential for treating organic pollutants, such as IBP and SMX, in water and wastewater.

Isolation, Characterization, and Identification of Bacterial Population from Textile and Tannery Effluents of Bangladesh

Ten effluent samples from two different sites located at Hazaribagh tannery belt and Dhaka EPZ, Savar were collected. This study aimed to compare the bacterial composition isolated from tannery and textile effluents and to investigate the occurrence of metal toxicity tolerant and dye degrading bacteria and to select the potential strains for the use in bioremediation. The average bacterial count of HT and DETDE varied in between 3.35×106 and 5.45×106 cfu/mL and 4.8×106 and 7.75×106cfu/mL, respectively. A total of 12 bacterial isolates were characterized as strains of Bacillus, Staphylococcus, and Pseudomonas. A few, however, were re-cultured on other recommended media for verification of diagnostic characteristics. Maximum numbers of bacterial species were isolated from textile effluent. The results showed that a Gram-positive bacillus with a yellow pigment was considered as a major group of the population. Among them three isolates were identified based on alignments of partial sequence of 16S rRNA gene. These are also being used in different wastewater and metal treatment plants all over the world.Bangladesh J Microbiol, Volume 29, Number 2, Dec 2012, pp 84-88

Near-road modeling and measurement of cerium-containing particles generated by nanoparticle diesel fuel additive use

Cerium oxide nanoparticles (nCe) are used as a fuel-borne catalyst in diesel engines to reduce particulate emissions, yet the environmental and human health impacts of the exhaust particles are not well understood. To bridge the gap between emission measurements and ambient impacts, size-resolved measurements of particle composition and mass concentration have been performed in Newcastle-upon-Tyne, United Kingdom, where buses have used an nCe additive since 2005. These observations show that the noncrustal cerium fraction thought to be associated with the use of nCe has a mass concentration ∼ 0.3 ng m(-3) with a size distribution peaking at 100-320 nm in aerodynamic diameter. Simulations with a near-roadway multicomponent sectional aerosol dynamic model predict that the use of nCe additives increases the number concentration of nuclei mode particles (<50 nm in diameter) while decreasing the total mass concentration. The near-road model predicts a downwind mass size distribution of cerium-containing particles peaking at 150 nm in aerodynamic diameter, a value similar to that measured for noncrustal cerium in Newcastle. This work shows that both the emission and atmospheric transformation of cerium-containing particles needs to be taken into account by regional modelers, exposure scientists, and policymakers when determining potential environmental and human health impacts.

Vermicomposting potentiality of Perionyx excavatus for recycling of waste biomass of Java citronella--an aromatic oil yielding plant

Laboratory investigation on vermicomposting efficacy of Perionyx excavatus for recycling of distillation waste biomass of java citronella (Cymbopogon winterianus Jowitt) was carried out in two seasonal trials i.e. summer and winter periods. The experiment was conducted in earthen pots using a mixture of citronella waste material and cowdung in the proportion of 5:1. A control treatment without earthworms was setup for comparison of the results. The vermicompost had shown 5.8 folds reduction in C/N ratio and 5.6 folds enhancement in ash content. The nutrient contents (N, P, K, Ca and Mg) in the vermicompost had increase in the range of 1.2 - 4.1 fold than the initial level. The FT-IR spectra of the vermicompost confirmed increase in nitrogen rich compounds and decrease in aliphatic/aromatic compounds as compared to the initial level of the biowaste materials. The vermicomposting process is influenced by seasonal variation and summer was more productive than winter.

Development of artificial neural network based metamodels for inactivation of anthrax spores in ventilated spaces using computational fluid dynamics

Linear, quadratic, and artificial neural network (ANN)-based metamodels were developed for predicting the extent of anthrax spore inactivation by chlorine dioxide in a ventilated three-dimensional space over time from computational fluid dynamics model (CFD) simulation data. Dimensionless groups were developed to define the design space of the problem scenario. The Hammersley sequence sampling (HSS) method was used to determine the sampling points for the numerical experiments within the design space. A CFD model, comprised of multiple submodels, was applied to conduct the numerical experiments. Large eddy simulation (LES) with the Smagorinsky subgridscale model was applied to compute the airflow. Anthrax spores were modeled as a dispersed solid phase using the Lagrangian treatment. The disinfectant transport was calculated by solving a mass transport equation. Kinetic decay constants were included for spontaneous decay of the disinfectant and for the reaction of the disinfectant with the surfaces of the three-dimensional space. To enhance the mixing of the disinfectant with the room air, a momentum source was included in the simulation. An inactivation rate equation accounted for the reaction between the spores and the disinfectant. The ANN-based metamodels were most successful in predicting the number of viable bioaerosols remaining in an arbitrary enclosed space. Sensitivity analysis showed that the mass fraction of the disinfectant, inactivation rate constant, and contact time had the most influence on the inactivation of the spores.

Vermicomposting of distillation waste of citronella plant (Cymbopogon winterianus Jowitt.) employing Eudrilus eugeniae

Laboratory experiment on vermicomposting of distillation waste of java citronella (Cymbopogon winterianus Jowitt.) was carried out employing Eudrilus eugeniae, in two seasonal trials, covering summer and winter periods. Two vermicomposting treatments were conducted in earthen pots, one with citronella plant waste only (CW) and the other, a mixture of citronella waste and cowdung in the proportion 5:1 (CW+CD). Vermicomposting of citronella waste resulted reduction in C/N ratio (83.5-87.7%), enhancement of ash content and a number of macro and micronutrients. The FT-IR spectroscopy of the vermicompost revealed the reduction in aliphatic and aromatic compound as well as increase in amide group after the 105 days stabilization process. The vermicompost output was significantly enhanced in CW+CD treatment than CW treatment. Even, nutrient content of the vermicompost was also higher in CW+CD treatment than CW alone indicating the positive role of cowdung in improvement of quantity and quality.

Using lot quality assurance sampling to improve immunization coverage in Bangladesh

OBJECTIVE

To determine areas of low vaccination coverage in five cities in Bangladesh (Chittagong, Dhaka, Khulna, Rajshahi, and Syedpur).

METHODS

Six studies using lot quality assurance sampling were conducted between 1995 and 1997 by Basic Support for Institutionalizing Child Survival and the Bangladesh National Expanded Programme on Immunization.

FINDINGS

BCG vaccination coverage was acceptable in all lots studied; however, the proportion of lots rejected because coverage of measles vaccination was low ranged from 0% of lots in Syedpur to 12% in Chittagong and 20% in Dhaka's zones 7 and 8. The proportion of lots rejected because an inadequate number of children in the sample had been fully vaccinated varied from 11% in Syedpur to 30% in Dhaka. Additionally, analysis of aggregated, weighted immunization coverage showed that there was a high BCG vaccination coverage (the first administered vaccine) and a low measles vaccination coverage (the last administered vaccine) indicating a high drop-out rate, ranging from 14% in Syedpur to 36% in Dhaka's zone 8.

CONCLUSION

In Bangladesh, where resources are limited, results from surveys using lot quality assurance sampling enabled managers of the National Expanded Programme on Immunization to identify areas with poor vaccination coverage. Those areas were targeted to receive focused interventions to improve coverage. Since this sampling method requires only a small sample size and was easy for staff to use, it is feasible for routine monitoring of vaccination coverage.

Pituitary adenylate cyclase activating peptide phase shifts circadian rhythms in a manner similar to light

The endogenous circadian pacemaker in mammals is located in the suprachiasmatic nuclei (SCN) of the hypothalamus. Various cues can reset circadian rhythm phase, thereby entraining the internal rhythm to the environmental cycle, and these effects can be investigated using an in vitro method to measure phase shifts of the SCN. Although pituitary adenylate cyclase activating peptide (PACAP) is localized in retinal inputs to the SCN, it has been reported to alter clock phase only during the subjective day (Hannibal et al., 1997), whereas light alters phase only in the subjective night. In this study we show that PACAP can reset the clock in the photic pattern during the subjective night when applied in 10 pM to 1 nM doses. This appears to be mediated via a glutamatergic mechanism, possibly by potentiation of NMDA currents as is seen at 10-100 pM. Given at higher doses (>10 nM), PACAP shifts in the subjective day, apparently via activation of adenylate cyclase and increased intracellular cAMP. These results indicate dose and phase specificity of the effects of PACAP, and a new role as a transmitter in the retinohypothalamic tract.

Adult T-cell leukemia/lymphoma in London: clinical experience of 21 cases

Adult T-cell leukemia/lymphoma (ATLL) is uncommon in the United Kingdom and has so far been restricted to people of Afro-Caribbean extraction. Between 1981 and 1995, 21 cases presented to 2 inner London teaching hospitals where 17% of the population are of Afro-Caribbean origin. Clinical presentations were similar to those of the disease in HTLV-I-endemic areas. Major responses (CR + PR) were obtained in 10/16 assessable patients (63%) treated with combination chemotherapy. However, median survival was only 5.5 months. Disease progression and opportunistic infection were the major causes of treatment failure and death. Three patients (14%) relapsed in the central nervous system (CNS). Our cases confirm the profound immunosuppression in ATLL. The poor prognosis of acute and lymphoma types of ATLL highlight the need for new approaches to treatment such as zidovudine and alpha-interferon, incorporating prophylaxis against CNS disease and opportunistic infections.

Abundance and Distribution of Bacillus thuringiensis in the Agricultural Soil of Bangladesh

Bacillus thuringiensis is distributed ubiquitously in the agricultural soil of Bangladesh. Simple correlation and regression analyses showed that the soil sand percentage and the available copper levels had significant negative and positive contributions, respectively, to the abundance and distribution of B. thuringiensis in the agricultural soil. Among the isolates, only 2.5% of strains showed larvicidal activity against the mosquito Culex quinquefasciatus. The larvicidal potency LD50 varied from 3.5 x 10(3) to 9.5 x 10(7) spores per milliliter among the isolates. Copyright 1997 Academic Press. Copyright 1997 Academic Press

NPY opposes PACAP phase shifts via receptors different from those involved in NPY phase shifts

The suprachiasmatic nuclei (SCN) of the hamster can be maintained for several days in vitro, allowing electrophysiological investigation of the mammalian circadian clock. Application of pituitary adenylate cyclase activating peptide (PACAP) at Zeitgeber time (ZT) 6 on the first day in vitro can phase shift the rhythm of firing rate expressed by SCN neurons on a subsequent day in vitro. Here we report that co-application of neuropeptide Y (NPY) will block the phase-shifting action of PACAP. This blocking action is mimicked by [Leu31,Pro34]NPY and [D-Trp32]NPY but not by NPY(22-36) or avian pancreatic polypeptide. The results indicate that NPY has actions in the SCN via receptors distinct from the Y2 receptor, which mediates the phase-shifting action of NPY.

Self-assessment of confidence of internee doctors in performing common surgical operations

A total of 140 internee doctors who had just completed or were about to complete their internship training from four leading Medical College Hospitals of Bangladesh were asked to fill up a pre-tested structured questionnaire. Of them 115 were male and 25 were female. All the participants had 6 months compulsory training in Medicine, 123 had 6 months training in Surgery and 17 had 6 months training in Obstetrics-Gynecology. Over 50% doctors expressed lack of confidence in performing ligation, vasectomy, splinting simple fractures, venesection, episiotomy, hydrocele operation, circumcision, proctoscopy and inguinal herniorrhaphy and expressed the need for further training in those procedures. Only 10% and 1.43% internees stated that they were confident about performing ligation and vasectomy independently. Internees from Chittagong Medical College Hospitals expressed their inability to perform ligation and/or vasectomy independently. So it was recommended that surgical training should be made mandatory for all internee Doctors with extension of the Internship period by at least 6 months. Emphasis should be laid on training in vasectomy and ligation. A pre-registration evaluation test may be introduced at the end of their training period.

Circadian rhythm photic phase shifts are not altered by histamine receptor antagonists

Histamine may play a role in synchronizing endogenous circadian rhythms with exogenous photic cues. Direct application of histamine to the suprachiasmatic nucleus, the site of the mammalian circadian pacemaker, phase shifts the circadian rhythm in neural activity [7]. Intraventricular injections of histamine also phase shift circadian rhythms [14]. The magnitude and direction of the phase shifting effects of histamine depend on circadian phase in a manner similar to light [7,14]. Depletion of brain histamine levels by inhibition of histamine synthesis reduces phase shifts to light [10].

Experience of human lymphotropic virus type I (HTLV-I) in an East London hospital

We describe the experience of The Royal London Hospital with human T-cell lymphotropic virus type 1 (HTLV-1) related disease. Twelve patients presented from 1988-1993, nine of them in 1993. None were born in the U.K. and 11 were of West Indian origin. Ten had overt lymphomas, one tropical spastic paraparesis/HTLV-1 associated myelopathy (TSP/HAM) and one atypical lymphocytosis and Strongyloidiasis. Five presented acutely ill to Casualty and three died shortly after presentation. Four had been referred to rheumatologists and five had predominantly gastrointestinal symptoms. The population of Caribbean origin served by the hospital is 23,700 and one would only expect one or two cases of lymphoma and one or two cases of TSP/HAM per year. Overall the spectrum of clinical disease at presentation was varied. Suspicion of HTLV-1 infection is merited in patients of West Indian origin between the ages of 30-65 years, who present with a sarcoid-like illness, gastrointestinal symptoms, leukaemia/lymphoma, myelopathy or myositis like-illness.

Plasma exchange therapy for endotoxin shock in puppies

The efficacy of plasma exchange (PE) therapy for endotoxin (ET) shock has not been evaluated. The following experimental study was designed to evaluate the feasibility of PE in infants and children and determine the efficacy as a therapeutic modality for ET shock. A compact circuit for PE designed for this experiment consists of two pumps and a membrane plasma separator for a venovenous extracorporeal circulation with the limited prime volume of 100 mL. The capacity of this device for PE was tested. When a membrane separator of 0.3 m2 in surface area was used, a plasma flux of 5 to 13 mL/min was satisfactorily obtained with the blood flow rate of 25 to 40 mL/min, which was taken through centrally placed catheters of 18 gauge or larger. Transmembrane pressure was maintained in a safe range (0 to 50 mm Hg) in the first 90 minutes, during which time a PE of 100 mL/kg was completed with a sieving coefficient greater than 0.8. In 14 puppies (1.8 to 3.5 kg), a shock state was produced by infusion of ET (Escherichia coli, 055:B5). Eight puppies were resuscitated simply with lactated Ringer's solution and bicarbonate. Six puppies were treated with PE using 100 mL/kg of fresh-frozen plasma prepared from adult dogs. A significant decrease in the mean blood pressure, platelet and leukocyte counts, total protein, and CH50 was documented in all animals after ET administration. Seven of eight control animals died within 24 hours of post-ET infusion. All of the six PE-treated animals survived for 48 hours or longer.(ABSTRACT TRUNCATED AT 250 WORDS)